Examination of Gait

Definitions

Gait: Gait is the cyclical pattern of musculoskeletal motion that carries the body forwards. It involves a cyclic loss and regaining of balance by a shift of the line of gravity in relation to the center of gravity. Normal gait is smooth, symmetrical and ergonomically economical.

Gait cycle: The time interval or sequence of motions occurring between two consecutive initial contacts of the same foot, i.e., cycle of stance and swing by one foot.

Stance phase: When foot is on the ground and bearing weight (60% of gait cylce)

Swing phase: When foot is not bearing weight and moves forward (40% of gait cycle)

Double support phase: When both feet are on the ground simultaneously which occurs twice and comprises of 25% of normal gait cycle (absent in running)

Double float phase: When both feet are off the ground (present in running)

Step: The distance from one heel strike to next contralateral heel strike

  • Normal: About 72 cm

Stride: The distance covered from one heel strike to the next ipsilateral heel strike (2 steps)

  • Normal: About 144 cm

Cadence (step rate): Number of steps per unit time

  • Normal: 90-120 steps/minute

Gait speed: Distance covered in a given amount of time

  • Normal: 3 mph

Step or base width: The lateral distance between the heel centers of two consecutive foot contacts

  • Normal: 5-10 cm or 2-4 inches)

Neuroanatomy of Gait

Walking requires the coordinated effort of several neurologic structures and functions:

  1. Frontal lobes: to generate the motor pathways to initiate gait
  2. Cerebellar and vestibular function: for co-ordination and balance
  3. Basal ganglia: for appropriate speed of movement
  4. Muscle strength: to move the legs and to overcome gravity to remain upright
  5. Sensation (particularly proprioception): to know where the feet and legs are in space

Normal Gait Cycle

1. Stance phase:

Mnemonic: I Like My Tea Pre-sweetened
1. Initial contact (heel strike)
2. Load response (foot flat)
3. Mid-stance (single leg stance)
4. Terminal stance (heel off)
5. Pre-swing (toe-off)

2. Swing phase:

Mnemonic: In My Teapot
1. Initial swing (acceleration)
2. Mid-swing
3. Terminal swing (deceleration)

Gait cycle
Source: N. Kour, Sunanda and S. Arora, “Computer-Vision Based Diagnosis of Parkinson’s Disease via Gait: A Survey,” in IEEE Access, vol. 7, pp. 156620-156645, 2019, doi: 10.1109/ACCESS.2019.2949744. [CC BY-SA 4.0]

Pelvic movement during gait

1. Lateral shift (pelvic list): Normally, pelvis and trunk shift 2.5-5 cm (1-2 inches) towards the stance phase leg to center the weight of the body

2. Vertical shift: Keeps the center of gravity from moving up and down more than 5 cm (2 inches) during normal gait

3. Pelvic rotation: Total of 8° pelvic rotation with 4° forward on the swing leg and 4° posteriorly on the stance leg

Muscle contractions

Concentric contractions of agonist muscle produce movement (when movement is against gravity)

  • Quadriceps in load response/foot flat phase to produce knee extension against the gravity

Eccentric contractions of antagonist muscle control movement (when movement is towards gravity), e.g.

  • Ankle dorsiflexors in load response/foot flat phase to control plantar flexion which occurs towards gravity

Isometric contractions stabilize the joint (when no movement occurs)

Top-down approach for gait analysis

1. Head and trunk position over the body

  • Shoulders lift off on stance side to relieve pressure during antalgic gait
  • Trunk sways towards affected side in trendelenburg gait
  • Shoulder moves up and down on affected side in short-limbed gait

2. Hip

  • Flex to 30 degrees and extend to 20 degrees in swing and stance phase during gait cycle
  • Pelvis sags down on normal side in trendelenburg gait

3. Knee – does the patella face forward?

  • Should have some flexion at initial contact
  • Extends through stance phase
  • Extend at toe off phase

4. Foot

  • Foot progression angle (angle between the line from calcaneus to 2nd metatarsal and line of progression averaged from heel strike to toe off during stance phase of walking for each step)
  • Angle of toe out (normally 8-15 degrees out-toeing)
  • Push off
  • Clearance in swing

Types or Patterns or Abnormalities of Gait

gait abnormalities patterns
1st row (from left to right): Scissoring gait, Ataxic gait, Circumduction gait
2nd row (from left to right): Gluteus maximus gait, Steppage gait, Trendelenburg gait
Type of gaitDescriptionProbable diagnoses
Antalgic or painful gaitPatient does not bear weight on affected side and the body lurches to opposite side. There is decreased stance phase, stride length and step length.Any painful lesion of the lower extremity i.e. foot, knee, hip
Toe-walking or Equinus gaitHeel strike is avoidedHeel pain

Clubfoot

Congenital short Achilles tendon

Muscle spasticity (Cerebral palsy)

Quadriceps weakness gaitInability to maintain knee extension at heel-strike and patient may push on thigh to extend the knee and lockQuadriceps paralysis
Gluteus medius gait or Abductor lurch or Trendelenburg gaitSound side hemipelvis drops downward during single-limb stance phase on weakened side (Trendelenburg gait)
Lurch of body towards affected side in every stance phase (Abductor lurch; in contrast to the unaffected side in antalgic gait)
Polio

Developmental Dysplasia of Hip

Legg-Calve’s Perthe disease


Slipped Capital Femoral Epiphysis

Dislocated hip

Fracture neck of femur

Congenital coxa vara

Gluteus medius paralysis

Gluteus maximus gait or Extensor lurch or Rocking horse gaitTrunk lurches backward at heel-strike on weakened side to interrupt forward motion of the trunkHip extensor weakness (e.g. poliomyelitis)
Flat foot or Calcaneal or Triceps gaitAbsent push-off phaseForefoot pain or rigidity

Weakness of calf muscles

High stepping or Steppage or foot drop or Dorsiflexor gaitThe affected foot is lifted high by flexing at hip and knee joint, in order to clear the toes from ground.

The foot may audibly slap the ground and 1st strike is not with the heel.

Weak dorsiflexors

Paralyzed dorsiflexors

Common peroneal/fibular nerve palsy

Hip-hike gaitHikes up the ipsilateral pelvis, in order to clear the floorStiff knee

Foot drop

Circumduction gaitLifts the entire leg higher than normal and swings the leg out along the side, in order to clear the floor (knee is extended and ankle is plantarflexed due to rigidity in UMN lesion)Stiff hip gait
Stiff knee gait

Cerebral palsy

Limb length discrepancy

Waddling gaitBilateral drooping of hip (trendelenburg gait); Lurches on opposite side with wide base of supportMyopathies
Winking gaitExcess pelvic rotation in axial plane toward affected hip will demonstrate a pelvic wink. The pelvic wink produces extension and rotation through the lumbar spine to attain terminal hip extension.Laxity
Hip flexion contracture
Anterior capsular injury or laxity
Ataxic gaitWide-based gait (>2-4 inches); patient sways in different direction during ambulationCerebellar ataxia
Hemiplegic gaitCircumduction gait with affected arm, elbow and wrist flexed on the affected sideHemiplegia
Paraplegic gait or Scissoring gaitHypertonia in the legs, hips and pelvis means these areas become flexed to various degrees, giving the appearance of crouching, while tight adductors produce extreme adduction, presented by knees and thighs hitting, or sometimes even crossing, in a scissors-like movement while the opposing muscles, the abductors, become comparatively weak from lack of useSpastic cerebral palsy (adductor contracture)
Stamping gaitHard thump resulting from inability to perceive the distance between the foot and the floorPosterior spinal column lesions
Short limb gait<1.5 cm – compensated by pelvic tilt while walking
Upto 5 cm – compensated by equinus
>5 cm – patient’s body dips down on that side
Shuffling or festinating gaitShort steps, stooped posture and patient is propelled forwards quickly as if trying to catch up with the center of the gravity which is placed anteriorlyParkinson’s disease
Duck footed (slew-footed) gaitIn-toeingIncreased femoral anteversion
Genu recurvatum gaitHyperextension at kneeParalysis of hamstrings (polio)

ACL injury
Varus thrust gaitVarus (bow-leg) alignment as the limb accepts weight (stance phase), with a return to less varus and more neutral alignment during lift-off and the non-weightbearing (swing) phase of gait.Posterolateral knee instability
Pseudolaxity due to medial knee compartment osteoarthritis
Valgus thrust gaitValgus (knock-knee) alignment visualized during the stance phase, with a return to less valgus (more neutral) alignment during lift-off and the swing phase of gaiLateral comparment osteoarthritis


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