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Gait Analysis: Principles and Applications

JAMES R. GAGE, PETER A. DELUCA and THOMAS S. RENSHAW
J Bone Joint Surg Am. 1995;77:1607-1623.

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 Gait Analysis: Principles and Applications
EMPHASIS
BY JAMES R. GAGE, M.D4, ST. PAUL MINNESOTA. PETER A. DELUCA. MDI. NEWINGTON.
AND THOMAS 5. RENSHAw,
An Instructional Course Lecture, The American
Gait analysis is the systematic measurement, de
scription, and assessment of quantities that characterize
human locomotion; more simply put, it is the evaluation
of a subject's walking pattern. A standard physical ex
amination cannot provide a complete description of the
complex pathology of abnormal human gait. Gait anal
ysis can. In the treatment of neuromuscular disorders
such as cerebral palsy, such precise assessment enables
the surgeon to assess all of the pathological components
of gait and to carry out all of the operations required
for their correction during the same anesthesia session.
This saves money, avoids unnecessary pain and incon
venience, and eliminates the need for more than one
postoperative period of rehabilitation7.
The Gait Cycle
The walking pattern is studied as a gait cycle (Figs.
1 and 2), which is defined as the movement of a sin
gle limb from heel-strike to heel-strike again4. The gait
cycle begins with stance phase, which is 60 per cent
of the cycle, at initial contact of the heel. Next comes
loading response, with plantar flexion occurring at the
ankle to get the entire foot on the ground, followed
by mid-stance, in which the weight of the body passes
forward over the stable foot as the ankle dorsiflexes.
Terminal stance then occurs, with the heel leaving the
ground and the foot plantar flexed in pre-swing, leading
to toe-off. Next comes the swing phase of gait, which is
40 per cent of the cycle, with initial swing, in
des control cadence and foot clearance; then mid-swing;
*prjnted with permission of The American Academy of Ortho
paedic Surgeons. This article will appear in Instructional
Lectures, Volume 45, The American Academy of Orthopaedic Sur
geons. Rosemont, Illinois, March 1996.
tNo benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article.
IGillette Children's Hospital. 200 East University Avenue, St.
Paul, Minnesota 55101.
§Newington Children's Hospital. Newington, Connecticut 06111.
lYale University School of Medicine. P.O. Box 208071, New
Haven, Connecticut 06520.
VOL. 77-A, NO. 10, OCTOBER 1995
ON ITS USE IN CEREBRAL PALSY*t
MDI. NEW HAVEN. CONNECFICUT
Academy ofOrthopaedic Surgeons
and finally terminal swing, with the foot prepared for
contact with the ground before the cycle begins again
with heel-strike. Heel-strike and toe-off are the instan
taneous events in the gait cycle. There are two periods
of double support, each of which is 10 per cent of the
cycle, when both feet are in contact with the ground;
these are the initiation (loading response) and termina
tion (pre-swing) of stance phase.
Familiarity with the following additional terminol
ogy is necessary for an understanding of the basics of
gait analysis. Direction of progression is the direction in
which the patient proceeds along the walkway during
the collection of gait data. Step length indicates the dis
tance from a specific stance-phase event of one foot
to the same event of the other foot. It is named after
the lead foot. For example, the right step-length is the
distance from left heel-strike to right heel-strike, or
the distance covered by the right lower limb in taking
one step. In abnormal gait, the step lengths of the two
sides may be unequal. Stride length is the distance from
the initial contact of one foot to the following initial
contact of the same foot; this sometimes is called cycle
length. Velocity refers to the average horizontal speed
of the body along the plane of progression, measured
over one stride or more. It is typically reported in centi
meters per second or meters per minute (in a normal
adult, velocity is 103 centimeters per second [sixty-two
meters per minute]). Given the same cadence, people
which mus with longer lower limbs walk at greater velocity than
those with shorter bower limbs because of their greater
step and stride lengths. Cadence is the number of steps
per unit of time, represented as steps per minute. It de
Course
creases from the age of four years through the age of
seven years. For a normal adult, cadence is 120 steps per
minute.
Ankle Rockers
A discussion of the ankle rockers described by
Perry― will help in clarifying the function of the stance
phase of gait, specifically at the ankle. This discussion
1607
 1608 J. R. GAGE. P. A. DELUCA. AND T. 5. RENSHAW

@
@
IDouble
Support
Double
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0% 10% 30% 50% 70% 85% 100%

@ ILoading I
I Midstancc
IResPonsej f Terminal
Stance Prcswing MidswingTenn@I
Swing
Initial Initial
Toe Off
Contact Contact
@ Stance(60%) @@i― Swing(40%)
@ Stride “¿ml

FIG. 1
Schematic representation of the gait cycle. Stance phase is separated into four components (loading response. mid-stance, terminal stance,
and pre-swing), and swing phase, into three components (initial, middle, and terminal swing). The position in the cycle where each phase begins
is recorded as a percentage. Initial contact and toe-off are instantaneous events.

Initial Loading Midstance Terminal Preswing Initial Midswing Terminal

Contact Response (MST) Stance (PS) Swing (MSW) Swing
(IC) (LA) (TST) (ISW) (TSW)
FIG. 2
Artist@srepresentation of a patient moving through the gait cycle. The position of the limbs at each phase represents a general instantaneous
position, since each joint is moving continually through each phase.

Ankle Plantar-Dorsiflexion

30
l@ 2@3@
Dors

10
Lr@
-10

PInt ry
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_i_-______._I @@._.@.@__________
0 25 50 75 100
% Gait Cycle
FIG. 3
Kinematic plot and sketch of the ankle as it moves through stance phase. Numbers 1. 2. and 3 represent the three ankle rockers during stance
phase. The third vertical line on the plot represents the point of toe-off.

also will serve as an introduction to the plots of the
normal gait cycle. Understanding what is necessary at
each joint level during each component of the gait cycle
makes the determination of the pathological condition
a relatively easy matter.
First rocker (Fig. 3, number 1) represents the period
from initial contact of the heel until the foot is flat on the
walking surface. This rocker involves a controlled lower
ing of the foot to the floor by means of eccentric contrac
tion (lengthening) of the dorsiflexors of the ankle. It is
obvious that anything that prevents heel-strike will lead
to an abnormal first rocker. Most commonly, this re
sults from paralysis of the dorsiflexors (as is seen in
association with peroneal palsy) or from overactivity of
the plantar flexors of the ankle (as is seen in association
with the spastic equinus deformity of cerebral palsy).
During second rocker (Fig. 3, number 2), the foot
remains flat on the ground, while the tibia advances
to allow continued forward movement of the body.
This motion is due to eccentric contraction of the
gastrocnemius-soleus muscles. Spasticity of the plan
tar flexors prohibits tibiab advancement and commonly

THE JOURNAL OF BONE AND JOINT SURGERY

 GAIT ANALYSIS: PRINCIPLES AND APPLICATIONS 1609

a) PELVIC OBLIQUITT

15
@Jp b

-5
2
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25 50 75 100
S Gait Cycle
a b

b) HIP AB-ADDUCTIOII

15
b—
Ad.
—¿
5
a

—¿5
Ab.
-15 a b C
FIG. 4
Coronal-plane kinematics for the pelvis (a) and hip (b). Schematics of the pelvis and hip are correlated with the kinematics at the points
indicated.

causes relative hyperextension of the knee as the body
attempts to move forward.
Third rocker (Fig. 3, number 3) is the push-off re
quired for advancement of the limb, which helps the
later-firing psoas muscle to drive the ipsilateral knee
into flexion. This is the first period of power generation
from the ankle and is due to a concentric contraction
(shortening) of the gastrocnemius-soleus. Weakness of
the plantar flexors prohibits push-off and can cause per
sistence of the crouched gait commonly seen in cerebral
palsy.
The prerequisites of normal gait, in order of pri
ority, are (1) stability of the foot, the ankle, and, in
fact, the entire lower limb in stance phase; (2) clear
ance of the ground by the foot in swing phase; (3)
proper pre-positioning of the foot in terminal swing; (4)
adequate step length; and (5) maximization
conservation4.
Components of Gait Analysis
The components of gait analysis include kinemat
ics, kinetics, electromyographic data, measurement of
videotape recordings, energy expenditure,
cal observation. Data from these areas
and presented in appropriate formats as descriptive
material. The material then is analyzed, integrated,
and interpreted by the clinician or other personnel,
and a report of the gait analysis is generated.
Kinematics describes the spatial movement of a
body without regard to the forces that caused the move
ment. The movements are linear and angular displace
ments, velocities, and accelerations.
Kinetics describes the mechanisms that cause move
ment. These are ground-reaction forces, joint moments,
and joint powers, and they require simultaneous acqui
sition of joint motion and force-plate data in order to
be calculated.
Analysis of the gait cycle is possible for all of the
joint levels (foot, ankle, knee, hip, and pelvis) with use
of kinematic plots for motion in the three planes of body
movement: coronal, sagittal, and transverse (Figs. 4, 5,
and 6). Familiarity with gait plots for the major joint
levels in the three planes of motion provides the frame
of energy work for understanding normal walking (Fig. 7). Devia
tions from these plots then become relatively easy to
visualize and understand.
Electromyographic data are acquired from the elec
trical signals that are generated by muscular contrac
tions; acquisition is accomplished by means of surface
and clini electrodes or fine wires that are inserted directly into
are acquired the muscles. Data on energy consumption can be ac
quired by measuring steady-state oxygen consumption
or carbon dioxide production, or both, after about six
minutes of walking; by estimating energy consumption

VOL. 77-A, NO. 10, OCTOBER 1995

1610 J. R. (PAGE. P. A. DELtJCA. AND T. S. RENSHAW

a) PELVIC TILT

30
Ant.
20
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a
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Poet
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d PLANTAR -DORS iFLUIOt4

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-30

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Sagittal-plane kinematics for the pelvis (a). hip (b). knee (c). and ankle (d). Schematics of the four levels are correlated with the kinematics
at the points indicated.

with segmental analysis (which usually underestimates mation from which is automatically digitized and fed to
actual energy consumption) using estimated mass, dis a computer. The data collector and reducer is the corn
tance, and acceleration kinematic data: by monitoring puter system and its algorithms. The information is pre
heart rate and walking speed to obtain a ballpark index: sented to the interpreter as graphic and numerical data
or by employing inverse dynamics using complete ki for kinematics, kinetics, and ground-reaction forces;
netic and kinematic data4. as electromyographic activity (usually, eight different
muscles arc sampled and reported): and as videotape
Techniques of Gait Analysis recordings. The interpreter also is presented with the
To acquire data, measuring devices such as active or clinical data obtained by the gait-laboratory personnel.
passive reflective markers, electrodes, or foot switches. These personnel are the clinicians who administer treat
or a combination of these, are attached to the subject, ment to patients, who must understand methodology
and force-plates are built into the floor of the babona and modeling theories, and the technologists who de
tory. Tracking systems include videotaping. electro velop. test. and operate the gait laboratory, who must
myographic telemetry. and optical detection of active on understand the clinicians' questions and needs as well
passive markers with use of specialized cameras, infor as the patients' problems.

THE JOURNAL OF BONE AND JOINT SURGERY

 GAIT ANALYSIS: PRINCIPLES AND APPLICATIONS 1611

Although there are variations in the types of gait sessment and documentation, operative planning, and
analysis systems. there are certain common prerequisites postoperative evaluation. Gait analysis also is useful
for the validity and utility of any gait-analysis labora for evaluating the effectiveness of prosthetic limbs, in
tory. These are unencumbering marker systems; flexible, cluding their alignment, design, and performance, and for
accommodating three-dimensional tracking systems; assessing orthotic designs and modifications. Gait analy
minimum distraction of the patient; short data turn sis can be used to study the progression of neuromuscu
around time: easily understandable data presentation; lar diseases and to differentiate and classify pathological
and multiple measuring methods, such as kinematics, conditions (for example, to distinguish between cere
kinetics, and electromyography. bral palsy and idiopathic toe-walking)6. It also is useful
Initially, and periodically thereafter, one must verify for assessing the function of totaljoint replacements and
the gait laboratory's methodology and the accuracy and for documenting rehabilitation after a sports injury.
repeatability of its data. Intrasubject repeatability has
been found to be better for patients who have cerebral Normal Walking
palsy than for normal subjects, but it is quite high for Normal walking is defined as a highly controlled.
both groups. Sagittal and coronal-plane data are slightly coordinated, repetitive series of limb movements whose
more repeatable than transverse-plane data4. function is to advance the body safely from place to
place with a minimum expenditure of energy.
Uses of Gait Analysis
Gait analysis has been found to be of great value in Components
many areas, especially cerebral palsy, in which assess The principal component required for normal walk
ment of locomotion is very useful for preoperative as ing is a sophisticated system of neurological control

a) PILVIC R0?Af 101

30
‘¿at.
b
10
a @:::@@:III@
-10
Ext.
-30
25 50 75 100

b@ HIP ROTATION

30
mt.
£0

-10
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@ -—@ 0
@—¿
IS 50 75 100

S Gait Cyol.

c) FOOTR0?ATIOW
30
mt.
10

-10
Ext.
:z=;;
-30 I II

A
FIG. 6
Transverse-plane kinematics for the pelvis (a). hip (b), and foot (c). Schematics of the three levels are correlated with the kinematics at the
points indicated.

VOL. 77-A. NO. 10. O('IOBER 1995

1612 J. R. GAGE. P. A. DELUCA, AND T. 5. RENSHAW

Pelvic Oblksuity Pthkllk P@IvIcRoadun

NEwIN(;Tos cHII.DRENS H(NP1TAI.
(;ArIANALYsLS iA&)RATOR@ IS 30
d Up Ant
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e .5 I0 —¿@III .10
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Is5.• 30
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.10
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% Gait Cycle

FootRotation

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I 10

.10
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.313
25 50 75 100
OUTPUT V1.2 % Gait Cycle

FIG. 7
Kinematic plot combining each plane of motion as a single output. This allows an overview of all joint motion in a specific gait cycle.

providing direction to a musculoskeletal delivery struc gait, some or all of these prerequisites are absent, but
tune. The basic necessities for flawless function are with thoughtful treatment they often can be restored.
a normal brain and normal nerve tracts and motor
units, with normal muscles working by means of the Efficiency
levers of the skeletal system to translate muscle con Normal human walking is an extremely efficient
tractions into the desired motions. Integrity of the process. The typical energy expended in normal gait
central nervous system allows central control of bal (2.5 kilogram-calories [10.5 kilojoules] per minute) is
ance and selectivity for highly complex maneuvers less than twice that spent while sitting or standing (1.5
such as variation of cadence or alteration of direc kilogram-calories [6.3 kilojoules] per minute). Devia
tion. A healthy peripheral nervous system allows pro tions from normal gait greatly increase this energy cost.
pnioception for the fine adjustments necessary for For example, approximate increases in energy expendi
activities such as running on moving over an uneven ture have been measured during fast walking (60 per
surface. Finally. cardiovascular and respiratory systems cent increase) and walking with a below-the-knee brace
with sufficient reserve are necessary power sources for (10 per cent), with a 15-degree knee-flexion contracture
maintaining or increasing velocity. Certainly, dysfunc (25 per cent), after a below-the-knee amputation (60
tion in any of these areas can contribute to distur per cent), after an above-the-knee amputation (100 per
bances in walking. cent), and with crutches (300 per cent)°.
The body uses a variety of biomechanical adjust
Priorities ments to make the energy costs of walking as low as
Perry'2 pointed out four priorities of normal gait: (1) possible. Muscles tend to lengthen prior to contracting,
stability of the weight-bearing foot throughout stance to maximize the amount of force generation possible;
phase, (2) clearance of the non-weight-bearing foot dur the gastrocnemius-soleus unit undergoes eccentric con
ing swing phase, (3) appropriate pre-positioning (during traction during the second rocker of gait and gives back
terminal swing) of the foot for the next gait cycle, and substantial energy during the end of stance phase (the
(4) adequate step length. third rocker) as it contracts concentrically. The three
To these priorities, we would add a more global dimensional excursion of the center of body mass is
fifth prerequisite: energy conservation. In abnormal minimized through the intricate interactions of the seg

THE JOURNAL OF BONE AND JOINT SURGERY

@ -@.

GAIT ANALYSIS: PRINCIPI.F.S AND APPLICATIONS 1613

ments of the lower extremity via joint functions. espe ative for adequate clearance of the foot. The knee then
cially at the knee and pelvis. Conversely. a stiff-knee must extend throughout the remainder of swing phase
gait. as is seen in spastic disorders (such as cerebral so that adequate step length is achieved.
palsy) and osteoarthrosis, can lead to increases in en Motion of the hip is measured in relation to the
ergy consumption and to early fatigue. pelvis. which has a total range of motion of only 4 de
Finally. efficiency is aided by the ability of the two grees through the gait cycle. The hip is flexed approxi
joint muscles, such as the psoas. hamstrings. rectus mately 35 degrees at heel-strike and extends throughout
femoris, and gastrocnemius, to transfer energy between stance phase to a position of 6 degrees of extension in
segments. It is no surprise that the loss of selective cen terminal stance. The pelvis rises a small amount (4 de
tral nervous-system control seen in cerebral palsy leads grees) in the coronal plane during loading response; this
to abnormal function of these highly complex muscles. occurs because of the eccentric contraction of the ab
ductors of the hip. The hip is adducted at this point in
Relationships the gait cycle. During later stance in single-limb support.
Normal functioning of the ankle and knee in the the hip abducts and the pelvis drops. During swing. the
sagittal plane is responsible for maintaining a relatively hip is abducted. which provides a mechanism for clear
stable center of body mass at low energy expendi ance for the foot.
ture. The knee functions as a shock absorber by flexing From the transverse plane. it can he seen that both
during early stance phase. but then, under control of the pelvis and the hip are internally rotated during early
the ankle plantar flexion-knee extension mechanism. stance, although in nornial gait the foot remains slightly
approaches full extension by terminal stance and pre externally rotated throughout stance. Abnormalities in
swing. Using the force of plantar flexion of the ankle in this plane are very difficult to evaluate by observation
pre-swing (third rocker) as well as the activation of the alone. and this is an example of the value of three
psoas muscle that follows shortly thereafter. the knee dimensional analysis.
and hip begin to flex. It is very important that peak
flexion of the knee occur approximately one-third of the Abnormal Gait
way into swing phase. At that time. the ankle has yet to Despite the fact that the effects ofcerehral palsy are
recover from plantar flexion and. therefore. normally readily apparent at the periphery —¿that is, in the mus
timed and sufficient peak flexion of the knee is imper des and hones of the extremities —¿the root problem is

(I 2d

MFXd=GRFx2d GRF
Fit@.8
Illustration of how the internal moments produced by the muscles relate to the external moments produced h@ground-reaction forces
(GRF) or inertial forces. The forces act on a skeletal lever. and their fulcrum is the center of the joint. Since a moment is equal to the force
times the distance to the fulcrum. it must be remembered that an inadequate moment can arise either from a deficient force or from a
shortened. malrotated, or defective (non-rigid) lever. In cerebral palsy. pes valgus often converts the foot into a malrotated. non-rigid lever.
which effectively prevents the ground-reaction force from maintaining extension of the knee in the second half of stance phase. d = distance
from force (moment arm or lever arm) to fulcrum. M = moment. and MF = muscle force.

VOL. 77-A. NO. 10. OCTOBER 1995

1614 J. R. (IA(jE. P. A. DELtJCA. AND T. S. RENSI-IAW

the irreparable damage that has occurred in the central response to the primary abnormality: and coping re
nervous system. This damage to the central control sys sponses. which are voluntary responses that the body
tern produces some or all of the following: loss of se uses to circumvent the difficulties imposed by the pri
lective muscle control, dependence on primitive reflex many abnormality (for example. the use of a vaulting
patterns for walking. abnormal muscle tone. relative im gait to clear the swinging limb because the primary ab
balance between muscle agonists and antagonists across normality. usually a spastic rectus femonis in this case,
joints. and deficient equilibrium reactions. prevents adequate flexion of the knee in swing). Be
As a consequence. many or all of the prerequisites fore an operation is performed on a child who has cere
of normal gait are absent in individuals who have cere bral palsy, it is important that these three types of
bral palsy. It is imperative that the physician have a good deviations be sorted out, since the primary and second
understanding of normal and abnormal gait so that an ary abnormalities require operative or onthotic con
optimum outcome can he achieved. rection. whereas the coping responses will disappear
spontaneously once they are no longer necessary.
Imm1f)ortamlt
Principles Seventh. an individual who has cerebral palsy has
First. in general. gait deviations fall under three deficient selective motor control: this deficiency usually
headings: those caused by weakness. which usually im increases as one goes distally down the limb, so that
plies that there is an inadequate internal joint moment: control of the trunk and the proximal joints is much
those caused by an abnormal joint position or range of better than that of the distal joints. A classification sys
motion: and those caused by muscle contracture, which tem for hemiplegic gait depends on this phenomenon'5.
may he either static or dynamic. As a result, an individual with spastic diplegia or spastic
Second, muscles always work as part of a force cou hemiplegia usually has fairly good control of the trunk
pie: that is. they act on an OSSdOUSlever arm to generate and hips. As the degree of involvement with cerebral
a force at the joint or joints upon which they act. This palsy increases, so does the involvement of the proximal
action is referred to as the internal joint moment. In musculature. Thus, a person with spastic quadriplegia
accordance with Newton's third law. which states that usually does not have good control of the trunk and hips.
for every action there is an equal and opposite reaction,
the internal joint moment is balanced by an external
joint moment produced by either ground-reaction or
inertial forces (Fig. 8).
Third. since moment is defined as force times dis
tance. it should he apparent that muscle weakness can
produce an inadequate moment. hut so can a deficient
or maldirected lever arm (for example. pes valgus or an
externally rotated foot). This latter situation, the so
called lever-arm dysfunction. generally is much easier to
correct than muscle weakness.
Fourth, the contractures that are present in a child
with cerebral palsy may be either static or dynamic. In
general. a static contracture acts throughout the entire
gait cycle. whereas a dynamic contracture may produce
abnormalities only in certain portions of the cycle. In
contrast to a contracture, muscle weakness usually has
its principal effect in the phase of gait during which the
muscle normally acts.
Fifth. in the stance phase of gait. the usual cause of
pathology is an abnormal joint position. which in turn
may he produced by a static or dynamic flexion contrac
ture. In swing phase. the pathology usually is generated
by either an abnormal position or an inadequate range
of motion (Fig. 9).
Sixth, patients who have cerebral palsy usually have
multiple gait abnormalities rather than an isolated ab
normality. There are three basic types: primary abnon Fui. 9
malities. such as spasticity. which arise directly from the This photograph of a young man illustrates the two most corn
damage to the central nervous system: secondary abnor mon problems in the swing phase of gait: ( 1) abnormal position
(an equinus deformity of the foot) and (2) inadequate motion (co
nlalities. such as muscle contractures or torsional de spasticity of the hamstrings and rectus femoris causing severe atten
formities of hone, which develop slowly over time in uation of motion of the knee).

I-HE JOURNAL OF BONE ANI) JOINT SURGERY

 GAIT ANALYSIS: PRINCIPLES ANI) APPLICATIONS 1615

ent that they play at least two critical roles in locomotion.

First, they function as energy-transfer straps: there
fore, precise control of the timing and intensity of their
action is crucial for normal function (Fig. 10). In this
Concentric role, it is estimated that they lower the consumption
of energy during walking by about 20 per cent in nor
mal gait'. As the precise action of hiarticular muscles
demands a very high level of control. it is apparent that
these muscles are the first to be affected by cerebral
@‘¿.

End Second, biarticular muscles allow rapid. coordi

nated, and linked motion of the joints that they span.
For example, action of the triceps surae starts with the
monoarticular soleus during second rocker. The hiartic
ular gastrocnemius comes in slightly later, and eventu
ally the two muscles together generate enough force to
reverse the progressive dorsiflexion of the ankle that
has been occurring during second rocker; thus. third
rocker begins. However, this can occur only if the action
GRF of the gastrocnemius is blocked at the knee. so that the
Fi;. 10 gastrocnemius can bring its full plantar-flexion power to
The power for propulsion of the lower limb during the swing phase hear on the ankle. Fortunately, the moment generated
of gait conies primarily from the flexors of the hip and the plantar
flexors of the ankle. In order to walk faster. more power must he at the knee by the ground-reaction force during second
added to the system by these two muscle groups. If the knee were not
restrained by the eccentric contraction of the rectus fernoris. it would
be driven into excessive flexion. Since the rectus fernoris takes its
origin from the pelvis. this energy also assists flexion of the hip.
GRF = ground-reaction force.

As the coping responses depend on selective motor

control, they usually occur at the more proximal joints.
A good way to remember this concept is to think of
the phrase “¿proximalcompensations for distal devia
tions.― In the case of hemiplegia, the compensatory or
coping response often comes from the normal side. For
example. spasticity of the rectus femoris may impose
limited flexion of the knee in swing phase in both spastic
hemiplegia and spastic diplegia. This, in turn, causes
difficulties with clearance of the foot during swing phase
(priority 2 of normal gait). A hemiplegic child usually
copes with this problem by vaulting on the normal side,
whereas a diplegic child never vaults because he or she
does not have enough ankle control to do so. Conse
quently. the child usually copes with the problem by
circumduction or excessive flexion of the hip.
Eighth, as the level of control necessary for a muscle
that spans two joints is greater than that necessary for
a monoarticular muscle, abnormal function produced
by cerebral palsy is much more likely in biarticular than
in monoarticular muscles. Thus, taking this principle
and the previous one together, one would expect that
an individual with mild cerebral palsy would have the
Fi;. 11
greatest difficulties with control of the distal biarticular
Photograph of a child with cerebral palsy and severe pes valgus.
muscles. This is. in fact, the case. The pes valgus produces external rotation of the foot and destroys
the normal stability of the foot in stance. Since the forefoot is the
The Role and Importance of Biarticular Muscles skeletal lever arm on which the ground-reaction force is acting. the
result is an insufficient extension moment at the knee in stance. This.
Until recently, the function and importance of two in combination with excessive Ilexion moments at the hip and knee.
joint muscles were not well understood. It now is appar can produce a crouched-gait pattern.

VOL. 77-A. NO. 10. OCTOBER 1995

1616 J. R. GAGE. P. A. DELtJCA. AND T. S. RENSE-IAW

this logic, gait errors of the knee and ankle essentially

should occur only in the sagittal plane. since this is the
plane in which most of their motion occurs. Torsional
deformity of a long bone, however, will introduce mal
rotation of its proximal or distal joint and. hence, de
formity in another plane.

The Ankle and Foot

The ankle and foot function as a unit, so it is easier
to consider their deviations together. There are three
general types of errors of the ankle in the stance and
swing phases: (1) malrotation, (2) varus or valgus de
formity. and (3) abnormal muscle moments. In stance
phase, these deviations interfere with priorities I and 4
of normal gait (stability in stance and adequate step
length): in swing phase. they interfere with priorities 2
and 3 (clearance of the foot in swing and pre-positioning
of the foot in terminal swing).
As the ankle does not move much in the transverse
plane. malrotation is a static deformity and usually is
caused by abnormal tihial torsion. Dynamic malrotation
of the foot and ankle also can occur, however, since
varus deformity of the foot is associated with internal
rotation. and valgus deformity, with external rotation. In
Fi;. 12
Lengthening the heel cord without due consideration of the abnor
mal flexion forces acting at the hip and knee will result in relative
weakness of the triceps surae referable to the flexors of the hip and
the hamstrings. The weakened triceps surae now is unable to resist
the forces acting to drive the tibia forward. As a result. the ground
reaction force moves behind the knee to generate an additional
flexion moment rather than an extension moment. The task of resist
ing this flexion moment falls mainly to the vasti and secondarily to
the extensors of the hip. Consequently. the amount of energy re
quired for walking is greatly increased. A = moment arm of ground
reaction force. and GRF = ground-reaction force.

rocker is sufficient to accomplish this. However. as soon

as the ground-reaction force falls behind the knee mid
way through third rocker. the knee is unlocked and the
gastrocnemius instantly shifts its action from the ankle
to the knee to produce rapid flexion of the knee.
It also has become apparent that although we pres
ently have fl() way to restore normalcy to the biarticular
muscles, their function often can be enhanced if their
action can he simplified or modified by. for instance,
transfer of the distal end of the rectus femoris to the
sartorius or intramuscular gracilis tendon4.

Specific Deviations of Individual Joints

In general, gait errors have the effect of interfering
with the major prerequisites of normal gait and of in
creasing the energy cost of walking. In discussions of Fi1. 13

errors of specific joints, it is important to remember Photograph of a child with hyperextension of the knee (recurva
turn) in stance. The hyperextension is not being caused by excessive
that deviations occur in every plane in which a joint quadriceps force hut rather by excessive triceps surae force. since the
can move. For example. the hip has three degrees of latter muscle is responsible for controlling the rate of forward pro
freedom —¿that is, it moves in the sagittal. coronal, and gression of the tibia during mid-stance. If. as is demonstrated here.
the triceps excessively retards the rate of progression of the foot. the
transverse planes —¿and therefore deviations of the ground-reaction force gets too far in front of the knee and an
hip can and do occur in all three planes. Following excessive extension moment is generated at the knee.

THE JOURNAL OF BONE AND JOINT SURGERY

 GAIT ANALYSIS: PRINCIPLES AND APPLICATIONS 1617

either case, malnotation in stance interferes mainly with

the first prerequisite of normal gait (stability in stance
phase) because the plane of the foot is rotated out
of the plane of progression. Dynamically. in gait. this
means that the center of mass passes outside of the
base of support prematurely. with the result that the
contrabateral step length is shortened. However. the
ground-reaction force also is rotated out of the plane of
progression, with the result that abnormal torques are
introduced at the proximal joints. For example. in nor
mal gait. the ground-reaction force produces an exten
sion moment at the knee in mid-stance. If the foot is
mabrotated substantially into external rotation. two ad
ditional moments are introduced at the knee, one acting
in valgus and one in external rotation. Bone grows and
models in response to the stresses placed on it: in a
growing child, therefore, these moments have the effect
of producing further external tihial torsion and valgus
deformities of the foot and knee (Fig. 11). In swing
phase, malnotation interferes with priority 3 of normal
gait (pre-positioning of the foot in terminal swing).
which in turn leads to instability at the time of the next
initial contact.
In cerebral palsy. varus deformity of the foot usually
is associated with hemiplegia. and valgus deformity.
with diplegia or quadniplegia. Varus and valgus defor
mities produce boss of stability throughout stance phase
because they introduce large external moments in the
Fi;. 14-A
coronal plane that must he balanced by large muscle
Photograph of a patient sslio had malrotation of the knee and foot
aeeonipanied h@' pes valgus and external tibial torsion. Rotational moments if stability is to he maintained. For example. at
deformIties of this type often are mistaken for genu valgum. initial contact. a varus deformity of the hindfoot im

HIP FLEXION.EXTENSION HIP ROTATION

45 30

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INTER.

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-30
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R KNEE FLEXION-EXTENSION FOOT ROTATION
E 70 -30
E FLEX.
S S INTER.
40
0
EXT. io ,@

EXT.
-20 _____________ ______ 30
%GAIT
CYCLE %GAIT
CYCLE

PatIent Data
Normal Data
Fu;. 14-B
As the kineniatic graphs illustrate. the valgus deformity is illusionary: what actually is present is a combination of internal femoral torsion
secondary to femoral anteversion and external rotation of the foot secondary to external tibial torsion or pes valgus. or both. Because the foot
15 50 external to the line of progression of the knee. lever-arm dysfunction and a resultant inadequate extension moment at the knee occur in
stance. This. in turn. results in a crouched gait. Any attempt to correct this problem must begin with restoration of the skeletal lever arms. which
would entail a combination of derotational femoral and tibial osteotornies.

V()l.. 77-A. NO. 1)). ()(‘IOI3ER 1995

 1618 J. R. GAGE. P. A. DELLJCA. ANt) T. S. RENSHAW

poses a large load on the peroneal muscles. If the pero

neals cannot neutralize this moment. an inversion strain
will occur at the ankle. Varus and valgus deformities of
the foot do not cause any specific problems in swing
phase. but they do interfere with priority 3 of normal
gait (pre-positioning of the foot in terminal swing).
Abnormal muscle moments are of two types: those
that are too large and those that are too small. In nor ‘¿V

mal gait. initial contact begins with heel-strike and the

ground-reaction force produces a plantar-flexion mo —¿ft
ment, which is resisted by eccentric contraction of the ‘¿I
..@

tihialis anterior and the extensors of the toes during first

@
rocker. Second rocker begins in mid-stance, with pro ‘¿(ii,

gressive dorsiflexion of the ankle as the tibia moves

over the fixed foot. This activity is controlled by eccen
tric contraction of the plantar flexors of the ankle and
the long-toe flexors. Finally. in terminal stance. when
the action of the plantar flexors becomes concentric, the
propulsive third rocker, which has its fulcrum at the
metatarsophalangeal joints. begins. During each of the
rockers, normal progression depends on an appropriate
internal muscle moment in response to the external
ground-reaction forces.
Weakness of the anterior tihial musculature pro
duces a foot slap at initial contact during first rocker.
Weakness of the triceps surae allows the tibia to pro
gress too rapidly during second rocker. and this causes
the ground-reaction force to fall behind the knee. When
this occurs, the knee becomes unstable and quadriceps Fiu. 15
action is necessary to prevent its collapse into flexion Photograph illustrating how weight shifts can substitute for made
(Fig. 12). Remember, however, that a moment is defined quate muscle power. This individual compensated for weak abduc
tors of the hip by shifting the upper body over the stance limb: this
as a force acting on a lever arm and that if the lever arm action shortened the lever arm of the ground-reaction force and
is too short or is non-rigid (for example. in a valgus reduced the external joint moment.
foot), then an inadequate moment will result despite an
adequate muscle force. extremity again must he jerked from the ground by the
In cerebral palsy. unless the triceps surae has been flexors of the hip.
operatively weakened. loss of extension of the knee in In swing phase. excessive action of the plantar flex
second rocker usually is due to an inadequate lever arm. ors or insufficient strength of the dorsiflexors results in
In second rocker. an excessive internal muscle moment a dropfoot, which. in turn. interferes with priorities 2
will abnormally restrain the rate of tihial progression. and 3 of normal gait (clearance of the foot in swing and
This has the effect of increasing the length of the lever pre-positioning of the foot in terminal swing).
arm of the ground-reaction force, which, in turn. pro
duces an excessive extension moment at the knee. This The Knee
either will result in recurvatum (Fig. 13) or will force the As the knee is essentially a hinge joint that enables
child to hear weight on the toes and avoid second rocker motion in the sagittal plane, the common dynamic errors
altogether. relate to this plane. In stance phase. the usual problem
In third rocker. an inadequate moment results in a is excessive flexion, although inadequate flexion during
persistent crouch so that. instead of the plantar flexors loading response or pre-swing, or both, also can occur.
thrusting the hip and knee into flexion and propel In swing phase. the most common error is due to mad
ling the limb into swing. the lower extremity must be equate motion. Malrotation. which is a static deformity,
pulled into the air by the flexors of the hip. An exces can cause problems in either swing or stance.
sive plantar-fiexion force in second and third rocker In normal gait. the three vastus muscles of the thigh
is equally deleterious in that the excessive ground work to stabilize the knee during only the first 20 per
reaction force that is produced in response to it main cent or so of stance phase. After that. stability of the
tains the knee in extension throughout third rocker so knee is maintained by the triceps surae and the muscles
that the 40 degrees of flexion of the knee that is needed in the posterior part of the calf. which act to restrain the
at toe-off cannot he reached. Consequently, the lower forward progression of the tibia appropriately during

THE JOURNAL OF BONE AND JOINT SURGERY

 GAIT ANALYSIS: PRINCIPLES AND APPLICATIONS 1619

\i
Fui. 16-A Fi;. 16-B
Figs. 16-A through 16-E: Photographs and kinematic plots of a seven-year-old girl who had spastic diplegic cerebral palsy.
Figs. 16-A and 16-B: Front and side photographs showing the internal rotation of the hip and foot as well as increased pelvic lordosis and
early heel-rise during mid-stance.

second rocker. This keeps the ground-reaction force an joint in direct proportion to the amount of flexion that
tenor to the knee. The ground-reaction force, acting is present at the hip. Consequently. larger internal mus
through the lever arm of the foot, stabilizes the knee by dc moments are required of the extensors of the hip
creating an extension moment. This moment often is as well. The effect of all of this is to increase both the
referred to as a plantar flexion-knee extension couple, energy requirements of walking and the magnitude of
as the magnitude of the extension moment at the knee the load on the hip and knee joints4. The magnitude
actually is under the control of the plantar flexors of of the load on the patellofemoral joint is extremely
the ankle. large, and premature degenerative osteoarthrosis may
If there is excessive flexion of the knee in mid result'3'4.
stance, the ground-reaction force moves posterior to the In normal walking, about 60 degrees of knee motion
knee and generates a flexion rather than an extension is required for adequate clearance of the foot in swing
moment. This renders the knee unstable, so stability of phase. The peak flexion is required during initial swing,
the knee must be maintained by an internal muscle right after toe-off. since at that point in the gait cycle the
moment throughout most of stance. The quadriceps is toe of the foot is still pointed toward the ground. In
the principal muscle group employed to do this. but the cerebral palsy. both the timing and the action of the
extensors of the hip assist to some degree. It is impor rectus femoris and the hamstrings often are abnormal;
tant to keep in mind that a moment consists of a force the resultant reduction in the total range of motion of
acting on a lever. Hence, muscle weakness will pro the knee in swing phase and the delay in the timing of
duce an inadequate moment, but so will a deficient or peak flexion cause difficulties with clearance of the foot
maldirected lever arm. Unfortunately, excessive flexion (priority 2 of normal gait).
of the knee also generates instability at the hip, since Malrotation of the knee and foot is extremely com
excessive flexion of the hip then is required to keep the mon in cerebral palsy. In spastic diplegia, femoral ante
center of mass over the base of support. This causes version often interferes with gait and almost always is
the ground-reaction force to move anterior to the hip present to some degree. Furthermore. it usually is ac

VOL. 77-A. NO. tO. OCTOBER 1995

1620 J. R. GAGE. P. A. DELUCA, AND T. 5. RENSHAW

companied by pes valgus or external
both (Figs. 14-A and 14-B). In stance phase, this pro
duces lever-arm dysfunction, which often is severe
enough to generate a crouched-gait pattern and the
false appearance of a valgus deformity of the knee. In
swing phase. the direction of progression of the mal
rotated thigh often is mistaken for an adduction defor
mity of the hip.
The Hip
The principal problems at the hip are inadequate
power, inadequate or inappropriate range of motion,
and mabrotation. On the basis of two-dimensional ki
tibial torsion, or power for walking from push-off during terminal stance,
children with cerebral palsy usually are forced to walk
with pull-up; that is, the bulk of the power is generated
from the flexors of the hip instead.
The hamstrings constitute a fairly substantial part of
hip extensor power but, in order to use the hamstrings
as power generators, children with cerebral palsy must
lock the knee with the quadriceps during the first half
of stance so that they can use the hamstrings as pure
extensors of the hip. The strong pull of the hamstrings at
the knee creates a considerable flexion force and con
tributes to the crouched-gait problem. In attempting to
correct deformities in these children, we often find our

Pshva@h Sy PWiihi1@k

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FIG. 16-C
Preoperative kinematic plots of one side of the patient. The band represents the normal range (one standard deviation on each side of the
mean). The solid line is the data on the patient.

netic data, Winter estimated that approximately 85 per
cent of the energy for normal walking comes from the
plantar flexors of the ankle and 15 per cent, from the
flexors of the hip. Ounpuu et al. evaluated normal gait
in children with use of three-dimensional
and found that about 36 per cent of the power for walk
ing comes from the plantar flexors; 32 per cent, from the
extensors of the hip; 22 per cent, from the flexors of the
hip; and 10 per cent, from the extensors of the knee8.
Because of poor control of the distal musculature in
children with cerebral palsy, the power of the plantar
flexors usually is severely reduced. Consequently, al
though normal children generate a large amount of the
selves between a rock and a hard place; although muscles
such as the hamstrings produce deformity, they also gen
erate a barge amount of the power required for walking.
An inadequate or inappropriate range of motion
kinetic data also frequently is found at the hip. As the flexors, adduc
tors, and internal rotators of the hip are dominant over
their antagonists, flexion, adduction, and internal rota
tion deformities tend to be the rule. This puts the exten
sors, abductors, and external rotators of the hip at a
disadvantage, and the individual is forced to resort to
coping responses to maintain an erect posture in the
presence of abnormally large external or inadequate
internal moments. As noted earlier, weakness is seen in

THE JOURNAL OF BONE AND JOINT SURGERY

 GAIT ANALYSIS: PRINCIPLES AND APPLICATIONS I 621

the phase of gait during which the muscle normally acts. antevension normally begins with the onset of erect pos
Weakness of the extensors of the hip (including the tune. As the hip comes into full extension, the anteverted
hamstrings) usually is seen at initial contact and during femoral head and neck come into contact with the an
loading response. Weakness of the flexors of the hip tenor iliofemoral (Bigebow@s) ligament. This creates
is best seen during pre-swing and initial swing as the a torsional stress, which, with time and growth. acts
child struggles to launch the limb into swing phase. to derotate the femur. Somerville pointed out that. if a
Weakness of the abductors of the hip is noted through child has excessive ligamentous laxity. Bigelow's liga
out the single-support phase of stance, as the abductors ment simply may stretch and allow antevension to pen
are required to prevent collapse of the pelvis toward the sist instead of creating a derotational moment on the
unsupported side. When there is weakness around the femoral head and neck. Somerville called this phenom
pelvic girdle, there are no additional muscle forces to enon “¿persistentfoetal alignment.―
call on. Therefore, the individual is forced to use weight There are two additional reasons for excessive fem
shifts of the upper body to compensate —¿that is, the oral anteversion in children who have cerebral palsy.

@ Pa!vIc
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FI;. l6-D
Postoperative kinematic plots of the same side of the patient as shown in Fig. 16-C. The band represents the normal range (one standard
deviation on each side of the mean). The solid line is the data on the patient.

mass of the upper body is shifted in a pendulum fashion First, spastic flexons of the hip, particularly the iliop
to compensate for the inadequate muscle moments soas, may not allow the femoral head to come into full
around the pelvis (Fig. 15). Weight shifts ofthe trunk are extension against Bigebow's ligament. Consequently.
readily seen in the gait of an individual who has cerebral no derotational moment can be generated. and fetal
palsy. alignment will persist. Second, in cerebral palsy, the in
For practical purposes. malrotation at the hip is see tennal rotators of the femur. particularly the adductors
ondary to femoral anteversion. Femonal antevension is and the medial hamstrings. tend to dominate their an
essentially a femorab torsion in which the axis of the hip tagonists. Torsional stresses on growing bones create
is anterior or external to that of the knee. At birth. torsional deformities oven time, as demonstrated by An
normal children have about 40 to 45 degrees of ante kin and Katz.
version, hut this normally decreases steadily through Femonal anteversion is common in children who
out childhood so that. by skeletal maturity. antevension have cerebral palsy. Children who have spastic hemi
averages about 15 degrees'5. Spontaneous denotation of plegia differ from those who have spastic diplegia on

@‘¿OL.
77-A. NO. 10. O(IOI3ER 1995
@ @I-@

1622 J. R. GAGE. P. A. DELUCA. AND T. S. RENSHAW

PeleicObi ‘¿a, Psleic R@

13 30 / 30:@4@

Up
20
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At
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it
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basic
FIG. 16-E
Combined kinematic plots of the same side of the patient as shown in Figs. 16-C and 16-D. The lighter line is the preoperative data and the
darker line is the postoperative data.

quadriplegia in that those in the former group tend to
have an equinovarus deformity of the foot and only
rarely have external tibial torsion, whereas those in
the latter two groups have external rotation of the
foot secondary to pes valgus or external tibial torsion,
or both. Consequently, hemiplegic children who have
femoral anteversion usually walk with internal rotation
of the entire lower extremity and generally compen
sate by walking with persistent lateral pelvic rotation,
keeping the hemiplegic side behind. In diplegic or quad
riplegic children, however, the anteversion usually is
fairly symmetrical and pelvic rotation usually is neu
tral or close to neutral. Nevertheless, these children
usually do not toe in, because the external rotation pro
duced by the tibia and pes valgus tends to balance
the internal rotation of the knee produced by the ante
version. Since the stability of the foot is decreased by
the pes valgus, and the plane of the foot may be 30
degrees or more external to that of the knee, lever-arm
dysfunction at both the hip and the knee is an important
problem in these children. At the knee, lever-arm dys
function means that the supple, externally rotated foot
cannot generate an adequate extension moment to ex
tend the knee in the second half of stance. Conse
quently. a crouched gait usually ensues. At the hip, the
degree of anteversion often is such that the individual
cannot compensate fully for the externally rotated foot
with internal rotation of the femur. As a result, the
femorab head still is directed forward. This may lead to
acetabular dysplasia and subluxation of the hip. In ad
dition, excessive lumbar lordosis (anterior pelvic tilt)
often is used as a mechanism to contain or cover the
anteverted femoral head.
Illustrative Case Report
A seven-year-old girl with spastic diplegic cerebral palsy walked
with a severe crouch and internal rotation of the lower limbs (Figs.
16-A and 16-B). The preoperative kinematic plot of one side of this
patient showed that there was excessive obliquity of the pelvis in the
coronal plane during stance phase (Fig. 16-C). As the limb achieved
stance, the hip moved rapidly into adduction because of weakness of
the abductors of the hip on this side. There was excessive anterior
pelvic tilt in the sagittal plane because of weakness of the extensors
of the hip or of the abdomina.J muscles or because of spasticity of
the flexors of the hip. The hip curve was shifted upward with exces
sive flexion. Although this could have represented overactivity of the
flexors, it more likely was secondary to the excessive anterior position
of the pelvis. The sagittal curves of the knee and ankle should be
assessed together. The knee was excessively flexed at initial contact
because of tightness or spasticity of the hamstrings, but it moved
rapidly into extension through mid-stance. The ankle also moved
rapidly into plantar flexion at this time; the result was an abnormal
second rocker. It is believed that the excessive plantar flexion-knee
extension couple resulting from spasticity in the gastrocnemius
soleus complex explains the knee motion. The knee also had limited
and delayed flexion during swing phase. which contributed to poor
clearance of the foot.
In the transverse plane. the pelvis maintained fairly normal mo

THE JOURNAL OF BONE AND JOINT SURGERY

 GAIT ANALYSIS: PRINCIPLES AND APPLICATIONS 1623

tion, but the hip and foot had internal rotation well beyond the normal as a result of the transfer of the rectus femoris. The ankle still had no
range. Clinical examination revealed excessive femoral anteversion. first rocker. but second rocker was restored.
On the basis of the results of gait analysis and a physical exami The preoperative and postoperative results are presented along
nation, the child was managed with bilateral proximal femoral with the laboratory's normal range so that the specific results at each
derotational osteotomy secured with a strong blade-plate (which joint level can be compared directly (Fig. 16-E).
allowed avoidance of a spica cast and thereby facilitated a more
immediate rehabilitation program), lengthening of the medial ham
Conclusions
strings (intramuscular tenotomy of the semitendinosus and gracilis The advent of gait analysis has enabled physicians
and release of the semimembranosus aponeurosis), lengthening of the and others to define, document, and analyze normal and
gastrocnemius aponeurosis, and transfer of the rectus femoris to the
sartorius.
abnormal human gait much more accurately and com
The postoperative kinematic plots from the same side of the prehensively than was previously possible. Gait analysis
patient showed correction to the normal range in the coronal and has been of great value for planning and documenting
transverse planes as a result of femoral derotational osteotomy (Fig. the outcome of one-stage corrective operations in pa
16-D). In the sagittal plane, the pelvis moved to a less anterior posi
tients who have cerebral palsy. As an important addi
tion, and the hip curve was similarly improved. This was accomplished
without a release of the hip flexors. The knee was improved as a result
tional benefit, gait analysis has stimulated a greater
of lengthening of the medial hamstrings, but it still maintained some depth of thought and study of both normal and abnor
crouch. The timing of flexion of the knee also was improved in swing mal human walking by many health-care professionals.
References
1. Arkin, A. M., and Katz, .1. F.: The effects of pressure on epiphyseal growth. The mechanism of plasticity of growing bones. J. Bone and
Joint Surg., 38-A: 1056-1076. Oct. 1956.
2. Chung, C. Y.: Unpublished data.
3. Gage, J. R.: Surgical treatment of knee dysfunction in cerebral palsy. Clin. Orthop., 253: 45-54, 1990.
4. Gage, J. R.: Gait Analysis in Cerebral Palsy. London. MacKeith Press, 1991.
5. Gage, J. R.; Perry, J.; Hicks, R. R.; Koop, S.; and Werntz, .1. R.: Rectus femoris transfer to improve knee function of children with
cerebral palsy. Devel. Med. and Child NeuroL, 29: 159-166, 1987.
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10. Perry, J.: Kinesiology of lower extremity bracing. Clin. Orthop., 102: 18-31, 1974.
11. Perry, J.: Distal rectus femoris transfer. Devel. Med. and Child Neurol., 29: 153-158. 1987.
12. Perry, J.: “¿Phases ofGait― Gait Analysis: Normal and Pathological Function. Thorofare. New Jersey. Slack, 1992.
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59-A: 934-939, Oct. 1977.
15. Shands, A. R., Jr., and Steele, M. K.: Torsion of the femur. A follow-up report on the use of the Dunlap method for its determination.
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