Physical Examination: Gait

Definition: Gait is the manner or style of walking. It is dependent upon muscles, joints, nervous system and labyrinthine functions.

Normal Gait Cycle

The gait cycle is 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 (60% of gait cycle)

It occurs when foot is on the ground and bearing weight.

Mnemonic: I Like My Tea Pre-sweetened

a. Initial contact (heel strike)
b. Load response (foot flat)
c. Mid-stance (single leg stance)
d. Push off:

  1. Terminal stance (heel off)
  2. Preswing (toe off)
gait cycle normal phases

Swing phase (40% of gait cycle)

It occurs when the foot is not bearing weight and moves forward.

Mnemonic: In My Teapot

a. Initial swing (acceleration)
b. Mid-swing
c. Terminal swing (decceleration)

Note: During the heel-strike of one foot (initial contact), the other foot is in the phase of toe-off (pre-swing phase) and vice-versa. This is called “double support” as both the feet remains in the ground and occupies 20% of the gait cycle. Hence, the gait cycle is symmetrical in both the feet.

In running, there is no period of double support; consequently, the time and percentage of the gait cycle represented by the stance phase are reduced. Instead, both the feet may be off the ground at some moment and this is known as “double float”.

Gait Analysis

Apart from the gait cycle, following components of gait must be noted:

1. Pelvic tilt: Normally, iliac crest on the side of swing leg drops approximately 5Āŗ below horizontal at mid-stance of opposite leg

2. Pelvic rotation: Normally, during swing phase, pelvis on ipsilateral side rotates 4Āŗ anteriorly and the pelvis rotates 4Āŗ posteriorly on opposite side

3. Lateral tilt: Normally, during stance phase, pelvis and trunk shifts 1 inch towards the stance phase leg

4. Width of base (horizontal distance between 2 feet during double support): Normally, 2-4 inches wide

5. Stride length (distance between 2 consecutive heel strikes of the same foot): Equal for both legs

6. Step length (distance between heel strike of one foot to the heel strike of another foot): Equal for both legs

7. Angle of toe out: During normal walking, there is slight out-toeing (8-15 degrees)

FootĀ progressionĀ angleĀ (FPA):Ā angleĀ betweenĀ theĀ lineĀ fromĀ theĀ calcaneusĀ toĀ theĀ secondĀ metatarsalĀ andĀ theĀ lineĀ ofĀ progressionĀ averagedĀ fromĀ heelĀ strikeĀ toĀ toeĀ offĀ duringĀ theĀ stanceĀ phaseĀ ofĀ walkingĀ forĀ eachĀ stepĀ (toe inĀ angleĀ isĀ positiveĀ andĀ toe-outĀ angleĀ isĀ negative).Ā 

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-Calveā€™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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