Section IV Lower

Extremily
TABL
ernts,
LE8 Gait Deviatíons at the Ankleroo Sccomdary to Specifie Ankle/Eoot Impairment Obser
the An
Mechanical Rationale and/or
Observed Gait Deviatíon at Selected Pathologic
the Anklc/Foot Associated Compensations
Likelý Itmpairmeni Precursors Excessi
"Foo slap": rapid ankle plan- Mild weakness of ankle Ankle dorsiflexors
have sufficient tar
Common peroneal nerve
dorsiflex the ankle dur- ankle
tar lexion occurs lollowing strength to,
heel
contact.t. The name dorsillexors palsy and distal pe-
ing swing
but
not enough
to control and a
foot slap is ripheral neuropathy flexion alter heel con-
Ankle r
deriyed,from
the characteristic noise
ankle plantar
tact. duni
made by the asso
the ground lorefoot hiting
t the t
the dorsiflexors drop
Entite plantar aspect of the Markèd wcakness of Common peroneal nerve Sufficicnt strength of
to partially, but not completely, dor-
foot touches the ground at
anklc dorsilexors palsy,and distal pe-
siflex thé ankle during swing.
Nor-
initial contactt Tollowed ripheral neurópathy mal dorsillexion occurs during
* An in=

by normal, passive ánkle T The te

as the.ankle has nor-

dorsilexion duing the esi stance as lông

mal range ol motion FInitial
of stance. initial cont
No active ankle dorsillexion is possible
Initial contact with the Severe weakness of an- Common peroneal nerve
ground is made by the kle dorsilexors palsy and distal pe- during swing. Normal dorsiflexion
as the
loreloot lollowed by the ripheral néuropathy occurs during stance as
long
heel Tegion Nomal passive ankle has normal range of motion. TABLE
ankle dorsillexion occurs Kne,
during stance
Initial contact is made with Heel pain Calcaneal fracture, plan-
Purposelul strategy to avoid weight Observ
the forefoot, but the heel tarfasciitis bearingon the heel Ankle
never makes. contact iwith To maintain the weight over the foot,
the ground during Plantar flexion contrac Upper motor neuron le Vaulting
stance rure(pes equinus sion/cerebral palsy,
the knee and hip are kept in flexion
demo
throughout stance, leading to a
delormity) or spaS cerebrovascular acci- planta
ticity of ankle plan- dent (CVA) "crouched gait." leads
tar flexors o the
Initial contact is made with Plantar ilexion contrac Upper motor neuron le- Knee hyperextension occurs during
Excessiv
the loreloot, and the heel is. sion (cerebral palsy, stance owing to the inability of the
ture (pes.equinus ibia to move forward over the foot.
is
calle
brought to:the ground.by a deformity). or spas- CVA)
posterior displacerment of ticity of'ankle plan- Ankle fusion in. a plan- Hip flexion and excessive forward
Reductio
thetibia (Fig:15-45) tar ilexoTS tar ilexed position trunk lean during teminal stance
during
occur to shift the weight of the body
n
over the foot.
Premature elevation of the" Lack ot ankle dorsi-
Congenital or acquired Characteristic bouncing gait patterm The te
heel in mid starce
tiexion muscular ightnessof
ankle plantar flexors
Heel remains in contaçt with Weakness or flaccid Peripheral or central Excessive ankle dorsilexion results in
the ground late in terminal paralysis of plantar nervous system disor prolonged heel contact, reduced
stance lexors with or with- ders push off, and a shorter step length.
outa fixed dorsi- Excessive surgical
lexed position of lengthening of the
the ankle (pes calca- Achilles.tendon
neus defomity)
Supinated foot position and Pes cavus deformity Congenital structural A high medial longitudinal arch is
weighi bearing on the lat-" deformity noted with reduced midíoot mobility
eral aspect of the foot dur
throughout swing and stance.
ing stance
Excessive foot pronation oc Rearfoot varus and/or Congenital or acquired Excessive foot pronation and associated
curs during stance with forefoot varus structural detormity
failure of the foot to supi- flattening
arch
of the medial longitudinal
may be accompanied by a gen-
nate in mid stance. Normal
medial,longitudinal arch
eral intemal rotation of the lower
extremity during stance
noted during swing:
Excessive:foot pronaüon with Weakness (paralysis) of Upper motor neurorn ley An overalN excessive intermal rotation of.
weight bearing on the me ankle invertors sion the lower extremity.during stance is
dial portion of the foot dur possible
ingstance, The medial lon- Pes plánus defomity Congenital structural FIGURE
gitudinal arch emains delormityY an ankle

absent during swing historice

 TABLE 15-6. Gaft Deviations at the AnkleFoot Secondary to Specific Ankle/Foot Impairments Continuca

Observed Gait Deviation at Selected Pathologic Mechanical Ratíonale and/or

the Ankle/Foot Likely Impairment Precursors Associated Compensátions
Excessive inversion and plan- Pes equínovarus delor Upper motor neuron le- Contact with the gròund is made with
sion (cerebral palsy, the lateral border of the forefoot
tar flexion of the foot and mity due to spasic
ankle occur during swing ity of the plantar CVA) Weight bearing on the lareral border
and at initial contact flexors and invertors of the foot duríng stance

Ankle remains plantar lexed
duringswing and can be
associatedwith dragging of,
the toes, typicaly callecd
dropfoot (Fig 15-46).
Weakness of dorsiflex- Comnon peroneal nerve Hip hiking, hip circumduction:or ex-
cessive hip and knee flexion of ihe
ors and/or pes palsy swing leg or vauluing ol the starice
equius delormity leg may be noted.to lilt the togs off
the ground and prevent the toes
from dragging during swng

anatomic structure or lunction.

impairment is a loss or an abnormality physiologic,
in psychologic, or
An
Ihe terms în bold indicate the time in the gait cyclc when the gait deviation is expressed. the section of the toot that makes
deviations the heel is not
of heel contact to rellect the fact that with many gait
t
contacl is often uscd instead
nital
initial contact with he ground.

for an Impairment of the Ipsilateral

TABLE5-7. Gait Deviations Secn at the Ankle/Foot as a Compensation
or Contralateral
Lower Extremity
Knce, Ipsilateral Hip,

Observed Gait Deviation at the Mechanical Rationale

Ankle/Foot
Likely Impairment
Strategy used to allow the foot ofa
Vaulting compensatory mechanism. Any impairment of the contralateral
hip flex-
functionally long, contralateral lower
lower extremity that, reduces exttemity to clear the ground durng.
demonstrated-by exaggerated ankle dorsiflex-
ion, knee llexion, or. ankle
plantar lexion during mid stance ion during swing
SWing.
movement
leads to excessive vertical
excessive toeing-ouE due to.
of the body (Fg 15-4) femur Foot is in
Retroversion of the neck of the excéssive external rotation of the
Excessive foot angle.during stance that or ight hip external rotators
is called toeing-out. lower extremity.
rotaion of the lower
Excessive femoral anteversion or spastic- General intermal
Reduction of the nonmal foot angle extremity
that is called toeing- ity of the hip adductors and/or hip
during stance iniermal-rotators

when the gait deviation is expressd.

The terms in bold indicate the time
in the gait cycle

Midswing
toe drag

retlective of weak
FIGURE 15-46. Drop foot during
swing phase,
15-45. Knee hyperextension and forward trunk lean with A: Motor Control: Theory and
FHGURE dorsiflexors. (From Shumway-Cook
Contractures: A Williams &' Wilkins, 1995)
ankie plantar ilexion (From Perry J:
contracture.
Praclical Applications.
Baltimore,
historical perspective Clin Orthop 219:8, 1987.) 63
 Section 1V Lower Extremity
TABLE 158. Gait Deviations at the Knee Secondary to Specific Knec Impairtmenis
Observed Gait Deviation
at the Knec
Rapid extension of the knee
knee externsor thrus)
immediately. after initial
contact
Kneefematnsexténded
dunng the loading re
sponse,but there?is no
extensorthnat,
Genu recunatüm (hyperex
tension) duringstance
Varus thrust during stance
Flexed position of the. knee
duning stance and lack
of knee extension in ter
minal swing (Fig.15-
9)
Reduced or absent knee
flexion duringSwing
The terms in bold indicate the time in the gait cycle when the gait deviation is expressed.
Likely Impairment
pasticitý of the quadnceps
Wcak quadriceps
Knee p4
Knee extensor weakness
see the two previously
described gait:deviations
in this table)
akity of the posterior and Traumatic injury or pro
lateral ligamentous j
structures'ot the knee
Kneelexion contracture
10 (genu flexium)
Hamstring overactivity
Spasticity)
Knee pain and joint etfu-
SIon
UPper motor neuron lesion
Spasticityof kne exten
SOrS
Knee extension contracture
Selected Pathologic
Precursois
Upper motor neuron lesion
Femoral nerve palsy LL
compressiónieuropathy
Arthritis
Poliomyelitis
gressive laxity
Upper moLor neuiorn lesion
Traunma or arthritis
Circumduction
Immobilization (cast
brace) or surgical tusion
Mechanical Rationaleand/or
Associated Compensations
7
the poste
Depending on the.status of
rior structures of theknee, may oc
cur with or without knee hyperex
tension.
Knee remains fuly exténded through
out starñce.An associated anterior
of
trunk lean in the harly part
stance moves the line ol gravity
ot
the trunk, slighily anterior to the
axis ol rotation of the khee (Fig
15-48). This keeps the knee éx-
tended without action ol the kriee
extensofs. This gait deviation may
lead to an excessive stretching of
the posterior cap[ule ot the knee
and eventual kneéhyperextension
genu recurvatun) duringstance.
Knee is kept in cxtension to reduce
the ieed for quadriceps activity
and associated compressive torces
IE may be accompanied by an ant
gat pattern characterized by
a
agic
Teduced stance time and shorter
steplength
Secondaryto progressive stretching of
the posterior capsule. of the knee
r
Rapid varus deviation of the knee
during mid stance, typically accom
panied by knee hyperexension
Associated increase in hip flexion and
ankle dorsiflexion during stance
Knee is kept in flexion since this is
the position of lowest inträarticular
Pressure:
Compensatory hip hiking and/or hip
could be noted.
 i

Kinesiology of Walking
Chapter 15

TABLE 15-9. Gait Deviations Seen at the Knee as a Compensation for an Inmpairment
Ipsilateral Hip, or Gontralateral Lower Extremity
Mechanical Rationale
Observed Gait Deyiation at the Knee Likely Impairment dorsiflexion or hip 1lexion
ankle
Knee is kept in flexion during stance Impairments at the ankle or the hip Exaggerated the
s t a n c e forces
knée in a flexed
swing
despite the khee having normal range including a pés calcaneus deformity, during contralateral (healthy)
position. The knee tlex
ol motion on examination. plantar flexor weakn ss, and hip exaggerated hip arndthe
flexion contracture leg shows t o é s owing to
func
ion to clear the s t a n c e
tionally shorter
leg
compensate lor
hyperextend to
Ankle plantar flexion contracture (pes Knee must forward displacement of the
Hyperextenision of the knee (genu recur the lack of 1545)
stance (see Fig,
of
vatum) from initialcontact to pre equinus deformity) or spasticityy tübiaduríng
ankle plantar llexors a shorter step
length
swing This is characterized
by
o n the side of
the painfuu
Antalgic gait Painful stance leg and stance time
it may be
accompanied

lower extremity; lean, if hip pain, con

byipsilateral trunk with knee and
lean óccurs
Lralateral, trunk
foot pain toe clearance of the
Strategy to increase accompanied by
lack of ankle. dorsilexion of swing
the
typically
Excessive knee flexion in swing legor a short starnce leg Swing leg and is
increased hip flexion

when the gait deviation is expressed.

The terms in bold indicate the time in the gait cycle

Anterior trunk
Normal bending

for lim-
on
unalfected side to compensate FIGURE 15-48. Weak quadriceps leading to anterior trunk lean.
FIGURE 15-47. Vaulting (From Whittle M:
Gait

functional shortening of the swing leg. Butterworth-Heinemann

(From Whittle M: Gait Analysis: An Introduction, 2nd ed. Oxford,
ited 2nd ed. Oxtord,
An Introduction, Butterworrh-Heinemann Ltd., 1996.)
Analysis:
Ltd., 1996.)
 Section IV Lower Extremity

TABLE 1510. Gait Deviations at the Hip/Pelvis/lrunk Secondary to Specific Hip/Pelvis/Trunk Impairments
Mechanical Rationale and/or
Observed Gait Deviation, at the Selected Pathologie Associated Compensations
Hip/Pelvis/Trunk Likely Impairment Precursors
This action moves the line of
Backward urunk lean during loadd Weak hip extensors Paralysis or poliomiyelitis of the trunk behind,
ing response gravity
the hip and reduces the need
for hip extension torque.
Tateral trunk lean toward the Marked weakness of Guillain-Barré or poliomyelitis Shifting the trunk over the sup-
the de-
stance leg: since this movement thehip abductors porting limb reduces
abductors.
compensates for a wealness, it is mand on the hip
Shifting the trunk over the sup-
often called "compensated" Tren Hip pain Athritis porting lower extremity re
delenburg gait and is referred to duces compressive joint forcess
asa waddling gait if bilateral associated with the action ol

hip abductors (see Fig. 15-

18).
Excessive downward drop_õf the Mild weakmess of the Guillain-Barré or poliomyelitis While the Trendelenburg sign
gluteus medius of may be seen in single-limb
Contralateral pelvis:during standing, a compensated
Tren-
stance. (Relerred to as positive the stance leg
Trendelenburg sign if present delenburg gait is often sëen in
durng single-limbrstanding) seyere weakness of the hip ab-
dúctors
Forward bendingof the trunk dur: Hip flexion contracture Hip osteoarihriis Forward trunk lean is used to

ingmid and terminal stance,as Compensate for lack of hip ex

the hip is moved over the foot. tensíón An altermative 2dapta-
tion could be excessive lum-
bar lordosis.
the hip at 30 degrees of
Hip pain Hip osteoarthritis Keeping
ilexion minimizes intraarticu-

Excessive lumbar lordosis, in termi
nal stance
Hip ilexion contracture
lar pressure
Lack of hip extension in termi-
Arthritis
nal stance is compensated for
by increased lordosis.

Trunk lurches backward and Hip-lexor weaknes L;L nerve compression Hip flexion is passively gener-
3toward the unaffected stance leg ated by a backward movement
from heel off to mid swing of the trunk.
Abdominals are used during ini-
Posterior tilt of the pelvis during Hip flexor weakness 1 nerve compression
tial swing to advance the
initial swing
swing leg
Hip tlexor weakness LL nerve compression Hip abductors are used as tlex-
Hipmovement
circumduction: semicircle:
of the hip durng OIs.

swingcombining hip flexion,

hip abduction, and forward rota-
tion of the pelvis (Fig 15 50).

The terms in bold indicate the time in the gait cycle when the gait deviation is expressed.
 Chapter 15 Kinesiology of Walking

TABLE 15-11 Gait Deviations Secn at the Hip/Pelvis/Trunk as a Compensation for an Impairment of the
Ipsilateral Ankle. Ipsilateral Knee. or Contralateral Lower Extremity
Observed Gait Deviation at the
Hip/Pelvis/Trunk
2,
Forward bendíng of the trunk dur-
ing the loading response
Forward bending of the trunk dur-
ingmid and terminal stance
Excessive hip and knee lexion dur
ing swing (Fig 15-51)
Hip cireumductton during swing
(Fig 15-50)
Hip hiking (elevation of the ipsilat
eral pelvis düring swing)
Excessive backward horizontal rota
tion of the pelvis on the side of
the stance leg in terminal stance
The terms in bold indicate the time in the gait cycle when the gait deviation is expressed.
Likely Impairment,
Weak quadriceps
Pes equinus delormit
Often due to lack of ankle dorsiflexion
ofthe swing legi may also be due to.
a functionaly or anatomically short
contralateral stance leg
Lack of shortening of the swing leg
Secondary toreducedhip 1lexion,re
duced knee flexion, and/or lack of
ankle dorsiflexion
Lack of shortening of the swing leg
secondary to reduced hip lexion, re-
duced knee flexion, and/ör lack off
ankle dorsilléxion
Functionally or anatomically short
stance eg
Ankle plantar flexor weakness
Mechanical Rationale
Trunk is brought forward to move the line of
gravty anterior tothe axis of rótatión of the
knee, theteby reducing the need for knee
extensors (see Fig, 15-48).
Lack.of ánkle dorsiflexion during stance results
in knee hyperextension and forward trunk
lean to move the weight of the.body over
thestance foot (see Fig. 15-45)
Used to clear the toes of the swing leg
Used to liftthe foot of the swing leg off the
ground and provide toe clearance
Used to lift the foot of the swing leg off the
ground and provide toe clearance
Ankle plantar flexor. weakness leads to pro
longed heel contact and lack of push off. An
increased pelvic horizontal rotation is used
to lengthen the limb and maintain adequate
step length.

Stance
foot
Swing
foot

FIGURE 15-49. Knee flexion contracture causing a crouched gait of FIGURE 15-50. Hip circumduction during swing. (From Whittle M:
the stance leg. (From Perry J: Contractures: A historical perspective. Gait Analysis: An Introduction, 2nd ed. Oxford, Butterworth-Heine
Clin Orthop 219:8, 1987.) mann Ltd., 1996.)