# UNDERSTANDING NORMAL & PATHOLOGICAL

GAIT
Mahmoud Sarmini, M.D. Assistant Prof. LSU-PM&R LSU-

Objectives:
Basis for Dx & Rx of pathological gait Rational prescription of orthotic devices Understanding & correction of prosthetic ambulation

Gait Cycle - Definitions:
Normal Gait = 
Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the center of gravity  series of controlled falls

Gait Cycle - Definitions:

Gait Cycle = 
Single sequence of functions by one limb  Begins when reference font contacts the ground  Ends with subsequent floor contact of the same foot

Gait Cycle .Definitions: Step Length =  Distance between corresponding successive points of heel contact of the opposite feet  Rt step length = Lt step length (in normal gait) .

Gait Cycle .Definitions: Stride Length =  Distance between successive points of heel contact of the same foot  Double the step length (in normal gait) .

Definitions: Walking Base =  Side-to-side distance between the line of the two feet Side-to Also known as stride width .Gait Cycle .

Gait Cycle .Definitions: Cadence =  Number of steps per unit time  Normal: 100 115 steps/min  Cultural/social variations .

Gait Cycle .Definitions: Velocity =     Distance covered by the body in unit time Usually measured in m/s Instantaneous velocity varies during the gait cycle Average velocity (m/min) = step length (m) x cadence (steps/min) Comfortable Walking Speed (CWS) =  Least energy consumption per unit distance  Average= 80 m/min (~ 5 km/h . ~ 3 mph) .

Components: Phases: Phases: (1)Stance Phase: (1) Stance Phase: reference limb in contact with the floor (2) Swing Phase: Phase: reference limb not in contact with the floor .Gait Cycle .

Components: Support: Support: (1) Single Support: only one foot in contact with the floor Support: (2) Double Support: both feet in contact with floor Support: .Gait Cycle .

2. initial contact of forefoot w. Heel contact: Initial contact contact: Foot-flat: Foot-flat: Loading response . vertical bisector of foot Heel-off: Heel-off: Terminal stance Toe-off: PreToe-off: Pre-swing . 3. 5. ground Midstance: Midstance: greater trochanter in alignment w. Stance phase: 1. 4.Gait Cycle .Subdivisions: A.

Swing phase: 1. Midswing: swinging limb overtakes the limb in stance Midswing: 3. Deceleration: Terminal swing Deceleration: . Acceleration: Initial swing Acceleration: 2.Subdivisions: B.Gait Cycle .

Gait Cycle .

Swing: Stance phase = 60% of gait cycle Swing phase = 40% B. Single vs. Double support: Single support= 40% of gait cycle Double support= 20% .Time Frame: Frame: A. Stance vs.

With increasing walking speeds: Stance phase: Swing phase: Double support: decreases increases decreases Running: Running: By definition: walking without double support Ratio stance/swing reverses Double support disappears. Double swing develops .

Path of Center of Gravity Center of Gravity (CG):  midway between the hips  Few cm in front of S2 Least energy consumption if CG travels in straight line .

CG .

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Vertical displacement: displacement: Rhythmic up & down movement Highest point: midstance Lowest point: double support Average displacement: 5cm Path: extremely smooth sinusoidal curve .Path of Center of Gravity A.

Path of Center of Gravity B. Lateral displacement: displacement: Rhythmic side-to-side movement side-toLateral limit: midstance Average displacement: 5cm Path: extremely smooth sinusoidal curve .

Path of Center of Gravity C. Overall displacement: displacement: Sum of vertical & horizontal displacement Figure 8 movement of CG as seen from AP view Vertical plane Horizontal plane .

Determinants of Gait : Six optimizations used to minimize excursion of CG in vertical & horizontal planes Reduce significantly energy consumption of ambulation Classic papers: Sanders. Inman (1953) .

8o on the swing-phase side swing Reduces the angle of hip flexion & extension  Enables a slightly longer step-length w/o further lowering of CG step- .Determinants of Gait :  (1) Pelvic rotation: rotation:  Forward rotation of the pelvis in the horizontal plane approx.

hip adduction)  In standing.Determinants of Gait :  (2) Pelvic tilt:  5o dip of the swinging side (i.e. this dip is a positive Trendelenberg sign  Reduces the height of the apex of the curve of CG .

20o dip  Shortens the leg in the middle of stance phase  Reduces the height of the apex of the curve of CG .Determinants of Gait :  (3) Knee flexion in stance phase:  Approx.

Determinants of Gait :  (4) Ankle mechanism:  Lengthens the leg at heel contact  Smoothens the curve of CG  Reduces the lowering of CG .

Determinants of Gait :  (5) Foot mechanism:  Lengthens the leg at toe-off as ankle moves from toedorsiflexion to plantarflexion  Smoothens the curve of CG  Reduces the lowering of CG .

Determinants of Gait :  (6) Lateral displacement of body: body:  The normally narrow width of the walking base minimizes the lateral displacement of CG  Reduced muscular energy consumption due to reduced lateral acceleration & deceleration .

Gait Analysis Forces: Forces which have the most significant Influence are due to: (1) (2) (3) (4) gravity muscular contraction inertia floor reaction .

Gait Analysis The force that the foot exerts on the floor due to gravity & inertia is opposed by the ground reaction force Ground reaction force (RF) may be resolved into horizontal (HF) & vertical (VF) components. Understanding joint position & RF leads to understanding of muscle activity during gait Forces: .

Gait Analysis: At initial heel-contact: heel transient heelAt heel-contact: heel Ankle:  Knee:  Hip: DF Quad Glut. Max&Hamstrings .

Gait Initial HC µHeel transient¶ HC Foot-Flat Mid-stance .

Gait Initial HC µHeelHeel-off transient¶ HC Toe-off .

GAIT Low muscular demand:  ~ 20-25% max. muscle strength 20 MMT of ~ 3+ .

D.COMMON GAIT ABNORMALITIES A. E. F. Antalgic Gait Lateral Trunk bending Functional Leg-Length Discrepancy LegIncreased Walking Base Inadequate Dorsiflexion Control Excessive Knee Extension . C. B.

Walk next to me and be my friend. Don t walk ahead of me. I may not follow. I may not lead. Albert Camus .Don t walk behind me.

tendinitis .COMMON GAIT ABNORMALITIES: A. Antalgic Gait Gait pattern in which stance phase on affected side is shortened Corresponding increase in stance on unaffected side Common causes: OA. Fx.

Abnormal hip joint . Hip abductor weakness C. Lateral Trunk bending Trendelenberg gait Usually unilateral Bilateral = waddling gait Common causes: A. Leg-length discrepancy LegD. Painful hip B.COMMON GAIT ABNORMALITIES: B.

Ex. 2: Hip abductor load & hip joint reaction force .

Ex. 2: Hip abductor load & hip joint reaction force .

Functional Leg-Length Discrepancy LegSwing leg: longer than stance leg 4 common compensations: A.COMMON GAIT ABNORMALITIES: C. Steppage D. Circumduction B. Hip hiking C. Vaulting .

COMMON GAIT ABNORMALITIES: D. Increased Walking Base Normal walking base: 5-10 cm 5Common causes:  Deformities Abducted hip Valgus knee  Instability Cerebellar ataxia Proprioception deficits .

Inadequate Dorsiflexion Control In stance phase (Heel contact Foot slap In swing phase (mid-swing): (midToe drag Causes:  Weak Tibialis Ant.COMMON GAIT ABNORMALITIES: E.  Spastic plantarflexors Foot flat): .

COMMON GAIT ABNORMALITIES: F. Excessive knee extension Loss of normal knee flexion during stance phase Knee may go into hyperextension Genu recurvatum: hyperextension deformity of recurvatum: knee Common causes:  Quadriceps weakness (mid-stance) (mid Quadriceps spasticity (mid-stance) (mid Knee flexor weakness (end-stance) (end- * * * .