Observational Gait Analysis [Revised] 0967633516, 9780967633510

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OBSERVATIONAL GAIT ANALYSIS

The Pathokinesiology Service and The Physical Therapy Department

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Rancho Los Amigos National Rehabilitation Center ■:h •

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Observational Gait Analysis

national institutes or health WIH LIBRARY

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APR 2 ? 2006

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8LDG 10, 10 CENTLR DR. 8ETHESDA, MO 20892-1150

The Pathokinesiology Service and The Physical Therapy Department Rancho Los Amigos National Rehabilitation Center

Observational Gait Analysis Handbook The Pathokinesiology Service & The Physical Therapy Department Rancho Los Amigos National Rehabilitation Center Published by: Los Amigos Research and Education Institute, Inc. Rancho Los Amigos National Rehabilitation Center Downey, CA 90242 Graphic Design: Thomas E. Hall Gait Figure Graphics: Lydia M. Cabico All rights reserved. Unless otherwise noted, no part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system without written permission from the publisher except for the inclusion of brief quotations in a review. The Full Body Evaluation on page 72 may be reproduced for clinical use. Copyright © 2001 by the Los Amigos Research and Education Institute, Inc. ISBN 0-609-60789-8 Printed in the United States of America Not printed at county expense

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Contents Dedication.. Preface.6 Normal Human Gait.7 Normal Gait Summary.26 Range of Motion & Muscle Activity Summary.32 Normal Stride Characteristics.33 Pathological Gait Analysis.34 Gait Deviations: Most Likely Causes and Significance Ankle, Foot & Toes.36 Knee.42 Hip.46 Pelvis & Trunk.50 Problem Solving Approach.57 Excess Plantar Flexion.60 Excess Dorsiflexion.61 Gait Analysis Tips.65 Instrumentation.66 Bibliography.68 Full Body Gait Form.72

Contributors

During the 25-year evolution of this gait analysis system, scores of professionals have contributed to its refinement. By far the most significant contributor has been Dr. Jacquelin Perry, whose research and clinical knowledge serve as the foundation for this problem solving approach to gait analysis.

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Physical therapists who have contributed are: Hazel V. Adkins, Lucinda Baker, Sheri Barham, Claire Beekman, Jocelyn Blaskey, Judith Burnfield, Joyce Campbell, Kay Cerny, Teresa England, Katie Gillis, Andrea Grek, JoAnne Gronley, Maureen Jennings, Lorrie Mercer, Leslie Porter, Jacqueline Montgom¬ ery, Sara Mulroy, Karen Parker, Margery Peterson, G. Maureen Rodgers, Marcia Rosen-Greenberg, Bill Schoneberger, Chuck Toman, Jane Wetzel, Carolee Winstein, Mary Ruth Velicki, and Cindy Zablotny.

Dedication This Fourth Edition of Observational Gait Analysis is dedicated to Dr. jacquelin Perry for her outstanding contributions to the clinical science of gait analysis and rehabilitation medicine.

Dr. Perry began her career at Rancho by developing innova¬ tive surgical approaches for individuals with poliomyelitis and unstable spines. With the eradication of acute polio in this country, she turned her atten¬ tion to the rehabilitation of patients with spinal cord injury, stroke, brain injury and many other disabling conditions. With each endeavor, she applied the same high standards and dedi¬ cation to improving patient care. In 1961 she began a reha¬ bilitation program for persons who had sustained a stroke. Initiation of early rehabilitation following a stroke prevented development of contractures and resulted in improved functional outcomes. Inconsistencies between pa¬ tients’ gait function and clinical tests led Dr. Perry to develop a gait laboratory to precisely identify muscle function with

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electromyography (EMG). This information led to the design of individualized surgical proce¬ dures, including the Split Anterior Tibialis Tendon trans¬ fer to correct equinovarus. This surgery continues to be a main¬ stay of the surgical approaches for many patient groups. In collaboration with engineers in her gait laboratory, Dr. Perry developed a footswitch system for timing gait events and documenting patient’s stride characteristics. Dynamic elec¬ tromyography was refined to allow quantification by com¬ puter to identify the precise timing and intensity of muscle activity. This established EMG as a valid clinical tool for the quantification of movement dysfunction and provided information needed to make surgical and therapeutic recom¬ mendations for the patient’s care. Motion analysis, initially performed by video observation, was later augmented by kine¬ matic and kinetic systems. These methods are now in daily clinical use and widely taught around the world.

Based on her continued patient care and clinical research in the gait laboratory, Dr. Perry has authored over 400 scientific papers (topics include: abnormal gait in stroke, brain injury, ampu¬ tation, myelodysplasia, cerebral palsy, arthritis, total joint replace¬ ments, incomplete spinal cord injury, muscular dystrophy, Guillain Barre, post-polio syn¬ drome, multiple sclerosis and severe fractures). Other areas of publication include the study of orthoses, assistive devices, and wheelchair propulsion. Her book on gait analysis published in 1992 is the culmination of her research and clinical expertise and is considered the definitive work of its kind.

In addition to her exceedingly productive research efforts utiliz¬ ing quantitative laboratory mea¬ sures of function, Dr. Perry re¬ mained an active clinician and continued to refine the clinical

tool of observational gait analysis. This has ensured that advances made in the gait laboratory were available to clinicians for use in daily patient care. Dr. Perry was, and continues to be, an outstand¬ ing mentor to individuals in many rehabilitation professions. She is an emeritus Professor of the departments of Orthopedic Surgery and of Biokinesiology and Physical Therapy at the University of Southern California. She also lectures to physicians, physical and occupational thera¬ pists, orthotists and prosthetists. She is generous with her time and talents and has enriched countless careers by her teaching and guidance.

Preface Observational Gait Analysis is written to assist physical therapists and physicians to effectively evaluate pathological gait using a method of gait analysis that can easily be applied in the clinic. The first edition, Normal and Pathological Gait Syllabus, was published in 1981. In 1989 the Observational Gait Analysis Handbook was published, and revised in the third edition which was released in 1996. This fourth edition contains changes in the joint motions that reflect a larger sample of subjects. Additionally, data reflecting the normal variability in motion throughout the gait cycle have been added. Muscle activity has been revised to include data from a larger sample of subjects, and for a greater number of muscles.

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Additionally, the period of peak electromyographic activity for each muscle has been added to provide insight into the changing demands on each muscle through¬ out the gait cycle. Joint torque data have been updated to reflect an expanded database derived using inverse dynamics. Normative stride characteristic data also have been included (velocity, stride length and cadence). Consistent with the previous edition, the phases and functional tasks are defined, and a problem solving approach to observational gait analysis is presented.

Normal Human Gait Normal human gait repeats a basic sequence of limb motions that serve to progress the body along a desired path while maintaining weight¬ bearing stability, conserving energy, and absorbing the shock of floor impact.

Initial Contact (IC): The moment when the foot contacts the ground.

A gait cycle is defined as the time from heel strike to the next ipsilateral heel strike. The most common method of dividing the gait cycle is into stance and swing. Stance is the entire period the limb is in contact with the ground and swing begins when the foot comes off the ground. To facilitate observational analysis, the gait cycle is further divided into eight phases. These phases are:

Mid Stance (MSt): The body pro¬ gresses over a single, stable limb.

Loading Response (LR): Weight is rapidly transferred onto the outstretched limb, the first period of double-limb support.

Terminal Stance (TSt): Progression over the stance limb continues. The body moves ahead of the limb and weight is transferred onto the forefoot. Pre-Swing (PSw): A rapid unloading of the limb occurs as weight is transferred to the contralateral limb, the second period of double limb support. Initial Swing (ISw): The thigh begins to advance as the foot comes up off the floor. Mid Swing (MSw): The thigh continues to advance as the knee begins to extend; the foot clears the ground. Terminal Swing (TSw): The knee extends; the limb prepares to con¬ tact the ground for Initial Contact.

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NORMAL HUMAN GAIT cn.^e. Another way to view the gait cycle is from a functional standpoint. Using this model, gait is divided into three functional tasks: • Weight Accceptance (WA) • Single Limb Support (SLS) • Swing Limb Advancement (SLA)

Weight Acceptance includes the phases of Initial Contact and Loading Response. This is the period when weight is rapidly loaded onto an outstretched limb. The impact of the floor-reaction force is absorbed and the body continues in a forward path while stability is maintained. Both feet are in contact with the ground. Single Limb Support is the period when the body progresses over a single, stable limb. Weight is transferred onto the metatarsal heads and the heel comes off the ground. This functional task in¬ cludes Mid Stance and Terminal Stance. Swing Limb Advancement is the time when the limb is unloaded and the foot comes off the ground. The limb is moved from behind the body to in front of the body, reach¬ ing out to take the next step. The phases of Pre-Swing, Initial Swing, Mid Swing and Terminal Swing are components of Swing Limb Ad¬ vancement. The figure below illustrates the relationship of the phases to the functional tasks.

STANCE: 62% IC

LR

Weight Acceptance

MSt

SWING: 38% TSt

Single Limb Support

PSw

ISw

MSw

Swing Limb Advancement

TSw

Specific joint positions or motions contribute to the accomplishments of the functional tasks. These positions or motions are referred to as critical events. Each phase has one or more critical events at the ankle, knee or hip in the sagittal plane. Other, more subtle motions occur in all three planes at the foot, knee, hip and pelvis. Because motions at the ankle, knee and hip in the sagittal plane are the most important in contributing to the critical events, they are the focus of observational gait analysis. For each of the eight phases of the gait cycle, the ankle, knee and hip will be described in four ways: joint range of motion, torque demand, muscle action and func¬ tional significance. These will be abbreviated as:

Range of Motion.ROM Torque Demand.TD Muscle Action.MA Functional Significance.FS

Joint positions are constantly changing during walking. The motions occur rapidly, making observation difficult. To make observational gait analysis easier, positions at each joint have been selected which are characteristic of the phase. Range of motion data

presented in the graphs show the average position (+/-1 s.d.) through¬ out the gait cycle. Torque demand was derived using an inverse dynamics approach. External torque demand during both stance and swing are included in this book. For simplicity, the intensity of the muscle activity is not presented; rather the muscle is shown to be “on” or “off.” The time of peak activity has been indicated by a triangle ( A ). Low level muscle activity, less than 5% of the intensity during a maximal isomet¬ ric muscle contraction, has not been included. An explanation of the instrumentation used to mea¬ sure range of motion, torque demand and muscle action can be found on page 66.

Ankle Weight Acceptance initial Contact

ROM: TD: MA: FS:

loading Response

ROM: TD: MA:

FS:

The ankle joint is at neutral. Ground contact posterior to the ankle joint center creates a plantar flexion torque. The tibialis anterior and the long toe extensors, together called the pretibial muscles, maintain the foot position for Loading Response. The foot is correctly positioned for the heel rocker action at Loading Response.

5° of very rapid plantar flexion occurs. Plantar flexion torque quickly forces the foot to the floor, and then diminishes in late Loading Response. The pretibial muscles contract eccentrically in reaction to the plantar flexion torque. Tibialis anterior activity peaks. Soleus and gastrocnemius become active in late Loading Response to control tibial advancement. A heel rocker action is created. The pretibial muscles, because of their proxi¬ mal attachments, pull the tibia forward. This creates forward momentum and initiates knee flexion.

Single Limb Support mid Stance

ROM: TD: MA: FS:

Terminal Stance

ROM: TD: MA: FS:

10

The ankle dorsiflexes to 5°. A markedly increasing dorsiflexion torque occurs. The soleus and gastrocnemius are active to control forward progression of the tibia. The body is able to progress forward over a stable foot and tibia. The calf muscles create knee stability by controlling tibial advancement. Forward momentum is maintained while the ankle moves into 5° of dorsiflexion. This action is known as the ankle rocker.

The ankle dorsiflexes to 10°. The metatarsophalangeal (MTP) joints extend to 30°. Dorsiflexion torque reaches a peak. This torque creates the greatest muscle demand at any joint during the gait cycle. Calf muscle activity peaks to prevent forward tibial collapse and to allow the heel to rise. The calf muscles allow maximal forward progression by controlling ankle dorsiflexion and allowing the heel to rise. This action is known as the forefoot rocker and contributes to contralateral step length.

Normal Ankle

Joint Motion, Torque Demand & Muscle Action

20 10 0 10 ■

Range of Motion

20 -

15 10 5 Torque Demand

o5 -

Muscle Action

Soleus

Gastrocnemius Tibialis Posterior Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus Peroneus Longus Peroneus Brevis

100

Gait Cycle %

11

Ankle

Continued

Swing Limb Advancement Pre-Swing

ROM: TD: MA:

FS:

Initial Swing

ROM: TD: MA: FS:

The ankle moves into 15° of plantar flexion. The MTP joints extend to 60°. The dorsiflexion torque rapidly decreases. Calf muscle activity ceases in early Pre-Swing. Residual plantar flexor activity and passive tension contribute to the ankle moving into plantar flexion. Pretibial muscle activity is initiated in preparation for dorsiflexing the ankle. The forefoot remains on the floor to provide a balance assist. Plantar flexion of the partially unweighted foot assists with knee flexion and Swing Limb Advancement. The ankle moves to 5° of plantar flexion. A very low level plantar flexion torque is present. The pretibial muscles are active to initiate dorsiflexion. Extensor hallucis longus and extensor digitorum longus peak in activity. The dorsiflexion needed to clear the foot in the next phase begins here; dorsiflexion to neutral is not yet achieved.

Mid Swing

ROM: TD: MA: FS:

The ankle dorsiflexes to neutral. A very low level plantar flexion torque is present. The pretibial muscles are active. The foot clears the ground by one centimeter.

Terminal Swing

ROM: TD: MA: FS:

The The The The

12

ankle remains at neutral. low level plantar flexion torque diminishes to zero. pretibial muscles are active. neutral position assures a heel contact for Initial Contact.

Normal Ankle

Joint Motion, Torque Demand & Muscle Action

20 Range of Motion

10 -

o10 20 '

15 10 5 Torque Demand

o5 -

Muscle Action

Soleus

Gastrocnemius Tibialis Posterior Tibialis Anterior Extensor Digitorum Longus Extensor Hallucis Longus Peroneus Longus Peroneus Brevis

Gait Cycle %

0

12

31

62

50

13

I

75

87

100

Subtalar Joint Weight Acceptance ROM: TD: MA:

FS:

During Loading Response, the calcaneus everts 5° and the subtalar joint moves into pronation. An eversion torque occurs because the calcaneus is lateral to the weight¬ bearing axis of the tibia. Both the tibialis anterior and the tibialis posterior contract eccentrically. The tibialis anterior ceases muscle activity after maximum pronation occurs. The tibialis posterior activation continues into Single Limb Support. Subtalar joint pronation assists in the shock absorption of the limb loading impact. Pronation induces internal rotation of the tibia. This reduces rotary stress on the ankle joint. Subtalar joint pronation also unlocks the midtarsal joint for shock absorption of forefoot floor contact.

i Floor Contact

LOADING RESPONSE

Single Limb Support ROM:

TD:

MA: FS:

During Mid Stance and early Terminal Stance, the eversion position remains relatively unchanged from the position achieved at the end of Weight Accep¬ tance. In late Terminal Stance, there is a progressive reduction of eversion to approximately 2° of eversion by the end of Single Limb Support. The eversion torque diminishes in Mid Stance. An inversion torque is created in Terminal Stance as the heel rises. This is caused by body weight progressing onto the obliquely aligned metatarsal heads and the pull of the soleus. The tibialis posterior, soleus, and the peroneals are active throughout Single Limb Support. Tibialis posterior and soleus activity initially provides eccentric control of eversion then concentrically acts to move the subtalar joint towards inversion. Reduction in calcaneal eversion increases stability of the midtarsal joints, helping to create a rigid forefoot lever during Terminal Stance. This action helps to promote the forefoot rocker. Activity of the peroneus longus and brevis provides lateral stability of the subtalar joint and foot.

Swing Limb Advancement ROM: The subtalar joint achieves a neutral position during Pre-Swing and then TD: MA: FS:

remains so throughout the remainder of Swing Limb Advancement. The inversion torque diminishes to zero during Pre-Swing and remains near this level throughout Swing Limb Advancement. The pretibials are active throughout swing. The foot clears the ground. The ankle and subtalar joint are positioned for heel contact.

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Knee Weight Acceptance Initial Contact

ROM: TD: MA: FS:

LOADING RESPONSE

ROM: TD: MA:

FS:

Observationally, the knee appears to be at neutral but may be technically flexed 5°. A brief extension torque occurs. The quadriceps continue to contract in preparation for Loading Response. The hamstrings act to counteract the brief extension torque. At the moment of Initial Contact, the extension torque stabilizes the knee.

The knee flexes to 15°. A rapid, moderate intensity flexion torque is caused by the heel rocker action and the position of the body behind the foot. Eccentric quadriceps activity peaks to meet torque demands and to absorb shock. Diminishing activity of the hamstrings primarily assists with maintain¬ ing the hip position. Shock is absorbed and limb stability is maintained while forward progression continues.

Single Limb Support Mid Stance

ROM: TD:

MA:

FS:

Terminal Stance

ROM: TD: MA:

FS:

16

The knee extends, although not completely (5° flexion). Observationally, it appears to be at neutral. The forward momentum created by the contralateral swing limb produces an extension torque. This torque allows the quadriceps activity to stop, even though the knee is not fully extended. Quadriceps activity provides dynamic knee stability until the knee extension torque begins. The knee is indirectly stabilized by the calf muscles which restrain the tibia, allowing the femur to advance faster than the tibia. Knee stability is maintained via the knee extension torque and calf muscle activity.

Observationally, the position of the knee appears unchanged from Mid Stance. The extension torque peaks and then diminishes by the end of the phase. No knee extensor muscles are active. Restraint of the tibia by the calf muscle continues to stabilize the knee. Biceps femoris short head activity may be present to prevent knee hyperextension in some subjects. Joint stability is maintained as forward progression continues.

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ORMAL KNEE

Joint Motion, Torque Demand & Muscle Action

60 50 40 30

Range of Motion

20 10 0 10 5 -

Torque Demand

0 5 10 ■

Muscle Action

Vastus Intermedius Vastus Medialis Longus Vastus Medialis Oblique Vastus Lateralis Rectus Femoris Biceps (Short Head] Gracilis Sartorius Biceps (Long Head] Semimembranosus Semitendinosus

Gait Cycle %

0

12

31

50

62

17

75

87

100

Knee

CONTINUED

Swing Limb Advancement Pre-Swing

ROM: TD:

MA:

FS:

initial Swing

ROM: TD: MA: FS:

mid Swing

ROM: TD: MA:

FS:

Terminal Swing

ROM: TD: MA: FS:

18

The knee rapidly flexes to 40°. Rapid unloading of the limb by transfer of body weight to the other foot allows the residual plantar flexion at the ankle to generate a flexion torque at the knee. Motion occurs with only minimal knee flexor activity from the gracilis. When rectus femoris EMG activity is present, it may act to restrain the rapid passive knee flexion. Pre-Swing knee flexion contributes significantly to the knee flexion required for limb clearance. The motion in this phase is more than half of the knee flexion required in swing. For this reason, Pre-Swing is included in Swing Limb Advancement even though the foot is still in contact with the floor.

Further rapid knee flexion to 60° occurs. Thigh advancement by active hip flexion combined with tibial inertia creates a knee flexion torque. Activity of the biceps femoris short head, sartorius and gracilis peaks. Knee flexion is aided by flexion at the hip. The foot clears the floor as the thigh begins to advance.

The knee rapidly extends to 25°. The tibia achieves a vertical position. Transition to a knee extension torque in late Mid Swing, due to tibial momentum, assists with knee extension. Knee extension is created by momentum and gravity. The short head of the biceps may control the rate of knee extension. The hamstrings become active in late Mid Swing. The knee extension necessary for step length begins in this phase.

The knee extends to neutral but then may move into 5° flexion. The knee extension torque, generated by the rapidly advancing tibia, continues. The quadriceps are active concentrically to insure full knee extension. The hamstrings peak in their activity as they function to decelerate the thigh. Step length is optimized by the leg reaching out.

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NORMAL KNEE

Joint Motion, Torque Demand & Muscle Action

0

A IC 60 50 40

Range of Motion

30 20 10 n u-

10 5 Torque Demand 5 10 Muscle Action Vastus Intermedius Vastus Medialis Longus Vastus Medialis Oblique Vastus Lateralis Rectus Femoris Biceps (Short Head) Gracilis Sartorius Biceps (Long Head) Semimembranosus Semitendinosus

Gait Cycle %

0

12

31

50

62

75

87

100

Hip & Pelvis All motions of the hip describe the femur relative to vertical, rather than the femur relative to the pelvis. Use of vertical as the reference makes observation easier, as the pelvis has its own motion pattern. The neutral position of the pelvis in the sagittal plane is 10° of anterior tilt.

Weight Acceptance Initial Contact

ROM:

I’D: MA:

FS:

Loading Response

ROM:

TD: MA:

FS:

The 20° of thigh flexion achieved in Terminal Swing is maintained. The pelvis is in 5° of forward rotation in the horizontal plane. A rapid, high intensity flexion torque begins. All hip extensors are active in preparation for their role in stabilizing the thigh during Loading Response. The primary muscles are the gluteus maximus and adductor magnus. The intensity of semimembranosus and biceps femoris long head activity is reduced. The hip and pelvis are in a position of forward reach.

The thigh remains in 20° of flexion. The pelvis remains in a position of 5° of forward rotation. A rapid, high intensity flexion torque is present. This is the second highest torque demand during the gait cycle. An adduction torque begins. The lower fibers of the gluteus maximus, the adductor magnus and the hamstrings are active to counteract the flexion torque. The posterior tensor fascia lata, gluteus medius, gluteus minimus and upper fibers of the gluteus maximus peak in activity as they contract to stabilize the pelvis in the frontal plane. The hip joint is stable during shock absorption. Trunk flexion is prevented and the thigh is stabilized. The pelvis is stable in the frontal plane.

Single Limb Support mid Stance

ROM:

TD:

MA: FS:

20

The thigh extends to neutral. The pelvis rotates backwards to neutral. The contralateral swing limb moves the body past the stance limb; this leads to a change from a flexion to an extension torque by the end of Mid Stance. The adduction torque continues. No hip muscle activity is required in the sagittal plane. The pelvis is stabi¬ lized in the frontal plane by the hip abductor group. A stable joint position is achieved in the sagittal plane without hip extensor muscle demand. The pelvis is stabilized to prevent a drop in the frontal plane.

Normal Hip

Joint Motion, Torque Demand & Muscle Action

30 20 10

Range of Motion

o■ 10 20 30 10

Torque Demand

5 ■ 0 5 10

Muscle Action

Gluteus Maximus, Lower Adductor Magnus Biceps (Long Head) Semimembranosus Semitendinosus Tensor Fascia Lata Gluteus Maximus, Upper Gluteus Medius Rectus Femoris Iliacus Adductor Longus Gracilis Sartorius

Gait Cycle %

0

12

31

50

62

21

I

75

87

100

Hip & Pelvis Terminal Stance

CONTINUED

ROM: TD: MA:

FS:

The thigh extends to a trailing position of 20° hyperextension. Anterior tilt and 5° of backward rotation of the pelvis contribute to thigh hyperextension. A hip extension torque keeps the hip joint stable. The adduction torque rapidly diminishes. Activity of the posterior fibers of the tensor fascia lata ceases while the anterior fibers become active during Terminal Stance, possibly to restrain hyperextension of the hip (tensor fascia lata EMG pattern is highly variable). The body is allowed to advance past the foot to maximize step length, while the limb remains stable. Pelvic rotation makes the gait pattern look smooth.

Swing Limb Advancement Pre-Swing

ROM: TD: MA: FS:

initial Swing

ROM: TD: MA: FS:

Mid Swing

ROM: TD: MA: FS:

Terminal Swing

The thigh falls forward. It appears to be vertical but is actually in slight hyper¬ extension (10°). The pelvis remains in 5° of backward rotation. As the limb is unloaded, the hip extension torque diminishes. Adductor longus activity dynamically contributes to the femur flexing for¬ ward, and rectus femoris contracts in some persons. Limb advancement begins. Hip flexion motion contributes to knee flexion.

15° of thigh flexion is achieved. The pelvis remains in 5° of backward rotation. Tibial inertia initially maintains the hip extension torque. By the end of Initial Swing the hip extension torque approaches zero. The iliacus, gracilis and sartorius peak in activity. Adductor longus also is active. Limb advancement continues.

25° of thigh flexion is achieved. The pelvis rotates forward to a position of neutral rotation. Limb inertia, due to the rapidly advancing tibia, creates a gradually increasing hip flexion torque. The hamstrings initiate activity in late Mid Swing. Thigh advancement slows. The momentum created by the swinging limb helps to carry the body past the contralateral stance limb.

ROM: The thigh falls slightly to 20° of flexion. The pelvis rotates forward 5°. TD: The hip flexion torque diminishes at the end of Terminal Swing. MA: The hamstrings peak in their activity as they function to decelerate the leg. The adductor magnus and lower fibers of the gluteus maximus initiate activity in preparation for their role in stabilizing the hip in the sagittal plane during Weight Acceptance. At the same time, the tensor fascia lata, gluteus medius and upper fibers of the gluteus maximus become active in preparation for their role in stabilizing the pelvis in the frontal plane during Weight Acceptance. The limb is positioned for a heel first initial contact. Forward rotation of the pelvis contributes to step length.

FS:

22

Normal Hip

Joint Motion, Torque Demand & Muscle Action

30 20 10

Range of Motion

0 10 20 30 10

Torque Demand

5 0 5

Muscle Action

10

Gluteus Maximus, Lower Adductor Magnus Biceps (Long Head) Semimembranosus Semitendinosus Tensor Fascia Lata Gluteus Maximus, Upper Gluteus Medius Rectus Femoris Iliacus Adductor Longus Gracilis Sartorius

Gait Cycle %

0

12

31

50

62

75

87

100

Trunk During walking, the back extensors and abdominal muscles stabilize the trunk in the sagittal, horizontal and frontal planes.

ROM

The trunk rotates approximately 5° in the horizontal plane. Trunk rotation results in shoulder rotation which causes arm swing. The direction of rotation of the shoulder is opposite to the direction of rotation of the pelvis. Although arm swing is obvious, segmental rotation of the trunk is imperceptible. The trunk appears erect in the frontal and sagittal planes.

MUSCLE ACTIVITY Abdominals The internal and external abdominal obliques are active at a low level through¬ out the gait cycle. When present, activity of the rectus abdominus usually occurs during ipsilateral and contralateral Mid and Terminal Swing.

Extensors The bilateral deep trunk extensors and rotators are active to stabilize the trunk during Loading Response when the flexion torque is greatest. The ipsilateral erector spinae are active during Pre-Swing as the contralateral limb is loaded.

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I

Notes

Normal Gait Summary This section condenses the previous information into the key concepts of normal gait. It may be used as a quick reference during the problem solving process. For each phase, the characteristic position at each joint and the major muscles acting there are listed. The critical events are those motions or positions which contribute to the accomplishment of the functional tasks.

1. Weight Acceptance ACCOMPLISHMENTS:

• Forward progression • Stability • Shock absorption

Initial Contact:

The moment when the foot strikes the ground.

Critical Event:

HIP

20° flexion

extensors

KNEE

5° flexion

quadriceps

ANKLE

0°

pretibials

Heel first contact

Q

0

26

Loading Response

Critical Events:

Shock is absorbed as forward momentum is preserved. A foot-flat position is achieved. HIP

20° flexion

extensors & abductors

KNEE

15° flexion

quadriceps

ANKLE

5° plantar flexion

pretibials

Hip stability; controlled knee flexion and ankle plantar flexion

s)

0

2. Single Limb Support • Stability • Forward progression

ACCOMPLISHMENTS:

Mid Stance

The body progresses over the foot in a controlled manner. The contralateral swing limb provides the momentum.

Critical Event:

HIP

0°

abductors

KNEE

5° flexion

quadriceps initially, then no muscle activity

ANKLE

5° dorsiflexion

calf

Controlled tibial advancement

0 28

terminal Stance

Critical Events:

The body progresses past the forefoot. HIP

20° apparent hyperextension

no muscle activity

KNEE

5° flexion

no muscle activity

ANKLE

10° dorsiflexion

calf

Controlled ankle dorsiflexion with heel rise; trailing limb

Q

0 29

3. Swing Limb Advancement ACCOMPLISHMENTS:

• Foot clearance • Limb advancement

PRE-SWING

The forefoot remains on the floor. The knee rapidly flexes while weight is shifted to the other limb.

Critical Event:

HIP

10° apparent hyperextension

adductors

KNEE

40° flexion

no muscle activity

ANKLE

15° plantar flexion

no muscle activity

Passive knee flexion to 40°; ankle plantar flexion

Q

0

INITIAL Swing

The thigh begins to advance; the knee continues to flex and the foot clears the ground.

Critical Events:

HIP

15° flexion

flexors

KNEE

60° flexion

flexors

ANKLE

5° plantar flexion

pretibials

Hip flexion to 15°; knee flexion to 60°

Q

0

30

Mid Swing

The thigh continues to advance as the knee begins to extend. Foot clearance is

maintained.

Critical Events:

HIP

25° flexion

flexors initially, then hamstrings

KNEE

25° flexion

flexors

ANKLE

0°

pretibials

Further hip flexion to 25° and ankle dorsiflexion to 0°

0

Terminal Swing

Critical Event:

The leg reaches out to achieve step length. HIP

20° flexion

hamstrings

KNEE

5° flexion

quadriceps

ANKLE

0°

pretibials

Knee extension to neutral (possibly 5° flexion)

Terminal Swing

Range of Motion & Muscle Activity

a 11 k 111 Weight Acceptance

Swing Limb Advancement

Single Limb Support

% Gait Cycle

0

0-12

12-31

31-50

50-62

62-75

75-87

87-100

Reference Limb

IC

LR

MSt

TSt

PSw

ISw

MSw

TSw

PSw

PSw

Opposite Limb

ISw MSw TSw

TRUNK

IC/LR

MSt

Abdomina Is

Abdominals -►

◄-Exter 5° Fwd Rot

5° Fwd Rot

0°

20° Flex

20° Flex

0°

5° Flex

15° Flex

5° Flex

5° Bkwd Rot

TSt

5° Bkwd Rot

5° Bkwd Rot

0°

5° Fwd Rot

25°

20°

Flex

Flex

Flex

60° Flex

25° Flex

PELVIS

THIGH VS VERTICAL (HIP)

20° 10° Apparent Hvperext Hyperext

5° Flex

40° Flex

KNEE L^UuLU ILLUj

◄-Flexors-► n°

cl° D PF

5° DF

10° DF

15° PF

5 PF

60° MTP Ext

0°

r»o

r»o

0°

0°

ANKLE ◄- — Calf- ►

0°

TOES

0°

0°

30° MTP Ext

©2001 LAREI, Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242

32

Normal Stride Characteristics (Mean, Standard Deviation)

The stride characteristic information was derived from Stride Analyzer and footswitch data recorded from 420 subjects tested at the Pathokinesiology Laboratory at Rancho Los Amigos National Rehabilitiation Center. Females (n=27)

Males (n=34)

Velocity (m/min)

67.9 (9.4)

70.7 (8.0)

Stride Length (m)

1.15 (.15)

1.18 (.14)

118.4 (10.3)

120.4 (7.8)

Females (n=28)

Males (n=25)

Velocity (m/min)

73.2 (8.9)

73.4 (11.6)

Stride Length (m)

1.36 (.13)

1.46 (-16)

Cadence (steps/min)

107.2 (6.8)

99.8 (8.0)

20-69 Years Old

Females (n=129)

Males (n=107)

Velocity (m/min)

79.3 (9.5)

82.1 (10.3)

Stride Length (m)

1.32 (.13)

1.48 (.15)

Cadence (steps/min)

121.0 (8.5)

111.0

70+ Years Old

Females (n=42)

Males (n=28)

Velocity (m/min)

67.4 (12.5)

74.3 (9.0)

Stride Length (m)

1.12 (.15)

1.34 (.13)

119.9 (10.6)

111.3 (7.4)

6-12 Years Old

Cadence (steps/min) 13-19 Years Old

Cadence (steps/min)

33

(7.6)

Pathological Gait Analysis In order to identify pathological gait deviations, the clinician must compare normal gait patterns and joint positions to the picture the patient presents. This is best learned segmentally, starting with the ankle and toes and then pro¬ ceeding to the knees, hips, pelvis and trunk. This section includes gait analysis forms for each body segment. Each form lists the most common deviations seen at that particular segment. A definition of each deviation is included. Following each segmental form is a list of the most likely causes and the signifi¬ cance of each deviation.

A deviation may be the result of problems at other joints. In those cases, the deviation at the other joint is listed as a possible cause. For example, the most likely cause of Excess Dorsiflexion in Weight Acceptance is “secondary to excess hip and knee flexion.” The reader should refer to the most likely causes of Excess Hip Flexion and Excess Knee Flexion to determine the cause of Excess Dorsiflexion in Weight Acceptance. In this section, the limb being evaluated is termed the reference limb. The possible causes listed are pathologies found in the reference limb unless otherwise indicated.

Once the learner has grasped the information presented on each segmental form, the Full Body form should be used to perform a full body analysis. Seeing the total picture facilitates a problem solving approach. It allows the observer to see how deviations at various joints are related. After performing a gait analysis, identify the major problems that prevent the accomplishment of the three functional tasks. Then determine the possible causes of each of these problems. Consider

what may be the source of the problem. Refer to the list of most likely causes to verify your suspi¬ cion or to refocus your thinking. The list is not meant to be exhaus¬ tive but rather suggests those causes which most frequently result in a deviation. The significance of each deviation tells how the deviation interferes or assists with the patient’s ability to accomplish one of the func¬ tional tasks of Weight Acceptance, Single Limb Support or Swing Limb Advancement.

The gait analysis forms are designed to aid the observer in determining the importance of each deviation in accomplishing each functional task. The boxes on the forms are keyed as follows: White box:

(Major Deviation) Indicates that the deviation significantly impacts the mechanics of walking. The deviation may be the primary or a contributory factor affecting the ability to accom¬ plish the functional task.

Light gray box: (Minor Deviation) Indicates that the deviation may occur in a phase, but it does not affect the accomplishment of the func¬ tional task. Dark gray box: Indicates that either the deviation does not occur during that phase, or that position would not be considered abnormal.

35

Ankle, Foot & Toes Reference Limb

LQ

rQ

PSw Ankle

Forefoot Contact Foot Flat Contact Foot Slap

Excess Plantar Flexion Excess Dorsiflexion Inversion/Eversion: Iv/Ev Heel Off No Heel Off Drag Contralateral Vaulting

Toes

Up

Inadequate Extension Clawed/Hammered: Cl/Ha

MAJOR PROBLEMS: (WA) Weight Acceptance

(SLS) Single Limb Support

(SLA) Swing Limb Advancement

36

ISw

MSw

TSw

Ankle & Foot Forefoot Contact Initial contact with the ground made by the forefoot

Excess Inversion/Eversion In version/eversion of the calcaneus or forefoot greater than normal for the specific phase

Foot-Flat Contact Initial contact with the ground made by the entire foot

Heel Off Heel not in contact with the ground during LR or MSt

Foot Slap Uncontrolled plantar flexion at the ankle joint after heel contact, accompanied by a slapping sound

No Heel Off Absence of heel rise during TSt or PSw

Excess Plantar Flexion Plantar flexion greater than normal for the specific phase

Drag Contact of the toes, forefoot or heel with the ground during SLA

Excess Dorsiflexion Dorsiflexion greater than normal for the specific phase

Contralateral Vaulting Rising on the forefoot of the opposite stance limb during limb advancement of the reference leg

TOES Up Extension of the toes beyond neutral Inadequate Extension Less metatarsalphalangeal extension than normal for the specific phase Clawed/Hammered Flexion of the distal interphalangeal joints and flexion or extension of the proximal interphalangeal joints

37

I

ANKLE & FOOT Task

Forefoot or Foot-flat Contact

wa

• Secondary to excess knee flexion in TSw • Compensatory for weak quadriceps to avoid normal LR • Secondary to excess plantar flexion in TSw • Heel pain

• Poor position for heel rocker • Decreases forward momentum of the tibia • Decreases shock absorption by limiting knee flexion (forefoot contact)

Foot Slap

WA

• Weak pretibials

• Decreases forward momentum of the tibia • Decreases shock absorption by limiting knee flexion

EXCESS Plantar flexion

WA SLS

• • • • •

Plantar flexion contracture Plantar flexor hypertonicity Weak quadriceps Impaired proprioception Ankle pain

• Poor position for heel rocker • Decreases shock absorption by limiting knee flexion (WA) • Decreases forward progression of the tibia over the ankle and forefoot

SLA

• • • •

Weak pretibials Plantar flexion contracture Plantar flexor hypertonicity Lack of selective dorsiflexion control (TSw)

• Interferes with foot clearance • Interferes with foot position for IC

WA

• Secondary to excess hip or knee flexion

• Increases the demand on the hip and knee extensors • Decreases limb stability

SLS

• Weak calf • Secondary to excess hip and knee flexion • Intentional to lower the opposite limb for contact (TSt) • Excess midfoot dorsiflexion secondary to limited ankle mobility

• Increases the demand on the hip and knee extensors • Interferes with heel rise and decreases step length of the opposite limb (TSt)

Excess DORSIFLEXION

Most Likely Cause

Significance

Major Problem

38

Major Problem

Task

Excess inversion

WA SLS SLA

• Tibialis anterior, tibialis posterior or soleus overactivity • Varus contracture • Plantar flexion contracture (SLS) • Weak peroneals • Lack of selective motor control of the pretibials • Variations in skeletal alignment resulting in a high arch • Internal tibial torsion

• Poor position for WA • Rigid foot resulting in decreased shock absorption • Decreases stability in SLS • Decreased foot clearance in SLA

excess Eversion

WA SLS

• Weak tibialis posterior (WA & SLS), soleus (SLS) • Plantar flexion contracture (SLS) • Valgus deformity • Referred from the knee or hip joint • Variations in skeletal alignment resulting in a low arch • Weak tibialis anterior • Peroneal hypertonicity

• Rotary strain on midfoot and knee • Interferes with rigid lever for forefoot rocker • Can be used to gain dorsiflexion range when ankle mobility is limited

SLA

Most Likely Cause

Significance

Heel Off

WA SLS

• Secondary to excess plantar flexion • Heel pain • Secondary to excess knee flexion

• Decreases the base of support due to smaller weight bearing surface • Increases pressure on the MT heads

NO HEEL OFF

SLS SLA

• Weak calf • Ankle or metatarsal head pain • Secondary to inadequate extension of the toes • Secondary to excess dorsiflexion

• Interferes with progression over the forefoot • Decreases step length of the opposite limb • Results in limited knee flexion in SLA

Drag

SLA

• Secondary to limited hip flexion, limited knee flexion or excess plantar flexion • Impaired proprioception

• May result in loss of balance • Interferes with limb advancement • May cause injury to toes

Contralateral Vaulting

SLA

• Compensatory for limited flexion of the swing limb • Compensatory for longer swing limb

• Increases the demand on the calf muscles

39

Toes Major Problem

Task Most Likely Cause

UP

SLA

• Compensatory for weak tibialis anterior or insufficient dorsiflexion • Toe extensor hypertonicity

• May help with foot clearance • May cause skin irritation or callouses on the dorsum of the toes from rubbing against the shoe

Inadequate Extension

SLS SLA

• Limited toe extension range of motion including hallux valgus, or hallux rigidus • Toe flexor hypertonicity • Forefoot pain • Secondary to no heel off

• Interferes with forward progression • Decreases step length of the opposite limb

Clawed/Hammered

SLS

•Toe flexor or extensor hypertonicity • Imbalance of the long toe extensors and intrinsic foot muscles • Compensatory for weak plantar flexors

• Interferes with forward progression • Decreases step length of the opposite limb

40

Significance

Notes

Knee Reference Limb:

lD rD Major Deviation Minor Deviation

Knee

Flexion: Limited Excess Wobbles Hyperextends Extension Thrust Varus/Valgus: Vr/Vl

Excess Contralateral Flexion

MAJOR PROBLEMS: (WA) Weight Acceptance

(SLS) Single Limb Support

(SLA) Swing Limb Advancement

42

I

Knee Limited Flexion Less than normal knee flexion for the specific phase

Extension Thrust Forceful motion of the knee towards extension

Excess Flexion Greater than normal knee flexion for the specific phase

Varus/Valgus Lateral/medial angulation of the tibia relative to the femur

Wobbles Alternating flexion and extension of the knee occurring during a single phase

Excess Contralateral Flexion Knee flexion greater than normal during LR, MSt or TSt of the opposite limb; this occurs during SLA of the reference limb

Hyperextends Position of knee beyond neutral extension

43

I

Knee Major Problem

Task Most Likely Cause

LIMITED FLEXION

WA

• Weak quadriceps • Secondary to forefoot or footflat contact with a tight calf • Knee pain • Quadriceps hypertonicity • Impaired proprioception

SLA

• Secondary to excess hip • Interferes with foot clearance (ISw) flexion or no heel off in TSt • Decreased knee flexion in PSw • Impaired motor control resulting in usually results in decreased knee inability to rapidly flex the knee flexion in ISw • Knee pain • Increases energy cost • Knee extension contracture • Extensor hypertonicity (plantar flexor and/or knee extensor) • Limited thigh advancement second¬ ary to hamstring hypertonicity or hip flexor weakness

WA SLS

• • • •

Excess Flexion

• • • •

SLA

Knee flexion contracture Knee flexor hypertonicity Secondary to excess hip flexion Secondary to decreased contralateral limb stance stability (WA) Secondary to excess dorsiflexion Knee pain Intentional to lower the opposite limb (TSt) Secondary to posterior pelvic tilt with hip flexion contracture (SLS)

• Knee flexion contracture • Inability to selectively extend the knee while maintaining a flexed hip • Weak quadriceps • Hamstring hypertonicity • Intentional to allow forefoot or footflat contact

44

Significance • Decreases shock absorption • Decreases forward momentum of the tibia • Potential injury to the posterior capsule of the knee joint

• Increases the demand on the plantar flexors, quadriceps, and hip extensors. • Decreases limb stability

• Decreases step length of the reference limb • Interferes with heel first contact

Major Problem

Task Most Likely Cause

WOBBLES

WA SLS

• Impaired proprioception • Quadriceps hypertonicity • Plantar flexor hypertonicity

• Decreases forward momentum • Decreases limb stability and balance

HYPEREXTENDS

WA

• Secondary to forefoot contact with excess plantar flexor tightness • Weak quadriceps • Impaired proprioception • Quadriceps hypertonicity • Intentional to increase limb stability

• Decreases shock absorption • Decreases forward progression of the tibia • Potential injury to the posterior structures of the knee joint

SLS

• Secondary to excess plantar flexion • Impaired proprioception • Intentional to increase limb stability

• Decreases forward progression of the tibia • Potential injury to the posterior elements of the knee joint

SLA

• Impaired proprioception • Intentional to extend the knee

• May assist in achieving maximum knee extension

Varus/Valgus

SLS

• Joint or ligamentous instability • Bony deformity • Resulting from a dysfunctional subtalar joint • Secondary to lateral trunk lean (valgus)

• Decreases limb stability • Necessitates compensation proximal or distal to the knee • May result in knee pain

Excess Contralateral FLEXION

SLA

• Intentional to lower reference swing limb to the ground • Secondary to excess knee flexion in SLS of the opposite limb

• Relatively lengthens the reference swing limb and interferes with foot clearance and limb advancement • Increases the energy demand on the opposite stance limb

or Extension Thrust

Significance

HIP (Thigh Vs. Vertical)

Reference Limb:

lD rD Major Deviation Minor Deviation

Hip

Flexion: Limited Excess Past Retract Rotation: IR/ER

AD/ABduction: AD/AB

MAJOR PROBLEMS:

(WA) Weight Acceptance

(SLS) Single Limb Support

(SLA) Swing Limb Advancement

46

H IP

(Thigh vs. Vertical) All definitions refer to the position of the femur relative to vertical rather than the position of the femur relative to the pelvis.

Limited Flexion Less than normal hip flexion for the specific phase

Internal Rotation Considered a deviation if the patella is facing medially

Inadequate Extension Less than normal hip extension for the specific phase

External Rotation Considered a deviation if the patella is facing laterally

Past Retract A visible forward and then back¬ ward movement of the thigh during TSw

Adduction Considered a deviation if other than neutral Abduction Considered a deviation if other than neutral

The term circumduction has been deleted because it is a composite movement of abduction and external rotation followed by adduction and internal rotation. Each component can be separately altered by pathology.

47

I

H IP

(Thigh Vs. Vertical)

Major Problem

Task Most Likely Cause

Limited flexion

WA

• Intentional to decrease the demand • May disturb the normal LR by on the hip extensors limiting knee flexion and ankle • Limited hip flexion achieved in TSw plantar flexion

SLA

• Weak hip flexors • Impaired motor control resulting in an inability to rapidly flex the hip • Range of motion of straight leg raise less than approximately 40° • Hip extensor hypertonicity • Hip pain • Limited hip flexion range of motion • Intentional to decrease the demand on the hip extensors at LR • Secondary to foot drag • Secondary to past retract in TSw

• Interferes with the ability to clear the foot, advance the limb and create forward momentum • Decreases step length

WA

• Hip flexion contracture • Secondary to excess dorsiflexion and excess knee flexion

• Increases the demand on the quadriceps and hip extensors • Decreases limb stability

SLS

• Hip flexion contracture • Secondary to excess knee flexion with excess ankle dorsiflexion • Hip pain • Secondary to no heel off

• Increases the demand on the quadriceps and hip extensors • Decreases step length of the opposite limb • Decreases limb stability

SLA

• Intentional to clear the foot in the presence of limited knee flexion, excess plantar flexion or longer swing limb

• Increases energy cost • May help with limb clearance

SLA

• Inability to selectively extend the knee while the hip is flexed • Impaired proprioception • Intentional to help achieve a stable knee in LR • Intentional to decrease the demand on the quadriceps and hip extensors at LR • Hamstring hypertonicity • Intentional to position the limb for IC with an excessively plantar flexed ankle

• Decreases step length

Excess Flexion

Past Retract

48

Significance

Major Problem

Task Most Likely Cause

INTERNAL ROTATION

WA SLS SLA

• Internal rotation contracture or hypertonicity • Femoral anteversion • Intentional to increase knee stability in the presence of weak quadriceps (stance)

• Results in a toe-in position which increases the relative length of the foot, impairs forward progression and may interfere with limb clearance • May increase stress on the lateral knee joint during forward progres¬ sion of body weight (WA, SLS)

External ROTATION

WA SLS

• External rotation contracture • Intentional to progress over the stance limb when ankle dorsiflexion mobility is limited

• Results in toe-out position which increases the base of support and decreases the forefoot lever • May result in stress on the medial knee joint during forward progres¬ sion of body weight

SLA

• Intentional to advance the limb to substitute for weak hip flexors • Intentional to functionally shorten the limb

• May help with limb clearance

ADDUCTION

WA SLS SLA

• Adductor hypertonicity/contracture • Secondary to contralateral pelvic drop

• Decreases the base of support • Decreases limb stability • May increase the relative leg length and interfere with limb clearance

ABDUCTION

WA SLS SLA

• Abduction contracture • Reference limb functionally longer • Compensatory to clear a longer swing limb

•• Increases the base of support • Decreases the relative leg length

Significance

49

Pelvis & Trunk Reference Limb:

lQ

rQ Major Deviation Minor Deviation

Trunk

Lean: B/F Lateral Lean: R/L Rotates: B/F

Pelvis

Hikes Tilt: P/A Lacks Forward Rotation Lacks Backward Rotation Excess Forward Rotation Excess Backward Rotation Ipsilateral Drop Contralateral Drop

Major

PROBLEMS:

(WA) Weight Acceptance

(SLS) Single Limb Support

(SLA) Swing Limb Advancement

50

Pelvis Hikes Elevation of one side of the pelvis above neutral, approximating the pelvis to the shoulder

Lacks Backward Rotation Less than normal backward rotation for a specific phase Excess Forward Rotation Greater than normal forward rotation for a specific phase

Posterior Tilt Tilting of the pelvis so that the pubic symphysis is directed up¬ ward, flattening the lumbar spine

Excess Backward Rotation Greater than normal backward rotation for a specific phase

Anterior Tilt Tilting of the pelvis so that the pubic symphysis is directed downward, increasing the lumbar lordosis Lacks Forward Rotation Less than normal forward rotation for a specific phase

Ipsilateral Drop Iliac crest on the reference limb lower than the iliac crest on the opposite side Contralateral Drop Iliac crest on the opposite side lower than the iliac crest on the reference limb

TRUNK Backward Lean Backward position of the trunk relative to vertical

Lateral Lean (R or L) Leaning of the trunk to one side relative to vertical

Forward Lean Forward position of the trunk relative to vertical

Rotates Back/Forward (B or F) Backward or forward rotation greater than neutral on the refer¬ ence side

51

I

Major Problem

Task

Most Likely Cause

HIKES

SLA

• Intentional to clear the swing limb

• May increase energy cost

POSTERIOR Pelvic Tilt

WA SLS SLA

• Tight hamstrings • Intentional to decrease the demand on the hip extensors (WA) • Intentional to advance the limb (SLA) • Low back pain • Limited lumbar extension

• May increase energy cost • May result in excess knee flexion in SLS

ANTERIOR Pelvic Tilt

WA SLS SLA

• Weak abdominals • Hip flexion contracture • Secondary to forward trunk lean

• May increase energy cost • May increase lordotic curve which may result in low back pain

LACKS FORWARD ROTATION

WA SLA

• Retracted pelvis • Compensatory to decrease the demand on the quadriceps and hip extensors at LR • Lack of backward rotation on the opposite limb • Back pain

• Decreases step length

LACKS BACKWARD ROTATION

SLS SLA

• Impaired motor control of the trunk and pelvic muscles • Back pain • Secondary to excess hip flexion

• Decreases step length of the opposite limb (TSt)

Excess forward ROTATION

WA SLS SLA

• Intentional to advance the limb • Excess backward rotation on the opposite limb

• Increases step length (TSw)

Excess backward Rotation

SLS SLA

• Inability to disassociate the pelvis from limb movement • Secondary to excess plantar flexion • Compensatory for excess hip flexion (SLS) • Weak calf with no heel-off

• May decrease forward progression (WA, SLA) • May decrease limb advancement (SLA) • Intentional to increase forward progression (SLS)

Significance

Major Problem

Task Most Likely Cause

IPSILATERAL PELVIC DROP

WA SLS

• Compensatory for shortened reference limb

• May result in back pain

SLA

• Weak hip abductors on the opposite limb • Intentional to lower the limb for IC • Adductor spasticity

• May decrease opposite stance limb stability • Increases the relative length of the reference limb • May increase energy cost

WA SLS

• Weak hip abductors on the reference limb • Intentional to lower the opposite limb for IC • Adductor spasticity

• May decrease stance limb stability • Increases the relative length of the opposite limb • May increase energy cost

SLA

• Compensatory for shortened opposite limb

• May result in back pain

CONTRALATERAL pelvic Drop

Significance

53

Trunk Major Problem

Task Most Likely Cause

Backward lean

WA SLS

• Intentional to decrease the demand on the hip extensors

• May increase energy cost • Decreases forward momentum

SLA

• Intentional to advance the limb

• May increase energy cost

FORWARD LEAN

WA SLS

• Secondary to excess hip flexion in WA or SLS • Intentional to reduce demand on the quadriceps Intentional to substitute visual input for impaired proprioception Use of upper extremity aids Limited trunk extension ROM Intentional to progress over an excessively plantar flexed ankle Abdominal pain

• Increases energy cost and the demand on the hip and trunk extensors • May improve stability and/or forward progression

Lateral Lean

WA SLS SLA

• • • • •

rotates Back

WA SLS SLA

• Inability to disassociate trunk move- • May increase energy cost ments from pelvic or limb movement • May decrease stability • Use of upper extremity aids • Decreases forward progression • Secondary to excess ankle plantar flexion (TSt)

ROTATES FORWARD

WA SLS SLA

• Inability to disassociate trunk move• May increase energy cost ments from pelvic or limb movements • May decrease stability • Excessive use of upper extremity aids Intentional to advance the limb

54

Significance

Weak hip abductors • May increase energy cost Intentional to avoid hip pain • Decreases forward momentum Compensatory for a short stance limb Intentional to clear the swing limb / Use of upper extremity aids

I

Notes

55

Gait Analysis: Full Body Example rancho los amigos National rehabilitation center physical therapy department

Reference Limb:

RD

L\X\

Major Deviation Minor Deviation

Trunk

Lean: B/F Lateral Lean: R/L Rotates: B/F

Pelvis

Major Problems:

Hikes Tilt: P/A

(WA) Weight Acceptance •

Lacks Forward Rotation •

Lacks Backward Rotation Excess Forward Rotation Excess Backward Rotation

contact

ejcceAA. knee{letUosi (9@)

•

Jz+iee (le/uxm, (-HR)

Ipsilateral Drop Contralateral Drop

Hip

Flexion: Limited Excess

(SLS) Single Limb Support

Past Retract Rotation: IR/ER AD/ABduction: AD/AB

Knee

Flexion: Limited Excess Wobbles Hyperextends Extension Thrust Varus/Valgus: Vr/Vl

(SLA) Swing Limb Advancement

Excess Contralateral Flex

Ankle

(lejucM

Forefoot Contact Foot Flat Contact Foot Slap

•

ejcceAA* plcuttasi (jlejua+i

Excess Plantar Flexion Excess Dorsiflexion Inversion/Eversion: Iv/Ev Heel Off

Excessive UE Weight Bearing

No Heel Off Drag Contralateral Vaulting

Toes

UP

Inadequate Extension Clawed/Hammered: Cl/Ha 2001 LAREI, Rancho Los Amigos National Rehabilitation Center, Downey, CA 90242

Name Patient #

\£) Diagnosis