Gait

(normal & abnormal)

Dr. P. Ratan Khuman (PT)

M.P.T., (Ortho & Sports)
 Definition
Locomotion or gait
It is defined as a translatory progression of the body as a
whole produce by coordinated, rotatory movements of
body segments.
Normal gait
It is a rhythmic & characterized by alternating propulsive
& retropulsive motions of the lower extremities.

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 Task involves in walking
According to Rancho Los Amigos (RLA), California
Weight acceptance
Single limb support
Swing limb advance

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 Gait initiation
A series of events occur from the initiation of
body movt to beginning of gait cycle.
It is stereotyped activity in both young & old
healthy people.
Total duration of this phase is about 0.60sec

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 Kinematics of gait

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 Phases of gait
Stance phase
Swing phase

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 Stance phase
It begins at the instant that one extremity
contacts the ground & continuous only as long
as some portion of the foot is in contact with
the ground.
It is approx 60% of normal gait duration.

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 Swing phase
It begins as soon as the toe of one extremity
leaves the ground & ceases just before heel
strike or contact of the same extremity.
It makes up 40% of normal gait cycle.

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 Double support
Lower limb of one side of body is beginning its
stance phase & the opposite side is ending its
stance phase.
During double support both the lower limb are in
contact with the ground at the same time.
It account approx 22% of gait cycle.
This phase is absent in running

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 Subdivision of phases
Stance phase Swing phase
1) Heel strike 1) Acceleration
2) Foot flat 2) Mid-swing
3) Mid-stance 3) Deceleration
4) Heel off
5) Toe off

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Comparison of gait terminology
Traditional RLA
1) Heel strike 1) Initial contact
2) Foot flat 2) Loading response
3) Mid-stance 3) Mid-stance
4) Heel off 4) Terminal stance
5) Toe off 5) Pre-swing
6) Acceleration 6) Initial swing
7) Mid-swing 7) Mid-swing
8) Deceleration 8) Terminal swing

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 Traditional phases of gait

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 Stance phase
Heel strike phase:
Begins with initial contact &
ends with foot flat
It is beginning of the stance
phase when the heel contacts
the ground.

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 Stance phase
Foot flat:
It occurs immediately
following heel strike
It is the point at which the foot
fully contacts the floor.

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 Stance phase
Mid stance:
It is the point at which the
body passes directly over the
supporting extremity.

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 Stance phase
Heel off:
the point following midstance
at which time the heel of the
reference extremity leaves the
ground.

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 Stance phase
Toe off:
The point following heel off
when only the toe of the
reference extremity is in contact
with the ground.

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 Swing phase
Acceleration phase:
It begins once the toe leaves the
ground & continues until mid-
swing, or the point at which the
swinging extremity is directly under
the body.

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 Mid-swing:
It occurs approx when the
extremity passes directly beneath
the body, or from the end of
acceleration to the beginning of
deceleration.

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 Swing phase
Deceleration:
It occurs after mid-swing
when limb is decelerating in
preparation for heel strike.

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Sub-divisions of stance phase

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 Sub-divisions of swing phase

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Sub component of stance phase

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Sub component of swing phase

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 RLA phases of gait

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 Initial contact
It refer to the initial contact of the foot of
leading lower limb.
Normally the heel pointed first to contact.
In abnormal gait it is possible to either
whole foot or toes rather than the heel to
strike.

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 Load response
Begins at initial contact &
ends when the contra lateral
extremity lifts off the ground
at the end of the double-
support phase.
It occupies about 11% of gait

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 Mid-stance phase (RLA)
Begins when the contra-lateral
extremity lifts off the ground at
about 11% of the gait cycle
Ends when the body is directly
over the supporting limb at
about 30% of the gait cycle.

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 Terminal stance (RLA)
Begins when the body is
directly over the supporting
limb at about 30% of the gait
cycle
Ends just before initial contact
of the contra-lateral extremity at
about 50% of the gait cycle.

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 Pre-Swing (RLA)
It is the last 10% of stance
phase and begins with initial
contact of the contra-lateral
foot (at 50% of the gait
cycle) and ends with toe-off
(at 60%).

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 Initial swing (RLA)
Begins when the toe leaves
the ground & continues until
max knee flexion occurs.

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 Mid-Swing (RLA)
Encompasses the period
from maximum knee flexion
until the tibia is in a vertical
position.

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 Terminal swing (RLA)
Includes the period from
the point at which the tibia
is in the vertical position
to a point just before initial
contact.

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 Gait cycle

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 Variables of gait
There are two basic variables which provide a basic
description of human gait.
Time/ Temporal variable & Distance variables.
Provide essential quantitative information about gait

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 factors affecting variables
Age, Joint mobility,
Gender, Muscle strength,
Height, Type of clothing &
Size & shape of bony footwear,
components, Habit,
Distribution of mass in Psychological status.
body segments,

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 variables
Temporal variable Distance variable
Stance time Stride length,
Single-limb & double- Step length and width
support time, Degree of toe-out
Swing time,
Stride and step time,
Cadence and
Speed

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 Stance time:
It is the amount of time that elapses during the
stance phase of one extremity in a gait cycle.
Single-support time:
It is the amount of time that elapses during the
period when only one extremity is on the
supporting surface in a gait cycle.

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 Double-support time:
It is the amount of time spent with both feet on
the ground during one gait cycle.
The % of time spent increased in elderly
persons and in those with balance disorders.
The percentage of time spent decreases as the
speed of walking increases.

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 Stride length:
It is the linear distance from the heel strike of one
lower limb to the next heel strike of the same limb.

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 Step length:
It is the linear distance from the heel strike of one
lower limb to the next heel strike of opposite limb.

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 Stride duration:
It refers to amount of time taken to accomplish
one stride.
Stride duration and gait cycle duration are
synonymous.
One stride, for a normal adult, lasts approx 1 sec

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 Step duration:
It refers to the amount of time spent during a
single step.
Measurement usually is expressed as sec/step.
When weakness or pain in limb, step duration
may be decreased on the affected side and
increased on the unaffected side.

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 Cadence:
It is the no of steps taken by a person per unit
of time.
It is measured as the no of steps / sec or per
minute.
Cadence = Number of steps / Time

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 Walking velocity:
It is the rate of linear forward motion of the body,
which can be measured in meters or cm/second,
meters/minute, or miles/hour.

Walking velocity (meters/sec)=Distance walked (meters)/time (sec)

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 Speed of gait:
It is referred to as slow, free, and fast.
Free speed of gait refers to a persons normal
walking speed
Slow & fast speeds of gait refer to speeds slower or
faster than the persons normal comfortable walking
speed, designated in a variety of ways.

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 Step width or width of the
walking base:
It is the measure of linear distance
between the midpoint of the heel
of one foot and the same point on
the other foot

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 Degree of toe-out (DTO):
It represents the angle of foot formed by each
foots line of progression and a line intersecting the
centre of the heel and the second toe.
The angle for men is about 70 from the line of
progression of each foot at free speed walking.
The DTO decreases as the speed of walking
increases in normal men.

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 Degree of toe out

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 Variables of gait

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

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

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 Lateral displacement:
Rhythmic side-to-side
movement
Lateral limit: mid-stance
Average displacement: 5cm
Path: extremely smooth
sinusoidal curve

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

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 SaunderS Determinants of gait
Gait determinants was first described by
Saunders & Coworkers in 1953.
Six optimizations used to minimize
excursion of CG in vertical & horizontal
planes.

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 The determinants represent adjustments
made by the pelvis, hips, knees, and ankles
that help to keep movt of the bodys COG
to a minimum.
By decreasing the vertical & lateral
excursions of the bodys COM it was
thought that energy expenditure would be
less & gait more efficient.
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 Pelvic rotation:
Forward rotation of the pelvis in the horizontal plane
is approx. 8o on the swing-phase side.
It reduces the angle of hip flexion & extension
It enables a slightly longer step-length

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 Pelvic tilt:
5o dip of the swinging side (i.e. hip abd)
In standing, this dip is
A +ve Trendelenberg sign
It reduces the height of the apex of
the curve of CG

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 Knee flexion in stance phase
Approx. 20o dip
It shortens the leg in the middle of stance phase
It reduces the height of the apex of CG curve

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 Ankle mechanism
It lengthens the leg at heel contact
It helps in smoothens the curve of CG
It reduces the lowering of CG

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 Foot mechanism:
Lengthens the leg at toe-off as ankle moves from
dorsiflexion to plantarflexion
Smoothens the curve of CG
Reduces the lowering of CG

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Lateral displacement of body
Physiologic valgus of the knee reduce side-to-
side movement of the COM in frontal plane.
The normally narrow width of the walking

base minimizes the lateral displacement of CG

Reduced muscular energy consumption due to

reduced lateral acceleration & deceleration

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Physiological knee valgus

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 Abnormal
(Atypical) Gait

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 There are numerous causes of abnormal gait.
There can be great variation depending upon the
severity of the problem.
If a muscle is weak, how weak is it?
If joint motion is limited, how limited is it?

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 Pathological gaits
Abnormality in gait may be caused by
Pain
Joint muscle range-of-motion (ROM) limitation
Muscular weakness/paralysis
Neurological involvement (UMNL/ LMNL)
Leg length discrepancy

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 Types of pathological gait
Due to pain
Antalgic or limping gait (Psoatic Gait)

Due to neurological disturbance

Muscular paralysis both

Spastic (Circumductory Gait, Scissoring Gait, Dragging or

Paralytic Gait, Robotic Gait[Quadriplegic]) and
Flaccid (Lurching Gait, Waddaling Gait, Gluteus Maximus
Gait, Quadriceps Gait, Foot Drop or Stapping Gait,)
Cerebellar dysfunction (Ataxic Gait)
Loss of kinesthetic sensation (Stamping Gait)
Basal ganglia dysfunction (FestinautGait)
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 Types of pathological gait
Due to abnormal deformities
Equinus gait
Equinovarous gait
Calcaneal gait
Knock & bow knee gait
Genurecurvatum gait
Due to Leg Length Discrepancy (LLD)
Equinus gait

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 Antalgic gait
This is a compensatory gait pattern adopted in
order to remove or diminish the discomfort caused
by pain in the LL or pelvis.
Characteristic features:
Decreased in duration of stance phase of the affected
limb (unable of weight bear due to pain)
There is a lack of weight shift laterally over the stance
limb and also to keep weight off the involved limb
Decrease in stance phase in affected side will result in a
decrease in swing phase of sound limb.

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 Psoatic gait
Psoas bursa may be inflamed & edematous, which
cause limitation of movement due to pain &
produce a atypical gait.
Hip externally rotated
Hip adducted
Knee in slight flexion
This process seems to relieve tension of the
muscle & hence relieve the inflamed structures.

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 Gluteus maximus gait
The gluteus maximus act as a
restraint for forward progression.
The trunk quickly shifts
posteriorly at heel strike (initial
contact).
This will shift the bodys COG
posteriorly over the gluteus
maximus, moving the line of
force posterior to the hip joints.

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 With foot in contact with floor, this
requires less muscle strength to
maintain the hip in extension during
stance phase.
This shifting is referred to as a
Rocking Horse Gait because of the
extreme backward-forward movement
of the trunk.

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 gluteus medius gait
It is also known as Trendelenberg gait or
Lurching Gait when one side affected.
The individual shifts the trunk over the
affected side during stance phase.
When right gluteus medius or hip abductor
is weak it cause two thing:
1. The body leans over the left leg during stance
phase of the left leg, and
2. Right side of the pelvis will drop when the right
leg leaves the ground & begins swing phase.

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 Shifting the trunk over the affected side is an
attempt to reduce the amount of strength required
of the gluteus medius to stabilize the pelvis.
Bilateral paralysis, waddling or duck gait.
The patient lurch to both sides while walking.
The body sways from side to side on a wide base
with excessive shoulder swing.
E.g. Muscular dystrophy

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 Quadriceps gait
Quadriceps action is needed during heel strike &
foot flat when there is a flexion movement acting at
the knee.
Quadriceps weakness/ paralysis will lead to
buckling of the knee during gait & thus loss of
balance.
Patient can compensate this if he has normal hip
extensor & plantar flexors.

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 Compensation:
With quadriceps weakness, the individual may lean
forward over the quadriceps at the early part of stance
phase, as weight is being shifted on to the stance leg.
Normally, the line of force falls behind the knee,
requiring quadriceps action to keep the knee from
buckling.
By leaning forward at the hip, the COG is shifted
forward & the line of force now falls in front of the knee.
This will force the knee backward into extension.

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 Another compensatory manoeuvre to
use is the hip extensors & ankle
plantar flexors in a closed chain action
to pull the knee into extension at heel
strike (initial contact).
In addition, the person may physically
push on the anterior thigh during
stance phase, holding the knee in
extension.

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 genu recurvatum gait
Hamstrings are weak, 2 things may happen
During stance phase, the knee will go into
excessive hyperextension, referred to as genu
recurvatum gait.
During the deceleration (terminal swing) part
of swing phase, without the hamstrings to slow
down the swing forward of the lower leg, the
knee will snap into extension.

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 hemiplegic gait
With spastic pattern of hemiplegic leg
Hip into extension, adduction & medial
rotation
Knee in extension, though often unstable
Ankle in drop foot with ankle plantar
flexion and inversion (equinovarus),
which is present during both stance and
swing phases.
In order to clear the foot from the
ground the hip & knee should flex.
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 But the spastic muscles wont allow the hip &
knee to flex for the floor clearance.
So the patient hikes hip & bring the affected leg
by making a half circle i.e. circumducting the leg.
Hence the gait is known as Circumductory Gait.
Usually, there will be no reciprocal arm swing.
Step length tends to be lengthened on the involved
side & shortened on the uninvolved side.

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 Scissoring gait
It results from spasticity of bilateral
adductor muscle of hip.
One leg crosses directly over the
other with each step like crossing
the blades of a scissor.
E.g. Cerebral Palsy

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 Dragging or paraplegic gait
There is spasticity of both hip & knee
extensors & ankle plantar flexors.
In order to clear the ground the patient has
to drag his both lower limb swings them &
place it forward.

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 Cerebral Ataxic or
drunkardS gait
Abnormal function of cerebellum result in a
disturbance of normal mechanism controlling
balance & therefore patient walks with wider BOS.
The wider BOS creates a larger side to side
deviation of COG.
This result in irregularly swinging sideways to a
tendency to fall with each steps.
Hence it is known as Reeling Gait.

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 Sensory ataxic gait
This is a typical gait pattern seen in patients
affected by tabes dorsalis.
It is a degenerative disease affecting the posterior
horn cells & posterior column of the spinal cord.
Because of lesion, the proprioceptive impulse
wont reach the cerebellum.
The patient will loss his joint sense & position for
his limb on space.

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 Because of loss of joint sense, the patient
abnormally raises his leg (high step) jerks it
forward to strike the ground with a stamp.
So it is also called as Stamping Gait.
The patient compensated this loss of joint position
sense by vision.
So his head will be down while he is walking.

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 Short shuffling or
festinate gait
Normal function at basal ganglia are:
Control of muscle tone
Planning & programming of normal
movements.
Control of associated movements like
reciprocal arm swing.
Typical example for basal ganglia leision is
parkinsonism.
Because of rigidity, all the joint will go for a
flexion position with spine stooping forward.
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 This posture displaces the COG anteriorly.
So in order to keep the COG within the BOS, the
patient will no of small shuffling steps.
Due to loss of voluntary control over the
movement, they loses balance & walks faster as if
he is chasing the COG.
So it is called as Festinate Gait.
Since his shuffling steps, it is otherwise called as
Shuffling Gait.
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 Foot drop or slapping gait
This is due to dorsiflexor weakness caused
by paralysis of common peroneal nerve.
There wont be normal heel strike, instead
the foot comes in contact with ground as a
whole with a slapping sound.
So it is also known as Slapping gait.

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 Due to plantarflexion of the ankle, there
will be relatively lengthening at the leading
extremity.
So to clear the ground the patient lift the
limb too high.
Hence the gait get s its another name i.e.
High Stepping Gait

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 Equinus gait
Equinus = Horse
Because of paralysis of dorsiflexor which result in
plantar flexor contracture.
The patients will walk on his toes (toe walking).
Other cause may be compensation by plantar
flexor for a short leg.

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 Unequal Leg Length
We all have unequal leg length, usually a
discrepancy of approx 1/4 inch between the right
and left legs.
Clinically, these smaller discrepancies are often
corrected by inserting heel lifts of various
thicknesses into the shoe.
Leg length discrepancy (LLD) are divided in
Minimal leg length discrepancy
Moderate leg length discrepancy
Severe leg length discrepancy
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 Minimal LLD
Compensation occurs by dropping the
pelvis on the affected side.
The person may compensate by leaning
over shorter leg (up to 3 inches can be
accommodated with these tech).

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 Moderate LLD
Approx between 3 & 5 cm, dropping the
pelvis on the affected side will no longer be
effective.
A longer leg is needed, so the person
usually walks on the ball of the foot on the
involved (shorter) side.
This is called an Equinnus Gait.

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 Severe LLD
It is usually discrepancy of more than 5 inches.
The person may compensate in a variety of ways.
Dropping the pelvis and walking in an equinnus
gait plus flexing the knee on the uninvolved side is
often used.
To gain an appreciation for how this may feel or
look, walk down the street with one leg in the
street and the other on the sidewalk.

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 Equinovarous gait
There will be ankle plantar flexion &
subtalar inversion.
So the patient will be walking on the outer
border of the foot.
E.g. CETV

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 Calcaneal gait
Result from paralysis plantar flexors causing
dorsiflexor contracture.
The patient will be walking on his heel (heel walking)
It is characterized by greater amounts of ankle
dorsiflexion & knee flexion during stance & a shorter
step length on the affected side.
Single-limb support duration is shortened because of
the difficulty of stabilizing the tibia & the knee.

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 Knock knee gait
It is also known as genu valgum gait.
Due to decreased physiological valgus of knee.
Both the knee face each other widening the BOS.

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 Bow leg gait
It is also known as genu varum gait.
Knee face outwards.
Due to increase increased physiological
valgus of knee.
The legs will be in a bowed position.

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 Reference
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Cynthia C. Norkin, joint structure and function: A
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