Gait presentation

GAIT

GAIT

GAITDR.KUMAR SUPRASHANT

DNB HINDU RAO HOSPITAL AND NDMC MEDICAL COLLEGE

Gait Normal Gait

Series of rhythmical , alternating movements of the trunk & limbs which result in the forward progression of the

center of gravity…

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Gait Cycle

• Defined as the period of time from one heel strike to the next heel strike of the same limb

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Gait Cycle

The gait cycle consists of two phases…

1) STANCE PHASE2) SWING PHASE

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• Gait is style , manner or a pattern of walking.• Walking pattern may differ from individual to individual

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STANCE PHASE

Begins when the heel of one leg strikes the ground and ends when the toe of the same leg lifts off. Constitutes approximately 60% of

the gait cycle.

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Swing phase represents the period between a toe off on one foot ad heel contact on the same foot.

Constitutes approximately 40%

of the gait cycle.

SWING PHASE

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GAIT TERMINOLOGIESTime and distances are two basic

parameters of motion. Distance and time mesurement

during gait analysis are reffered to as Cadence parameters

1. Temporal (Time) variables2. Distance (Spatial) variables

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TEMPORAL VARIABLES

1. Single limb support time2. Double support time3. Cadence4. Speed

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Amount of time spent during the gait cycle when only one limb is supporting the body wt.

Single Limb Support Time

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Double Support TimeAmount of the time spent with both feet on the ground during the gait cycle. The time of double support may be

increased in elder patients and in those having balance disorders

The time of double support decreases when speed of walking increases

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As the speed at which person walks increases time spent in double limb support

decreases .During running double limb support disappears and is replaced by double

limb float , a period during which neither leg is in contact with the ground

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Distance Variables

1. Stride length2. Step length3. Degree of toe out

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Stride length

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Step length

Degree of toe out Referred to as foot progression angle.It is the angle the foot makes with the path the subject is walking.Normally it is 10 to 15 degree external

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Neurological control

Muscular actions that occour during gait are programmed as involuntary reflex arc at the level of brain and spinal cord.Extrapyramidal system responsible for most complex unconcious pathway.Golgi tendon unit, muscle spindle, and joint receptors produce neurological feedback.Voluntary modulation is done by motor cortex. 24

Neurological control

Cerebellum controls balance.

In case of a child earlier with immature neurological control child walks with flexion at hip, knee and arms with wider base of gait. As the neurological system continues to develop in cephalocaudal direction efficiency and smoothness of gait increases

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GAIT ENERGY

• Bipedal gait is inherently unstable and inefficient to make it efficient joints and muscles of lower limbs minimize the change in centre of gravity(CG) which is located just anterior to S2.

• CG moves 1/8th inch during gait with lowest part at 50 % of gait cycle during double limb support.

• Amount of energy = oxygen consumption = indirect measurement with heart rate

KINEMATICS

• Study of angular rotation of each joint during movement, in three planes

saggital coronal transverse

SAGGITAL

• Flexion and extension• HIP– Initial contact- flexed– Stance phase – extends fully and body advances

over plantigrade foot– At heel rise - flex to take the limb off the ground

and continues to flex during swing phase

• KNEE– Initial contact – flex 15 degree– Stance phase – extends to neutral position or

minimal flexion– As heel rise – knee begin to flex again, max flexed

at early swing to allow foot to clear of the ground, then during rest of swing phase extends passively using forward momentum

• ANKLE– Initial contact – neutral position– Foot flat – plantar flexion of 5 to 10°(FIRST ROCKER)– Midstance – dorsiflex and tibia moves over talus (SECOND ROCKER)– Heel rise – ankle plantar flexes and heel rise in preparation for push

off (THIRD ROCKER)– During swing phase – dorsiflexion of ankle back to neutral position

to allow for clearing of foot (if this dorsiflexion is hampered during swing phase as in foot drop it is compensated by hyperflexing the knee and hip in swing phase leading to steepage gait.

CORONAL PLANE

• Adductin and abduction, rise and fall• Minimal hip movement in coronal plane – Slight adduction during stance phase– Slight abduction during swing phase

TRANSVERSE PLANE

• Rotation• Pelvis and hip – rotates minimally• Tibia – minimal range of motion or mild fixed

external rotation

STANCE Subphases IC: Initial Contact (Heel Strike)

> Both limbs are in contact – Double stance> The heel strikes the ground> The stance knee begins to flex slightly.> The ankle is at the neutral position> The knee is close to full extension Knee – 0o Flexion, Tibia externally rotated> Hip 30° of flexion Femur externally rotated

STANCE Subphases LR: Loading Response (Foot Flat)

>Flattening of the foot – reacting to impact of body weight

>Double stance ends

>Knee – 15o flexion, tibia internally rotates and then begins to externally rotate

>Hip – 30o flexion, femur internally rotating moving to neutral

>Maximum Impact Loading occurs>Foot rapidly moves into pronation>Weight has still not been been shifted to the support leg

STANCE Subphases MS: Mid Stance

Early Midstance - Late Mid Stance

> Single stance> Knee – 15o flexion, tibia externally rotating

> Hip – 25o flexion, femur internally rotated

STANCE Subphases TS: Terminal Stance (Heel-off)

>Single stance – “Falling forward” forward fall of the body moves the vector further anterior to the ankle, creating a large dorsiflexion moment >Begins as COG passes over foot and ends when opposite foot touches ground

>Knee – 5o flexion to 0o, tibia externally rotates>Hip – 0 to 10o extension, femur externally rotates and begins abduction

STANCE Subphases PS: Pre-Swing (Toe-Off/ Knee Break)

>Double stance – “Transition”>Limb is rapidly unloaded – “Toe-off”

>Knee – 0-30o flexion, tibia externally rotates>Hip – 20o extension, femur externally rotates with abduction>The ankle moves rapidly from its dorsiflexion position at terminal stance to 20 degrees of plantarflexion

SWING Subphases IS: Initial Swing ( acceleration )

>From “toe-off” until maximum knee flexion>Knee – 30–60o flexion, tibia internally rotates>Hip – 0–20o flexion, femur moves from internal rotation to neutral (externally rotating)

SWING Subphases MS: Mid Swing

>Goal is for tibia to reach vertical position perpendicular to surface

>Knee – moves to 0o, tibia externally rotates

>Hip – 20-30o flexion, femur externally rotates

>Knee extension and hip flexion continue by inertia

SWING Subphases TS: Terminal Swing

>Preparing for initial contact >Knee – 0o, tibia externally rotated

>Hip – 30o flexion, femur externally rotates

MUSCLE ACTIVITY

• Gait is maintained by combination of muscle activity , momentum , and gravity.

• Muscle contraction-– Concentric – muscle shorten ,generate power and

accelerate body forward.– Eccentric – muscle lenghten despite electrical

stimulation which slows down and stabilizes motion during gait.

• At any time eccentric contraction outnumber concentric contraction

• CONCENTRIC contraction • At terminal stance phase – Gastrosoleus - to lift heel off the ground – Iliopsos – flexes the hip to pull the stance phase

limb off the ground• During swing phase – Tibialis anterior which dorsiflexes the foot and

help in easy clearance

• ECCENTRIC contraction• Slows down and smoothens the motion – At initial contact to plantar flexion –Tibialis anterior

contract so that foot is gently lowered to ground (if it does not fire foot slaps to the ground at initial contact)

– During 2nd rocker – gastrosoleus contract and limit the rate of dorsiflexion( if it does not contract ankle dorsiflexes excessively leading to poor push off and calcaneal gait)

– During weight acceptance of stance phase – adductors of stance limb fire to limit contralateral pelvis drop(if do not contract opposite pelvis drops ,trendelenburg gait)

– Meanwhile the stance limb adducts slightly

GAIT KINETICS

• Study of force generated by joints during gait• Reported as moments(force acting around a centre of

rotation) and powers.• Eg – TA eccentrically contract at initial contact to lower

foot which can be measured as power absorption.• Gastosoleus concentrically contract at push off leading

to power generation• Kinetics depend on walking velocity and an adult

pattern of kinetics is reached at 5 years of age

(1) ANTALGIC GAIT :- - Any gait which relieves pain is known as antalgic gait.Patient does not

bear weight on the affected side.Therefore, body lurches to the same side.

- decrease stance phase - decrease step length - decrease stride length

(2) TRENDELENBURG GAIT :- -Abductor lever mechanism :- -Ask patient to stand on one leg opposite side pelvis tends to dip down . -This is prevented by contraction of the abductors (gluteus medius & minimus) on

the same side. -So pelvis drop is preventedHere body weight acts as load, hip joint as the fulcrum & abductors as the power.

Defect in fulcrum i.e. fracture neck femur dislocation of hip Defect in power Opposite pelvis dips down i.e. Poliomyelitis i.e TRENDELENBURG SIGN POSITIVE Gluteii paralysis

(3) WADDLING GAIT :-

When Trendelenburg sign is present bilaterally, it will result in swaying of the patient side to side on a wide base.This is called waddling gait (duck gait).

(4) HIGH STEPPAGE/FOOT DROP/EQUINUS GAIT :- During heel strike attempt,toes drop to the ground first due to the foot drop. Hence,

to clear the ground,patient will flex hip and knee excessively, raises the foot and slaps it on the floor forcibly.

Common in foot drop due to muscle paralysis (common peroneal nerve palsy).

(5) STAMPING GAIT :-

In posterior column affection of the spinal cord,there is loss of joint, position & vibration sense.One is not able to percieve the distance of floor from the feet resulting in a hard thump.

e.g tabes dorsalis,syringomyelia,diabetes mellitus,leprosy,etc.

(6) CEREBRAL PALSYScissoring gait

Here one lower limb passes in front of the other lower limb due to marked adductor spasm as seen in cases of cerebral palsy.

– Spastic gait as a result of hypertonicity and imbalanced activity between muscle groups.

– Spasticity of hamstrings restrict extension of knee and child crouch at knee and walk with shortened stride length

– Spastic quadriceps may result in stiff extended knee gait

– Sustained activity of gastrosoleus cause toe walking and ankle equinus

(7) IN TOEING AND OUT TOEING :- When there is increased anteversion of femoral neck,there is internal rotation of the

hip joint to contain femoral head in the acetabular cavity results in internal rotation of the entire lower limb noted by inward pointing of the toes.

This may persist or compensatory external torsion of tibia may occur.Hence, the toes point forward.In such a case, look at the patella.Due to femoral torsion, both patella point inwards rather than forwards KISSING PATELLA.

Normal range of out toeing is from 8 – 15 degrees….Usually associated with lateral tibial torsion…..results in CHARLIE CHAPLIN GAIT.

(8) SHORT LIMB GAIT :-

In an effort to keep the pelvis level throughout the gait cycle the person will walk on the toes of the shorter limb.the longer limb hip and knee may be forced to be kept in flexion during stance phase.

(9) GLUTEUS MAXIMUS GAIT :-

Due to gluteus maximus paralysis,it is not possible to extend the supported hip in the swing phase.This is overcome by backwaed lurch of the trunk.Therefore, while walking, forward & backward movements of the trunk occur.Hence, also called as ROCKING HORSE GAIT.

(10) HAND TO KNEE/QUADRICEPS GAIT :-

Normally ,to transmit weight of lower limb during midstance, the knee is locked by quadriceps contraction.If it is weak,locking is hampered & buckling at knees will occur.Therefore, to stabilise the knee for weight bearing,patient places his hand in front of the knee and lower thigh region.

e.g poliomyelitis

(11) CALCANEUS GAIT :- Just before the swing phase,there is push off at the ankle joint by plantar

flexion.This is absent in paralysis or rupture of tendo-achilles.Weight is largely borne by the heel & there is widening & thickening of heel. Foot remains flat on the ground.

(12) SHUFFLING/FESTINANT GAIT :-

Here, the patient takes short steps, has a stooping posture (flexed neck, trunk, hip, knee) and is propelled forward quickly as if trying to catch up with the centre of gravity which is placed anteriorly. Seen in parkinsonism.

(13) ATAXIC/CEREBELLAR GAIT :-

Here, there is loss of sense of balance . patient sways in different directions or generally towards the stance phase limb during ambulation.

(14) HEMIPLEGIC GAIT :-

There is rigidity in lower limb muscles due to UMN lesion. Therefore, extension at knee & plantar flexion at ankle prevail. Hence, there is circumduction of limb at hip while swinging the limb to achieve forward propulsion.

(15) STIFF HIP GAIT :- In normal gait, 20 degree flexion occurs at the hip.In stiff hip, patient does not

flex hip.To compensate, patient raises the pelvis & semi-circumducts the limb to propel it forward.

(16) STIFF KNEE GAIT :- Due to loss of flexion at knee,patient raises pelvis to clear off the ground and

swing sideways with circumduction to propel it forward.Looks like that of a German Soldier marching.

(17) FLAT FOOT :- There is affection of arches of the foot.Foot is flat on the ground.There is loss of

spring in the gait.

OTHERS :-(1) BROAD BASED GAIT :- - Rare - Earlier seen in seamen due to habit of standing in boat with a broad base to balance self (centre of gravity falls between two feet).(2) HELICOPOD GAIT :- - Legs & feet thrown in half circles as in hemiplegia.(3) LATHYRIATIC GAIT :- -Combination of spasticity, hyperabduction & dragging of lower limb elements.(4) DRUNKERS/REELING GAIT :- - Irregular walk on a wide base,sideways swing without stability,tendency to fall with every step. - seen in drunken state or cerebellar inco-ordination.(5) KNOCK KNEE GAIT :- - Knees point & oppose each other while ankle & feet are kept apart.(6) GENU RECURVATUM GAIT :- - Hyperextension at knee.Seen in paralysis of hamstring (e.g polio).(7) CHARCOT GAIT :- - In hereditary ataxia.

VARIATIONS OF NORMAL GAIT :-

(1) ATHLETE’S GAIT :- At end of game,the players have a crouching attitude.This keeps the

centre of gravity as low as possible Prevents fatigue.

(2) MOURNER’S GAIT :- In a mourning ceremony,people of various height are present. But crowd moves together at the same pace.This can be done by altering

the cadence.However,this alteration cannot be sustained for a long time.Hence a tall person will alter his step length.he takes a step forward & then brings it back a bit.In such a case,there is more expenditure of energy.

GAIT ANALYSISLABORATORIES

• Dates back to 1957 for polio, cp, myelomeningocele

• Nowdays computer software used to allow 3D analysis which can assess motion at large as well as small joints(foot)

• Gait analysis are used for preoperative planning and outcome evaluation of neurological as well as postsurgical non neurological orthopaedic conditions.

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