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of contact forces. Other forces are the result of interactions of the action-at-a-distance type (eg, gravitation
CURRENT Diagnosis & Treatment: Physical Medicine & Rehabilitation
11: Gait Analysis
INTRODUCTION
Normal human locomotion has been the focus of intense clinical observational analysis for several decades.
Through these e orts, the basic components of the gait cycle, its phases, and subphases have been
identified, defined observationally, and linked to their kinematic, kinetic, and muscle behaviors. More in-
depth analysis has revealed combinations of subphases that define the operational features of gait—
organized components of the gait cycle reflecting functional features that achieve important operating
objectives of the locomotion system. These objectives include advancement of the body’s center of mass by
means of swing phase and stance phase propulsion mechanisms, foot–floor clearance mechanisms of the
swinging limb, and antigravity stability mechanisms that operate during loading of body weight and the
subsequent period of single limb support. Common gait deviations have also been analyzed in terms of how
they relate to the larger context of the operational features of gait, providing insight into rehabilitative
strategies that can best address operational features gone awry.
KEY CONTRIBUTORS TO HUMAN LOCOMOTION
This chapter describes human locomotion as a sequence of repetitive bodily motions organized functionally
as a gait cycle. The chapter provides working descriptions of the gait cycle, its phases and sub phases, its
kinematics, kinetics, and muscle kinesiology. Major objectives of the gait cycle are delineated including
advancing the body’s center of mass, controlling upright stability against gravity and clearing the foot from
the floor in order to avoid stumbling and falling. The chapter goes on to develop the concept of operational
features of gait, namely, clinically observable components of the gait cycle that work together to achieve
major gait objectives such as translation of the center of body mass and maintaining upright stability. Based
on concepts developed in the paper, the chapter ends with case scenarios of patients with gait dysfunction
that will hopefully alert the reader to useful ways of analyzing and treating problems of human locomotion.
In analyzing human gait, the examiner must be knowledgeable about three contributors that have key roles
in locomotion: ground reaction force, joint moments, and center of mass.
Ground Reaction Force
A force is a push or pull on an object that results from its interaction with another object. Forces result from
interactions. Some forces result from contact interactions; normal, friction, and tension forces are examples
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and magnetic forces). According to Newton, whenever objects A and B interact with each other, they exert
forces upon each other.
When a person stands on the floor, the body exerts a downward force on the floor (at minimum, the force of
body weight). In a reciprocal manner, the floor exerts an upward force on the person’s body. Two forces result
from this interaction: a force on the floor, and a force on the person’s body. These two forces are called action
and reaction forces. Newton’s Third Law of Motion formally describes the relationship between these two
forces: for every action, there is an equal and opposite reaction. To illustrate the concept of action–reaction
forces, imagine preparing to get o a rowboat on a lake. What happens when we step o the rowboat onto
the dock? As we move in the direction of the dock, the boat tends to move (accelerate) in the opposite
direction. Acceleration is produced when a force acts on a mass.
What happens when we take a step on the ground? Does the ground move in the opposite direction (like the
boat)? Physical analysis of this question involves Newton’s Second Law (F = ma), which describes the
relationship between force, mass, and acceleration. The greater the mass of an object being accelerated, the
greater the amount of force needed to accelerate that object. When we step o the rowboat onto the dock,
the rowboat moves because its mass is relatively small. When we step on the ground, however, the mass of
the earth is so large that the force exerted by the body against it can only minutely accelerate the earth. On
the other hand, the body’s mass is small so that the reaction force of the earth, termed the ground reaction
force, can easily accelerate the body. By Newton’s Third Law of Motion, the body’s pushing force on the earth
is the same as the earth’s push back force on the body. Schematically, equation 1 below reflects the reaction
force exerted by the earth on the person’s small body mass, resulting in a large acceleration. Equation 2
reflects the action force exerted by the person on the earth, resulting in a very small acceleration of the very
large mass of the earth.
(1) F = m × a
(2) F = m × a
In summary, a person’s body has mass and, when the body stands on the ground, the body mass exerts a
force on that ground. When the body exerts a pushing force on the ground, the ground exerts a push back
force of equal magnitude on the body. This push back force is called the ground reaction force (GRF). When
entities of di erent masses exert a force on each other, the entity with the smaller mass will have the larger
acceleration. The ground reaction force is one of the keys to human locomotion because the smaller mass of
the human body is easily accelerated by the ground reaction force during the gait cycle.
Joint Moments
The fundamental objectives of human locomotion are to move the body’s mass from one place to another
and provide antigravity stability so that a person doesn’t fall down. Locomotion mechanisms in the bipedal
human are built around two facts: each lower limb is configured with many movable joints and, during
walking, movements within and across each limb must be coordinated because both limbs are connected to
the superincumbent mass by a pelvis. Translating body mass by means of bipedal locomotion depends on a
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repetitive sequence of joint motions that simultaneously move the body’s center of mass along an intended
line of progression while counteracting the e ects of gravity on upright posture and joint motion.
Movable joints in the walking human generate changing joint rotations that require control by muscular, so
tissue, and body weight forces. To understand how joint motion is controlled, we introduce the concept of
joint moment, or force exerted by means of leverage. In general, a moment M is defined by a force exerted
through a lever arm r, namely, M = rF (where force F is applied at a distance r from the axis of rotation). Figure
11–1 illustrates a person standing in equilibrium with a flexed knee. If unopposed by the quadriceps, body
weight force (B) falling behind the knee would promote knee flexion collapse because of the rotary e ect of
joint moment Ba. The force generated by quadriceps contraction (Q) produces a counter joint moment, Qb.
When Ba equals Qb, the system is in equilibrium and no motion occurs, all joint moments being perfectly
counterbalanced. (Conversely, net unbalanced moments do result in joint motion, a finding characteristic of
normal locomotion.)
illustrates for a standing person, the location of the CoM is not a fixed point because it varies with body
segment configuration. Similarly, as the body propels forward during ambulation, the CoM moves vertically
and laterally; it does not behave as a fixed point. Viewed in the sagittal plane, the vertical displacement of the
CoM moves as a smooth sinusoidal curve (Figure 11–3). This curve’s amplitude in a normal individual is
approximately 5 cm (2 in.). The center of gravity also oscillates side to side during ambulation, generating
another sinusoidal curve whose amplitude is approximately 6 cm (2.5 in.) (Figure 11–4). The significance of
CoM motion for this discussion is that forces acting on the body during locomotion are conceptualized as
acting through its CoM. In an upright standing human, the CoM is located just anterior to the S2 segment of
the sacrum and, in general, during normal locomotion, it can be assumed to reside approximately there as
well.
Figure 11–2
Displacement of center of mass (CoM).

Figure 11–1
Forces generated when standing with a flexed knee.

Figure 11–3
Vertical displacement of CoM (Reproduced with permission from Inman VT, Eberhart HD. J Bone Joint Surg
Am 1953;35:543.)

Center of Mass

The center of mass (CoM) of any object is a point location where all of that object’s mass is imagined as
concentrated. If we think of all bodily segments connected by joints as separate “objects” having their own
CoM, we now assert that the CoM of the whole human body is that point in space where all joint moments
created by the configuration of jointed body segments (ie, limb, trunk, and head postures) are in equilibrium.
(Joint moments include all forces derived from muscle contraction, so tissue resistance, and
superincumbent body weight acting on the lever arms of their respective axes of rotation). As Figure 11–2
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Figure 11–4
Displacement of CoM with gait: horizontal displacement (a), vertical displacement (b), and a composite of
both horizontal and vertical displacement (c) (Reproduced with permission from from Inman VT, Ralston HJ,
Todd F: Human Walking. Williams & Wilkins, 1981).
Putting It All Together
When a person stands, his or her body weight is applied as a force against the support surface of the ground
and conceptualized as originating from the CoM. Newton’s Third Law states that when two bodies exert force
on each other, these forces (termed action and reaction forces) are equal in magnitude, but opposite in
direction. By this law, a reaction force is generated by the ground against the standing person’s body weight,
the so-called ground reaction force (GRF). The GRF can be depicted as a vector having magnitude and
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direction. As a person walks and weight is shi ed from one limb to the other, a series of GRFs are generated
as weight is loaded onto, fully borne by, and then unloaded from each limb respectively and repetitively.
GRFs can be measured in the laboratory using force plates situated in the lab’s flooring. Force plate output
(normal and tangential shear forces) can then be processed electronically to generate a visible line
superimposed over the video of a walking subject that represents the GRF vector in magnitude and direction.
The GRF provides clinical information on magnitude and direction of joint moments for the weight-bearing
limb as the vector passes anterior, posterior, lateral, or medial to the various joint centers of rotation. Many of
the photographs and illustrations in this chapter depict the GRF generated by a subject walking in a gait
laboratory.
PHASES & SUBPHASES OF GAIT
Human locomotion is characterized by a sequence of limb and trunk motions that have functional
significance for advancing the body’s CoM and providing upright stability. The organized, complex sequence
of joint motions inherent in walking has good repeatability and tight variability (ie, the standard deviation of
gait parameters is small). Furthermore, bipedal human locomotion is a cyclical behavior, especially involving
one or another lower limb maintaining contact with the ground at all times (Table 11–1).
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Table 11–1
Characteristics of gait.
Term Definition/Description
Gait cycle Behavior that begins with
an event involving one
extremity and continues
until the event is repeated
once again with the same
extremity.
Stride One complete gait cycle.
length
Step Activity that begins with
an event involving one
extremity and continues
until the event is repeated
with the contralateral
extremity.
Step length Longitudinal distance
between successive heel
contacts of opposite feet;
varies directly with height
and inversely with age.
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Term Definition/Description Example/Values
Example/Values
The distance measured from a point on one foot to the same
point on that same foot at the next stance.
The distance measured during double support, from the foot
Free Rate of ambulation chosen Normal adult = 80 m/min, 1.3 m/s, 4.3 /s, 3 mi/h; 90% of all
that has just completed single support to the foot that has just
velocity by a person when asked to individuals fall in the range 0.9–1.8 m/s (3.0–5.9 /s).
completed swing. Le step length is measured when the le
walk comfortably; varies
foot has just completed swing; likewise, right step length is
directly with height and
measured when the right foot has just completed swing.
inversely with age.
Cadence The number of steps per Normal adult = 90–120 steps/min. (See earlier figure.)
unit time (1 min).
Base of Mean lateral distance 90% of individuals fall in the range of 2.5–12.7 cm (1–5 in.).
support* between the heels.
Substitution Motion used in an attempt Circumduction is a mechanism used to achieve clearance
mechanism to remedy the loss of one when knee flexion or dorsiflexion is inadequate.
or another component of
the normal gait pattern.
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sudden knee flexion collapse resulting from the abrupt impact of heel contact with the floor, especially at
Term Definition/Description Example/Values
higher gait velocities.
Open Movement of a limb when The lower limb during the swing phase of gait.
Hip: The hip at initial contact is flexed 30 degrees. With the GRF falling anterior to the hip and creating a
kinetic the distal end is free to
flexion moment, previous muscle activity of the hamstrings that has helped to decelerate the swinging limb
chain move in space.
now helps to control the hip’s flexion moment at initial contact, taking note that gluteus maximus and
adductor magnus contraction are only just beginning to activate.
Closed Movement of a limb when The lower limb during the stance phase of gait.
kinetic the distal end is fixed. Figure 11–5

chain Initial contact.

Line of Hypothetical line

progression corresponding with the
direction of walking.

Frontal view As seen from the front or

back.

Sagittal As seen from the side.

view

The cyclical nature of gait, with its repetitive sequencing of joint motions, has led to eight descriptive
functional units or subdivisions of the gait cycle, including two major phases, seven subphases, and one
event. (Some authors do away with the term subphase entirely and refer to seven phases and one event).
The two major phases, swing and stance, incorporate the seven subphases and one event, as discussed
below.

Initial Contact

Definition: The instant the foot contacts the ground (Figure 11–5).

Commentary: For normal locomotion with a continuum of gait velocities ranging between 0.9 and 1.8 meters
per second (m/s), initial contact is characterized by a heel strike. At initial contact, the GRF generates three
joint moments: ankle plantar flexion, knee extension, and hip flexion.
Ankle: At initial contact, the ankle joint is about neutral, held there by contraction of dorsiflexor muscles of
the foot. The GRF falls posterior to the ankle joint axis, resulting in a plantar-flexion moment that leads to
subsequent plantar flexion of the ankle.
Knee: At initial contact, the knee is fully or almost fully extended, the quadriceps muscle is active and acts to
absorb the shock of heel strike, and the GRF falling anterior to the knee also contributes to preventing
Loading Response
Definition: Shi ing body weight onto the stance limb immediately following initial contact (Figure 11–6,
right) to li of the opposite extremity (Figure 11–6, le ).
Commentary: Loading response reflects the shi of body weight from the contralateral support limb to the
new support limb. During the loading response subphase, a period of double support exists because both
limbs are actually in contact with the ground until the contralateral limb is li ed o .

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Ankle: The loading response subphase begins immediately a er initial contact and, at the ankle, is marked
by gradual plantar flexion of 15 degrees, controlled by activity of the pretibial muscles (tibialis anterior, great
and long toe extensors, and peroneus tertius). Heel strike may be heard but, normally, controlled plantar
flexion prevents foot slap. The GRF falls posterior to the ankle joint (see Figure 11–6).
Knee: During the loading response, a flexion joint moment occurs at the knee, the GRF falling posterior to the
knee joint. Eccentric contraction of the quadriceps group controls the rate at which the knee flexes.
Contraction of the hamstrings quiets down as their role in decelerating the swinging limb comes to an end. At
end of the loading response, the knee is flexed approximately 15 degrees.
Hip: Hip flexion of 30 degrees remains fairly constant throughout loading response. The GRF, initially anterior
to the hip at initial contact, moves closer to the hip’s axis of rotation during the loading response. This
reduces the e ect of the hip flexion moment that is present at the instant of initial contact. Restraint of the
hip flexion moment is provided by the gluteus maximus and adductor magnus. The activity of both of these
muscles increases a er initial contact while activity of the hamstrings deactivates.
Figure 11–6
Loading response.
Midstance
Definition: Li of the contralateral extremity (Figure 11–7, right) to a position in which the body is directly
over the stationary foot (Figure 11–7, le ).
Commentary: In normal locomotion, li of the contralateral extremity occurs concurrently with toe-o ,
especially the great toe. When the contralateral toes come o the ground, the period of ipsilateral single limb
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support of body mass begins. During midstance, the foot maintains contact with the ground throughout the
entire subphase.
Ankle: At the onset of midstance, the ankle remains slightly plantar flexed (about 5 degrees). As the period of
midstance develops, ankle movement to about 5 degrees of dorsiflexion materializes. The GRF moves over
the forefoot as the tibia progresses forward (see Figure 11–7). With the GRF now anterior to the ankle, a
dorsiflexion moment takes e ect, reflecting forward acceleration of the tibia. This moment is controlled by
activity of the soleus. However, gastrocnemius activity also contributes to attenuating the dorsiflexion
moment that controls the rate of advancement of the tibia.
Knee: Maximum stance phase knee flexion is present at the beginning of midstance. During this subphase the
knee undergoes extension by virtue of active quadriceps contraction. By the middle of midstance, the GRF
moves just anterior to the knee joint’s axis of rotation, resulting in an extensor joint moment. Therefore, at
the end of midstance, there is no longer any need for quadriceps activity as extension stability is provided
passively by bony segment alignment and posterior so tissue structures.
Hip: During midstance, the hip progressively extends as the tibia and femur advance forward. In the early
part of the subphase, the hamstrings (semitendinosus and semimembranosus) contribute to extension, but,
by late midstance, no further muscular e ort is required. During the single support of midstance, the weight
of the contralateral swing limb causes the pelvis on that side to drop about 4 degrees. The hip abductors,
chiefly gluteus medius, are responsible for preventing excessive pelvic tilt.
Figure 11–7
Midstance.
Terminal Stance
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Definition: Subphase immediately following the position in which the body is directly over the stationary foot
(Figure 11–8, right) to a point just prior to initial contact of the contralateral limb (Figure 11–8, le ).

Commentary: The main force of propulsion advancing the body forward occurs during terminal stance. As
the tibia continues to rotate forward in early terminal stance, buildup of calf muscle tension soon raises the
heel o the ground. The GRF moves well into the forefoot and the CoM follows its sinusoidal path,
descending from its high point at the end of midstance.

Ankle: In early terminal stance, the ankle continues to dorsiflex approximately 10 degrees, allowing the tibia
to rotate forward. Calf muscle contraction subsequently intensifies and the heel rises. Dorsiflexion motion
gives way to plantar flexion such that by the end of terminal stance (ie, the end of single support), the ankle
reaches about 5 degrees of plantar flexion. The GRF has moved well anterior to the ankle joint along the
forefoot (resulting in a long lever arm) so that strong contraction of both the soleus and gastrocnemius
muscles is able to accomplish heel rise and control the dorsiflexion moment generated by the GRF. Heel rise
also initiates dorsiflexion at the metatarsophalangeal joints. When body weight is transferred to the
contralateral limb, calf muscle contraction deactivates quickly.

Knee: During terminal stance, the knee is in full extension and remains so for the duration of this subphase.
No quadriceps activity is needed to control the knee because the GRF vector is anterior to the knee joint. Pre-Swing
Knee stability is maintained and hyperextension is prevented by the posterior ligamentous and capsular
Definition: Interval from initial contact of the contralateral limb (Figure 11–9, right) to a point just prior to li
structures.
(Figure 11–9, le ) of the ipsilateral limb from the ground.
Hip: As the CoM advances beyond the supporting foot and the GRF passes posterior to the hip, passive
Commentary: Pre-swing is technically a stance phase entity but it is given a swing appellation because hip
extension of the hip occurs and hip extensor contraction is not required throughout terminal stance. By the
flexor contraction coupled with unloading of the limb is an important source of acceleration of the CoM along
end of terminal stance, the hip has moved into about 10 degrees of hyperextension, a position exerting
its sinusoidal trajectory.
stretch on the iliacus that commonly initiates hip flexor contraction. The forward propulsion e ect of calf
muscle contraction in terminal stance followed by hip flexor contraction in pre-swing combine to advance Ankle: During pre-swing, the ankle plantar flexes to about 20 degrees of plantar flexion. This is a momentum-
the body along the line of progression, with the CoM falling forward and downward, driven by momentum. driven behavior since the plantar flexor muscles have already ceased contraction at this point, their role in
Figure 11–8
active propulsion being complete.
Terminal stance.
Knee: During pre-swing, the knee flexes about 35 degrees, driven passively by actively contracting hip flexors;
no knee flexor muscles are active during this subphase. From another perspective, a flexion torque is created
by the GRF falling behind the knee, as the tibia advances forward.

Hip: Dynamic flexion of the hip is generated during this subphase, primarily by contraction of the iliacus as
well as the rectus femoris.

Figure 11–9
Pre-swing.

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Initial Swing
Midswing
Definition: Interval from li of the foot o the ground (Figure 11–10, right) to maximum knee flexion (Figure
Definition: Subphase immediately following maximum knee flexion (Figure 11–11, right) to a vertical tibia
11–10, le ).
position (Figure 11–11, le ).
Commentary: As the hip continues to flex, bringing the thigh segment upward and forward, the knee also
Commentary: As the swing limb advances and the tibia moves toward a vertical position, clearance of the
flexes, keeping the toes of the plantar-flexed foot away from the floor.
foot from the floor is facilitated by active ankle dorsiflexion.
Ankle: Active dorsiflexion of the ankle takes place in this subphase but only 10 degrees of plantar flexion is
Ankle: Dorsiflexion of the ankle to neutral is completed and sustained by the anterior compartment muscles.
achieved. Therefore, toe clearance in early swing does not depend on ankle dorsiflexion. Muscles that act to
Development of a vertical tibia continues the need for active foot control by the tibialis anterior, peroneus
dorsiflex the foot include the tibialis anterior, extensor digitorum, hallucis longus, and peroneus tertius. The
tertius, and extensor digitorum longus.
antagonist calf muscles are silent.
Knee: The knee undergoes passive extension in preparation for initial contact. This movement is driven by
Knee: Momentum generated by contracting hip flexors generates knee flexion torque, bringing the knee to an
momentum and facilitates advancement of the swing limb. When the tibia is vertically oriented at the end of
angle of about 60 degrees by the end of initial swing. The knee flexion moment may have contributions from
midswing, the knee angle is in approximately 30 degrees of flexion.
the biceps femoris, sartorius, and gracilis, especially at higher gait velocities.
Hip: The hip reaches 30 degrees of flexion, its maximum value, during midswing by contraction of the iliacus
Hip: At the end of pre-swing, the hip has achieved the neutral position. During the initial swing subphase, the
muscle.
hip moves to 20 degrees of flexion. The iliacus is the prime hip flexor at this point; however, activity of the
sartorius, gracilis, and adductor longus may also contribute. Figure 11–11
Midswing.
Figure 11–10
Initial swing.

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The subphases thus far described are defined with respect to the sagittal plane. In the frontal plane, key
observations are made regarding stability in single limb support, primarily during midstance (Figure 11–13).

Figure 11–12
Terminal swing.

Terminal Swing

Definition: Subphase immediately following a vertical tibia position (Figure 11–12, right) to a point just prior
to ground contact (Figure 11–12, le ). Figure 11–13
Midstance in frontal plane.
Commentary: The foot is the leading edge of limb advancement. As advancement of the swing limb ends, the
limb is positioned for the upcoming stance phase by deceleration of hip flexion, knee extension, and
continued dorsiflexion of the ankle.

Ankle: The ankle basically holds in neutral through action of the pretibial muscles.

Knee: The tibia moves from a vertical position with respect to the ground to an oblique position at the end of
terminal stance (see Figure 11–12), placing the knee in roughly full extension. At this point the hamstrings are
active to decelerate the rate of knee extension and prevent hyperextension, particularly at higher velocities.
The quadriceps group also becomes active to stabilize the joint during the impact of initial contact and in
anticipation of the flexor moment that will be encountered in the loading response.

Hip: The hip maintains 30 degrees of flexion throughout terminal swing. Momentum moves the limb forward
while active contraction of the hamstrings restrains further hip flexion, decelerating forward momentum (as
it does for knee extension). In e ect, restraint by hamstring muscles, such as the semimembranosus,
semitendinosus, and biceps femoris, functions to control the acceleration and position the swinging limb in
preparation for initial contact.

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OPERATIONAL FEATURES OF GAIT

In a gravitational environment, translation of the human center of gravity by means of a bipedal strategy
requires management of certain operational objectives or features. These operational features include (1)
advancing the CoM continuously along the direction of progression from a swing phase perspective and a
stance phase perspective; (2) stability of loading of the stance limb during double support and the
subsequent single limb support; and (3) foot clearance (of the floor) during swing phase. The individual
subphases described previously are combined in specific ways to achieve these operational features of
human locomotion on level ground. The operational features discussed here— swing phase advancement,
stance phase advancement, weight-bearing support, and foot–floor clearance—promote several “functional”

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products of locomotion, such as step and stride length, base width, cadence, velocity, and rhythmicity,
mentioned later in the chapter.
Swing Phase Advancement
Swing phase advancement refers to the forward propulsion of the CoM, accompanied by a swinging limb
(Figure 11–14). Dynamic flexion of the hip is powered by the iliacus during the subphase of pre-swing, o en
accompanied by rectus femoris activity. Active hip flexion is a strong contributor to forward acceleration of
the CoM and thigh advancement. Smooth advance of the swing phase limb begins at initiation of pre-swing
(Figure 11–14, right) when the contralateral limb makes initial contact, beginning the loading process for the
“contra-” limb simultaneously with the unloading process for the “ipsi-” limb. Hip flexor contraction during
pre-swing begins a process of thigh advancement by means of a hip flexion moment, eventually adding leg
advancement during mid- and terminal swing. The thigh segment advances forward in pre-swing, even as
the anterior portion of the foot retains waning contact with the ground. As a consequence of thigh
advancement in pre-swing, during which some contact between foot and ground still remains, the knee
begins to flex. Momentum generated by the hip flexors continues to generate a knee flexion moment through
the next subphase of initial swing. The knee flexion moment may be supplemented by contraction of the
biceps femoris, sartorius, and gracilis. Knee motion reverses in the next subphase of midswing when the
knee begins to extend, continuing its extension through the subphase of terminal swing. If one observes the
trajectory of the foot from pre-swing through terminal swing and initial contact, one can appreciate swing
phase advancement in the form of a stride.
Figure 11–14
Swing phase advancement.
Stance Phase Advancement
Forward progression of the body from a stance phase perspective begins during early loading response as
the pretibial muscles activate in order to control plantar flexion of the foot (Figure 11–15). A er initial
contact, the foot plantar flexes onto the ground in a controlled manner. When the foot is planted on the floor,
the pretibial muscles are able to act in a closed kinetic chain to pull the tibia forward. Similarly, contraction
of the quadriceps group further up the chain brings the femur forward in tow, advancing the thigh segment
with the leg. The segments of leg and thigh, working synchronously, continue to rotate forward. With the foot
on the ground, the ankle continues dorsiflexing until the CoM passes anterior to the ankle joint, at which
time the calf muscles engage to control the rate of leg advancement until they cause heel rise in terminal
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stance. Heel rise itself is associated with forward propulsion of the body, namely, calf muscle pusho against
the ground. Heel rise also accelerates the forward fall of the body, the tibia and femur being angled forward
in this part of the gait cycle. At the point of heel rise, the CoM is ahead of the metatarsal heads (in the sagittal
plane), thus the body’s mass is moving “downhill” from its previous high point at the end of midstance.
Figure 11–15
Stance phase advancement.
Note that in the preceding description, the heel, ankle, and metatarsophalangeal joints provide fulcrum
points, transitioning the mass along the line of progression to their respective contact points with the
ground. Specifically, they facilitate advancement of the superincumbent mass of the body over the stance
phase support limb. E ective execution of these mechanisms assumes that the ankle has the required range
of motion for plantar and dorsiflexion. If range of motion in either direction is limited, the position of the GRF
relative to proximal joints will be altered. Advancement will then elicit compensatory mechanisms, resulting
in deviation from the “normal” gait described here. Likewise, the knee and hip must be able to move through
their respective ranges of motion to allow fluid progression. Finally, the configuration of the foot and ankle,
especially that part of the foot making initial contact, will have implications for the configuration of more
proximal joints, again owing to the position of the GRF.
Weight-bearing Support
Two units comprise weight-bearing support: the first is the period when weight is shi ed onto the postswing
limb entering the stance phase, a period of double support, as both limbs are in contact with the floor (Figure
11–16). The second is when only one limb, the stance limb, is solely in contact with the ground, and weight
bearing with full single support passes through this limb (Figure 11–17). Weight shi s onto the limb entering
stance phase during the loading response.
Figure 11–16
Weight-bearing support.
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Figure 11–17
Weight shi ing onto the limb entering stance phase.
A. Period of Double Support
This period comprises one event (initial contact) and the subphase of loading response. The hip is flexed 30
degrees at initial contact. The GRF falls in front of the hip joint, creating a strong flexion moment. Both the
gluteus maximus and the hamstrings are activated in order to control this flexion moment during the loading
response. Similarly, the torso is under the same forward momentum during terminal swing, and the abrupt
stop at initial contact calls upon the erector spinae group to prevent flexion just above the hip at the
intervertebral joints.
For the knee at initial contact, the GRF falls anterior to the joint axis, creating a knee extension moment.
Continuing on from the previous terminal swing, activity of the quadriceps and hamstring help stabilize the
neutral position of the knee joint. Shortly a er initial contact, the GRF moves behind the knee and the knee
flexes approximately 15 degrees. The quadriceps fire eccentrically, helping to absorb energy of the somewhat
jarring impact of initial contact on the heel (Figure 11–16, right).
As the limb enters stance phase, ankle–foot position is critical for receiving weight of the superincumbent
mass (Figure 11–16, middle and le images). At initial contact, the ankle is in neutral. In the sagittal plane,
the GRF is posterior to the ankle joint, creating a plantar-flexion moment. The pretibial muscles (tibialis
anterior, extensor digitorum longus, and extensor hallucis longus) control this plantar-flexion moment by
means of a lengthening contraction during the loading response, when the foot plantar flexes 15 degrees.
When the foot becomes fixed on the ground, the relationship between the body and the stance limb is akin to
an inverted pendulum. The stance limb represented by this pendulum will rotate forward, controlled by an
interplay of dorsiflexor and plantar-flexor muscles, starting at double support and ending during single limb
support.
B. Period of Single Support
The period of single limb support begins with contralateral toe-o during the subphase of midstance.
Throughout midstance, the hip extends as the tibia and femur advance forward in order to maintain an
upright posture of the spine and torso (Figure 11–17, middle three images from right). At this point these
actions occur devoid of any need for muscle contraction.
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At the beginning of midstance, the knee is at its point of maximum flexion during the stance phase (about 15
degrees). Because the GRF falls behind the knee, quadriceps action is necessary to prevent collapse and
provide stability. By the second half of midstance, knee extension stability is provided passively by the
posterior ligamentous structures as the GRF is now anterior to the knee joint center.
At the beginning of midstance, the ankle remains slightly plantar flexed and as the subphase develops, the
ankle gradually dorsiflexes. As the tibia rotates forward, the GRF moves along the forefoot (Figure 11–17,
middle three images from right). When the GRF is positioned anterior to the ankle joint, a dorsiflexion
moment is generated that would lead to instability were it not for the eccentric contraction of the soleus and
gastrocnemius. As the soleus slows the forward progression of the tibia, preventing a “fall” into dorsiflexion,
it does so in a closed kinetic chain that simultaneously holds back knee flexion, facilitating knee extension as
the femur maintains its forward velocity and ultimately passes over ankle. In midstance, when viewed from a
frontal plain, there is an additional element of stability that can be appreciated during single limb support.
Because of the closed kinetic chain, the pelvis is apt to rotate on the head of the femur. At this time, the CoM
is medial to the axis of rotation of the weight-bearing hip. The medial CoM produces an adduction moment of
the joint, allowing the pelvis to rotate around a sagittal axis through the hip joint. Pelvic tilt or pelvic drop to
the side of the swing limb requires muscular control. The stabilizing forces here are the hip abductors,
particularly the gluteus medius. By providing an eccentric contraction, the tilt of the pelvis is controlled
(about 4 degrees) and the pelvis remains in a more or less horizontal position.
Clearance
Advancement of the swing phase limb requires clearance of the foot from the floor, especially the toes.
Starting with the end of terminal stance and continuing on through the end of pre-swing (Figure 11–18, three
images on right), the toes come o the floor as a result of proximal hip and knee flexion. At the end of pre-
swing (Figure 11–18, middle image), the knee is flexed about 30 degrees. The knee continues to flex during
initial swing to a maximum of about 60 degrees (Figure 11–18, le image). The hip flexes to 30 degrees.
Proximal hip and knee flexions are the main clearance mechanism during early swing. By the end of initial
swing, the ankle is still in plantar flexion, giving evidence that hip and knee flexion rather than ankle
dorsiflexion are prime factors generating clearance of the swinging foot from the ground during early swing.
As the thigh and leg continue to advance forward (Figure 11–19), the ankle continues to dorsiflex, reaching
neutral by the end of midswing (Figure 11–19, le image) and remains so until just a er initial contact.
Figure 11–18
Clearance resulting from hip and knee flexion.
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Figure 11–19
of the trunk is present. Ankle plantar flexion does not develop in terminal stance and there is no pusho to
As the swing limb advances dorsiflexion becomes instrumental in clearance.
power translation of the center of gravity. The functional consequences of these gait deviations are a
shortened contralateral step length and a slow gait velocity. Restrained motion at the ankle, knee
hyperextension, an anterior trunk lean, and a flexed hip, collectively and individually, typically result in a
slow gait velocity and a shortened contralateral step length (see Figure 11–21).

Figure 11–20
Normal stance advancement.

PATHOLOGIC GAIT
Functional Performance & Common Gait Deviations

Normal locomotion generates several functional “products.” These include the production and ability to Figure 11–21
manage (1) a range of step and stride lengths; (2) a range of base widths; (3) a range of surface contours and Impaired stance advancement.
topographies, including ramp and stair climbing; (4) a range of velocities and cadences; (5) a range of energy-
consuming gaits; and (6) changing direction and making turns. A range of normal performance parameters is
presented in Table 11–1, cited earlier.

As previously described, there are four major operational features of gait that result in the production of
functional gait “products.” These include stance phase advancement, swing phase advancement, weight-
bearing stability with support against the e ect of gravity on jointed body segments, and foot–floor
clearance. Neurological, musculoskeletal, cardiopulmonary, and psychological impairments generate gait
deviations that a ect the operational features of gait, resulting in performance deficits such as shortened
step and stride lengths and a narrowed range of available gait velocities. The next section describes various
common gait deviations, detailing how they relate to the operational features of gait and, as a result, how
functional performance is a ected. Swing Limb Advancement & Gait Deviations

Stance Limb Advancement & Gait Deviations
Mechanisms that contribute to stance limb advancement include active ankle dorsiflexion during early
stance, active extension of the knee in midstance, passive hip extension throughout stance, ankle plantar
flexion in terminal stance, and knee flexion control in late stance in conjunction with ankle plantar flexion.
Figure 11–20 illustrates the normal sequence of stance phase advancement for a right lower extremity. In
contrast, Figure 11–21 reveals a patient who has di iculty with stance limb advancement. Ankle dorsiflexion
does not develop a er full contact of the foot with the floor during loading response and onward through
early terminal stance. Knee hyperextension develops by the end of loading response and persists through
most of the subsequent stance phase. Passive hip extension is absent throughout stance and an anterior lean
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Mechanisms that contribute to swing limb advancement include active hip flexion during early swing,
contralateral arm swing during early and midswing, passive knee extension (mid- and terminal swing), pelvic
rotation about a vertical axis (the pelvis rotating 4 degrees forward and 4 degrees backward during normal
gait), and forward falling of the trunk a er midstance. Figure 11–22 illustrates the normal sequence of swing
phase advancement for a right lower extremity. In contrast, Figure 11–23 reveals a patient who has di iculty
with swing limb advancement. Active hip flexion during early swing is an important mechanism underlying
swing limb advancement. The sequence in Figure 11–23 reveals a patient whose hip is fused in neutral,
preventing active hip flexion. As a consequence, he generates a posterior trunk lean in order to advance the
right lower limb and achieve a right step. The compensatory gait deviations that actually enable the
posterior lean to materialize include excessive dorsiflexion of the le ankle and excessive flexion of the le
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knee in terminal stance (see Figure 11–23, last two images on right). The combined deviations of posterior
trunk lean, excessive le ankle dorsiflexion, and knee flexion in terminal stance enable the patient to
compensate for absent hip flexion on the right, resulting in the production of a reasonable right step length.
Walking for this patient is arduous, and he walks slowly.

Figure 11–22
Normal swing advancement.

Figure 11–23
Impaired swing advancement.

Clearance & Gait Deviations

An important mechanism of swing phase advancement is passive knee extension during mid- and terminal
swing, normally generated by momentum consequent to contralateral pusho and ipsilateral active hip
Mechanisms that contribute to clearance of the floor by the foot include hip and knee flexion during pre-
swing and initial swing, ankle dorsiflexion in mid- and terminal swing, and tilt of the pelvis to the side of the
swing limb controlled by the contralateral hip abductors during single limb support. Figures 11–25, 11–26,
and 11–27 illustrate the normal sequence for clearance of the swing phase limb.
Figure 11–25

flexion. Figure 11–24 reveals a patient who is just making initial contact with the le lower extremity. A At the end of pre-swing, the knee flexes about 30 degrees.
vertical le tibia is indicative of absent knee extension in terminal swing, the latter subphase of gait having
dropped out completely for this patient. This patient has an upper motor neuron syndrome and involuntarily
active hamstrings restrain knee extension during the operational feature of swing phase advancement,
resulting in a shortened le step.

Figure 11–24
Shortened step length owing to loss of knee extension.

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pelvic tilt (also termed positive Trendelenburg) results in a greater drop of the swing limb toward the floor,
impaired clearance being a potential consequence if the patient is unable to compensate (Figure 11–28).

Figure 11–28
Trendelenburg gait. Solid line indicates normal 5-degree pelvic tilt (about a sagittal axis through the pelvis);
horizontal arrow points to shaded hip abductors (gluteus medius); solid line from pelvis to medial foot
represents the GFR (ground reaction force); dotted line, excessive pelvic tilt; vertical arrow, excessive drop of
whole limb toward the floor.

Figure 11–26
At the end of initial swing, the knee flexes as much as 60 degrees. The hip is flexed 30 degrees.

Figure 11–27
By the end of midswing, the ankle has dorsiflexed to neutral (0 degrees).

Figure 11–29 depicts a patient using circumduction to clear the foot from the floor during swing phase on the
le . The patient has a “sti ” (extended) knee in swing phase, and knee flexion during pre-swing through
midswing is particularly deficient, resulting in a functionally increased leg length and potentially impairing
foot–floor clearance. The patient uses the compensatory motor behavior of circumduction, a gait deviation
best viewed behind the patient (see sequential heel positions of le swing). Note how the trajectory of the
heel takes a circuitous anterolateral to anteromedial route.

Figure 11–29
A patient using circumduction to clear the foot from the floor during swing phase on the le .
In the frontal plane, the pelvis normally tilts about 5 degrees to the side of the swing limb, resulting in a drop
of the whole limb toward the floor. Too much pelvic tilt owing to weakness of the contralateral hip abductors
of the stance limb can result in a foot drag (impaired clearance) of the swing limb. The deviation of excessive

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Weight-bearing Stability
Transfer of body weight normally begins during the loading response. Patients with equinovarus deformity of
the ankle–foot system make initial contact with the lateral border of the foot (Figure 11–30; compare A and
B). Such contact puts pressure on the lateral border of the foot and, especially, on the head of the fi h
metatarsal bone. Weight bearing in this type of unstable configuration, especially if painful, is poorly
tolerated, and patients attempt to shorten the time they spend in stance phase on such a limb. The
contralateral step becomes shortened as the patient hurriedly shortens stance time on the equinovarus limb.
Overall gait performance is slowed and dysrhythmic.
Figure 11–30
A: Equinovarus in terminal swing. B: Comparison of terminal swing in the same patient.
Single support begins with contralateral toe-o (Figure 11–31, far le ) and terminates with contralateral
initial contact (Figure 11–31, far right). Antigravity support of body weight is most critical during the period of
single support. Figure 11–31 illustrates the sequence of lower limb configurations during the period of single
support. The amplitude of the GRF for the right lower limb in the photo is approximately constant and
represents full body weight. Knee extension beyond midstance is observed, and hip extension is noted to
occur throughout the period of single limb support.
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Figure 11–31
The sequence of lower limb configurations during the period of single support.
Figure 11–32 reveals a patient who has a problem with single limb support. The patient is observed holding
onto the parallel bars during single limb support for the le lower extremity. The middle image in Figure 11–
32 reveals that the patient has a flexed hip and a flexed knee in what should be the subphase of terminal
stance. These deviations are in striking contrast to the extended hip and knee seen in the rightward
comparison figure of normal terminal stance. The magnitude of the patient’s GRF is small, suggesting that a
large proportion of body weight is being absorbed by the upper limbs grasping the parallel bars. Excessive
dorsiflexion of the patient’s le ankle may be contrasted with plantar-flexion pusho and heel-o of normal
terminal stance seen in the rightmost figure. Because the patient has absent pusho , a flexed knee, and a
flexed hip, the right step length is shortened. A flexed right knee in terminal swing also contributes to the
shortened right step length.
Figure 11–32
A patient who has a problem with single limb support.
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CLINICAL CASE STUDY

The following case example of a patient with spastic hemiparesis, who has problems with two operational
features of gait, illustrates how identifying impairments in the operational features of a patient’s gait cycle
helps a clinician understand a patient’s clinical complaints and maladaptive performance. Describing
impairments related to advancing the CoM, foot–floor clearance, and upright stability provides important
information for conceptualizing treatment of gait dysfunction, especially regarding the use of lower
extremity orthotics and assistive devices.

Description

A 55–year–old woman sustained a right hemiparesis as the result of a stroke involving the le internal
capsule. When she was seen 6 months a er the stroke, she complained of tripping on the edge of a living
room rug and, occasionally, on the lip of a threshold entrance into her bathroom. Clinical examination of her
right side revealed full passive range of motion of hip and knee while ankle dorsiflexion was to +10 degrees
(mildly reduced range of motion). Pinprick of the foot and proprioception of the great toe and ankle were
intact. Hypertonia was present for the ankle plantar flexors (Ashworth 2), knee flexors (Ashworth 3), knee
extensors (Ashworth 3), and hip flexors (Ashworth 2). She did not have selective control of lower limb joints
individually, and she moved the lower limb forward as a whole unit during swing phase. She was able to bear
weight on the limb during stance while using a cane contralaterally. Her gait pattern during early swing is
shown in Figure 11–33.

Figure 11–33
Failure of clearance in early midswing secondary to lack of knee flexion.

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Figure 11–33 depicts the end of the pre-swing phase, when the toe is about to come o the floor. The three
middle images reveal a drag of the anterior portion of the shoe along the floor, with clearance coming only in
the far right image. (The duration of the drag is approximately 100 ms or 0.1 s.) The images also reveal the
cause of the drag: inadequate hip and knee flexion. At the end of pre-swing (far le image), the knee is flexed
about 30 degrees, as expected, but the hip is inadequately flexed due to proximal hip retraction. As the
patient’s gait proceeds, the subphase of initial swing drops out entirely as the knee does not flex more than
30 degrees, even though up to 60 degrees of knee flexion is normally expected by the end of initial swing. The
ankle is plantar flexed, but during the pre-swing through initial swing part of the gait cycle, the ankle is not
expected to be fully dorsiflexed to neutral. Hence, the drag of the foot on the floor (ie, the lack of foot floor
clearance) is a result of proximal hip and knee flexion inadequacy and not of inadequate dorsiflexion, or
“drop foot.” Treatment will have to take these observations into account. (Consider: Given a patient with
inadequate hip or knee flexion, or both, in early swing phase, would an ankle–foot orthosis set in neutral
alleviate an early swing phase toe drag?) This initial examination of the case focuses on an impairment of
clearance, corresponding to the patient’s complaint of toe drag and tripping on low-level elevations (rug
edges, raised room thresholds) that ordinarily would be cleared by an advancing swing phase limb.

A second problem area unmasked by observational gait analysis relates to the operational feature of stance
phase advancement. The patient’s gait pattern during the operational feature of stance advancement is
shown in Figure 11–34.

Figure 11–34
Shortened step length on the le side because of lack of dorsiflexion on the right side.

Discussion

Recall that advancement of the swing phase limb requires clearance of the foot from the floor, especially
clearance of the toes. During the early part of swing phase, the toes come o the floor as a result of proximal
hip and knee flexion, the distal ankle remaining in the range of plantar flexion during pre-swing, even as
ankle dorsiflexor muscles begin to contract. Active continuation of hip flexor contraction and passive knee
flexion during initial and midswing li the toe to clear the floor and advance the limb. The le most image in
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At initial contact (Figure 11–34, far le ), the whole sole connects with the ground as a unit and the ankle
configures in plantar flexion. At the end of the loading response (second image from le ), with the
contralateral toe about to come o the floor, the right ankle remains in a high degree of plantar flexion,
di erent from the slight degree of about 5 degrees of plantar flexion that characterizes normal locomotion.
Figure 11–34C (end of midstance) and Figure 11–34D (end of terminal stance) reveal the persistent plantar
flexion attitude of the ankle. The tibia remains oriented posteriorly rather than anteriorly, the heel remains
on the ground, and, as a consequence, the le step is very short (Figure 11–34, far right). In this hemiparetic

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patient, the tibia is restrained by a tight heel cord that does not allow the tibia to advance forward. In Access Provided by: Universidad de la Sabana
addition, weakness of calf muscles prevents heel rise in terminal stance. The absence of calf muscle pusho Silverchair
eliminates one of the main propulsive drivers of the limb in the subsequent swing phase. Restraint of the
tibia during stance phase combined with absent pusho results in a retarded advancement of the CoM over
the stance phase limb. The functional result is a shortened contralateral step, a slowed gait velocity, and
temporal asymmetries of step time, stance time, and swing time that create an awkward, dysrhythmic gait,
requiring more time for the patient to get where she is going and frequently making for feelings of self-
consciousness.

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