ASSESSMENT OF GAIT

The clinician begins the gait assessment with an overall look at the patient while they walk and noting the cadence, stride length, step length, and velocity. The arm swing during gait also should be observed. If an individual has a problem with the foot or ankle on one side, the opposite arm swing often is decreased. The patient is observed from head to toe and then back again, from the side, from the front, and then from the back. In addition to observing the patient walking at his or her normal pace, the clinician should observe the patient walking at varying speeds. This can be achieved by asking the patient to change walking speed. Gait is assessed by having the patient walk barefoot, and with footwear. Barefoot walking provides information about foot function without support and can highlight compensations, such as excessive pronation, and foot deformities, such as claw toes. Having the patient walk with footwear can provide information about the effectiveness of the footwear to counteract the compensations. The patient should be asked to walk on the toes, and then on the heels. An inability to perform either of these actions could be the result of pain, weakness, or a motion restriction. Metatarsalgia is indicated if the metatarsal heads are made more painful with barefoot walking. Pain at initial contact may indicate a heel spur, bone contusion, calcaneal fat pad injury, or bursitis. The patient’s footwear is examined for patterns of wear. The greatest amount of wear on the sole of the shoe should occur beneath the ball of the foot, and in the area corresponding to the first, second, and third metatarsophalangeal joints, and slight wear to the lateral side of the heel. The upper portion of the shoe should demonstrate a transverse crease at the level of the metatarsophalangeal joints. A stiff first metatarsophalangeal joint can produce a crease line that runs obliquely, from forward and medial to backward and lateral. Scuffing of the shoe might indicate tibialis anterior weakness or adaptively shortened heel cords. The patient’s foot also is examined for callus formation, blisters, corns, and bunions. Callus formation on the sole of the foot is an indicator of dysfunction and provides the clinician with an index to the degree of shear stresses applied to the foot, and a clear outline of abnormal weight-bearing areas. Adequate amounts of calluses may provide protection, but in excess amounts they may cause pain. Callus formation under the second and third metatarsal heads could indicate excessive pronation in a flexible foot, or Morton’s neuroma if just under the former. A callus under the fifth, and sometimes the fourth, metatarsal head may indicate an abnormally rigid foot. The patient is asked to walk in his or her usual manner and at the usual speed.

A “bouncing” gait is characteristic of adaptively shortened gastrocnemii. hip adductor contracture or spasticity. Amount of lateral displacement of the trunk and pelvis.” The term toe-out refers to the angle formed by the intersection of the line of progression of the foot and the line extending from the center of the heel through the second metatarsal. resulting in anteversion or retroversion. Amount of hip adduction or abduction that occurs. and this angle decreases as the speed of gait increases. Degree of “toe-out. and contralateral hip abduction contracture. Because positioning the lower extremity in external rotation decreases the stress on the subtalar joint complex. hamstring weakness. or increased tone of the gastrocnemius and soleus. impaired balance. Movements of the upper trunk and limbs usually occur in the opposite directions to the pelvis and the lower limbs. obesity. Whether the elbows are flexed or extended. or hip abductor shortening or overuse. Degree of rotation of the whole lower extremity. Excessive hip abduction may be caused by an abduction contracture. • • • • • • Amount of valgus or varus at the knee. the clinician can note the following: • Head position. Whether there is excessive swaying of the trunk or pelvis. Hip hiking can indicate a leg-length discrepancy. or elevated. Whether any hip hiking occurs. Amount of vertical displacement. The subject’s head should not move too much during gait in a lateral or vertical direction and should remain fairly stationary during the gait cycle. Causes of excessive adduction include an excessive angle of the coxa vara. or shortening of the quadratus lumborum. • • Whether any circumduction of the hip occurs. Vertical displacement can be assessed by observing the patient’s head. The normal toe-out angle is approximately 7 degrees. • • • • • Reciprocal arm swing. a short leg. • • . Hip circumduction can indicate a leg-length discrepancy. or hip flexor weakness. Whether the shoulders are depressed.Anterior View When observing the patient from the front. an individual with a foot or ankle problem often adopts this position during gait. Evidence of thigh atrophy. decreased ability of the knee to flex. Width of the base of support. respectively. hip abductor weakness. retracted. Amount of lateral tilt of the pelvis. respectively. Excessive internal or external rotation of the femur can indicate adaptive shortening of the medial or lateral hamstrings.

iliotibial band contracture. • Ankle dorsiflexion and plantar flexion. excessive ankle plantar flexion. the ankle dorsiflexes and the body pivots over the stationary foot. Causes of excessive knee flexion and inadequate knee extension include inappropriate hamstring activity. Forward leaning during the loading response and early midstance intervals may indicate hip extensor weakness. the ankle should be seen to plantar flex to raise the heel. and excessive ankle plantar flexion. hip flexor weakness. hip flexion contracture. Compensation can occur in the lumbar spine for a loss of motion at the hip. knee. Individuals with genu recurvatum may have a functional strength deficit in the quadriceps muscle or gastrocnemius that allows knee hyperextension. Cadence. • Orientation of the pelvic tilt. with equal motion. An anterior pelvic tilt of 10 degrees is considered normal.Lateral View • • Amount of thoracic and shoulder rotation. • • Stride length of each limb. moving into dorsiflexion as the swing period progresses and reaching a neutral position at the time of heel contact at the termination of the swing. and knee extension contractures. Causes of inadequate hip flexion may include hip flexor weakness or hip joint arthrodesis. and loading response may be caused by pretibial (especially the anterior tibialis) weakness. The cadence should be normal for the patient’s age . ankle fusion. pain. or pain. Excessive plantar flexion also may be caused by plantar flexion contracture. or hip flexor spasticity. During midstance. A backward lean of the trunk may result from weak hip extensors or inadequate hip flexion. initial contact. Excessive dorsiflexion may be caused by soleus weakness. abdominal muscle weakness. The trunk should remain erect and level during the gait cycle as it moves in the opposite direction to the pelvis. there must be sufficient knee flexion. followed by slight flexion during the loading response interval. Causes of inadequate flexion and excessive extension at the knee include quadriceps weakness. Excessive anterior tilting can be caused by weak hip extensors. soleus and gastrocnemius spasticity. Causes of inadequate hip extension and excessive hip flexion include hip flexion contracture. At the end of the stance period. knee flexion contracture. Each shoulder and arm should swing reciprocally. or weak quadriceps. hip flexor spasticity. quadriceps spasticity. or hip flexion contracture. Excessive posterior pelvic tilting during gait usually occurs in the presence of hip flexor weakness. • Degree of hip extension. the ankle is plantar flexed. Excessive plantar flexion in midswing. decreased spinal mobility. Orientation of trunk. A forward lean of the trunk may result from pathology of the hip. The knee should be extended during the initial contact interval. or ankle. At the beginning of the swing period. During the swing period. soleus weakness. • Knee flexion and extension. or persistent knee flexion during the midstance period.

An early heel rise indicates an adaptively shortened Achilles tendon. . • • • Base of support. Pelvic list. Causes for this can include ankle or foot pain or weakness of the plantar flexor muscles. or premature action by the calf muscles. Causes of excessive external hip rotation may include gluteus maximus overactivity and excessive ankle plantar flexion. whereas valgus tends to be more common with flaccid paralysis. and quadriceps weakness. A low heel contact during initial contact may be caused by plantar flexion contracture. Excessive inversion and eversion usually relate to abnormal muscular control. • • Amount of hip adduction or abduction. excessive femoral internal rotation past the midstance of gait will accentuate genu recurvatum. Preswing. weakness of the dorsiflexors. Causes of excessive internal hip rotation include medial hamstring overactivity.• • • Heel rise. and knee flexion occurring at midstance. A decreased preswing is often characterized by a lack of plantar flexion at terminal stance and preswing. adaptive shortening or increased tone of the triceps surae. Generally speaking. An exaggerated preswing is manifested by the patient walking on the toes. As in standing. Heel contact. Amount of knee/ tibial rotation. tibialis anterior weakness. varus tends to be the dominant dysfunction in spastic patients. Degree of hip rotation. Causes include pes equines deformity. anterior abductor overactivity. hip adductor overactivity. Delayed heel rise may indicate a weak gastrocnemius-soleus complex. Posterior View • Amount of subtalar inversion (varus) or eversion (valgus).

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