GaitGaitFor DNB For DNB

PGT’sPGT’s

GaitGaitFor DNB PGT’sFor DNB PGT’s

G G KarG G Kar

‘‘Walking is one of the most Walking is one of the most complicated motor activities’complicated motor activities’

Olney, Aminoff : Harrison’s Principles of Int MedOlney, Aminoff : Harrison’s Principles of Int Med

From cerebral cortex to skin of the sole (and From cerebral cortex to skin of the sole (and almost everything in-between and beyond) almost everything in-between and beyond) can affect normal, smooth, cyclic bipedal can affect normal, smooth, cyclic bipedal ambulation.ambulation.

Lumbosacral spinal cord centers are Lumbosacral spinal cord centers are responsible for the cyclical stepping responsible for the cyclical stepping movements and they are modified by movements and they are modified by cerebral cortex, basal ganglia, brainstem cerebral cortex, basal ganglia, brainstem and cerebellum.and cerebellum.

Gait cycleGait cycle

The series of events taking place The series of events taking place between the time a foot touches the between the time a foot touches the ground and when the same foot ground and when the same foot returns to the ground once againreturns to the ground once again

This is arbitrary, because gait is a This is arbitrary, because gait is a cyclic process.cyclic process.

The whole body takes part in gaitThe whole body takes part in gait

Two basic phasesTwo basic phases

Stance phase for a limbStance phase for a limb Some part of the foot is touching the Some part of the foot is touching the

groundground

Swing phase of the limbSwing phase of the limb The foot is off the groundThe foot is off the ground

there is significant overlap of these there is significant overlap of these two of the two limbs in walkingtwo of the two limbs in walking

Stance phase (60%)Stance phase (60%)

Heel strikeHeel strike

Foot flatFoot flat

MidstanceMidstance

Push off Push off Heel offHeel off Toes offToes off

Swing phaseSwing phase

AcclerationAccleration Mid-swingMid-swing Decelaration Decelaration

Orthopedic issues in gaitOrthopedic issues in gait

Antalgic gaitAntalgic gait

Self – protecting adaptation of the gait to Self – protecting adaptation of the gait to minimize pain during weight bearingminimize pain during weight bearing

Cause may be anywhere in the lower Cause may be anywhere in the lower extremityextremity

Removes the weight from affected side Removes the weight from affected side as quickly as possible << stance phase of as quickly as possible << stance phase of this side and swing phase of the normal this side and swing phase of the normal side are lessened, side are lessened,

So, stride length and velocity are So, stride length and velocity are decreased.decreased.

Short limb gaitShort limb gait

Pelvis tilt down to the affected side Pelvis tilt down to the affected side (‘Hip-hiking)(‘Hip-hiking) Compensates length Compensates length Allows ground clearance of the longer limb Allows ground clearance of the longer limb

In supra-trochanteric shortening with abductor In supra-trochanteric shortening with abductor insufficiency, walking becomes difficult insufficiency, walking becomes difficult

Foot may supinate or patient may walk Foot may supinate or patient may walk on toes to compensateon toes to compensate

Normal limb may compensate by Normal limb may compensate by flexion at hip / knee flexion at hip / knee

Pelvis and hip considerations : Pelvis and hip considerations : Anterior << Posterior Anterior << Posterior

assessmentassessment Abductor mechanism function Abductor mechanism function

(normal)(normal) Normally, CG is in midlineNormally, CG is in midline In swing phase of a limb, body tends to f In swing phase of a limb, body tends to f

all towards the same side like a car all towards the same side like a car leans towards the side with two flat leans towards the side with two flat tyrestyres

Gluteus medius and minimus abduct the Gluteus medius and minimus abduct the hip to shift CG towards midlinehip to shift CG towards midline

An X-ray in (Lt) stance An X-ray in (Lt) stance phasephase

Distance form the Distance form the midline to femoral midline to femoral head is almost twice head is almost twice that between abductor that between abductor and femoral head and femoral head

Abductor pull is about Abductor pull is about double the wt of upper double the wt of upper bodybody

Generates tremendous compressive forces across the hip weight-bearing area

About 3 times of upper body weight

Trendelenburg’s gaitTrendelenburg’s gait

Abductor mechanism fails to lift up the Abductor mechanism fails to lift up the opposite hemi-pelvis opposite hemi-pelvis

Pelvis droops toward the floor in the Pelvis droops toward the floor in the stance phase of the diseased limbstance phase of the diseased limb

Exaggerated up-down motion of Exaggerated up-down motion of pelvispelvis

Bilateral pathology leads to waddlingBilateral pathology leads to waddling

Abductor lurch / limpAbductor lurch / limpmost of the modern books do not tear hair over differences most of the modern books do not tear hair over differences

between limp and lurchbetween limp and lurch

If the abductor mechanism is further If the abductor mechanism is further weakened, trunk muscles come into weakened, trunk muscles come into play. The entire body moves (and the play. The entire body moves (and the shoulder tilts) towards the diseased shoulder tilts) towards the diseased side in stance phase of that limb. side in stance phase of that limb. This is abductor lurch.This is abductor lurch.

Abductor lurch / limpAbductor lurch / limp

Same thing can occur in painful hip Same thing can occur in painful hip even if abductors are normaleven if abductors are normal By tilting the body to the affected side, By tilting the body to the affected side,

the CG is shifted near the femoral head the CG is shifted near the femoral head center :center :

And by that, the reaction force is And by that, the reaction force is reduced, in an attempt to reduce the reduced, in an attempt to reduce the painpain

Pelvis and hip considerations : Pelvis and hip considerations : lateral viewlateral view

Gluteus maximus lurchGluteus maximus lurch Normally, the gluteus maximus prevents Normally, the gluteus maximus prevents

toppling forwards in stance phase as the toppling forwards in stance phase as the CG is anterior to the hipCG is anterior to the hip

In GMax weakness, this toppling is In GMax weakness, this toppling is prevented by trunk muscles, thrusting prevented by trunk muscles, thrusting the pelvis forwards and the trunk the pelvis forwards and the trunk backwards to bring CG posterior. This backwards to bring CG posterior. This results in GMax or extensor lurch.results in GMax or extensor lurch.

Pelvis and hip considerations : Pelvis and hip considerations : lateral viewlateral view

Flexion contracture of hip /kneeFlexion contracture of hip /knee Increased lumbar lordosis / stoopingIncreased lumbar lordosis / stooping Short stride lengthShort stride length

Knee considerations : A << P Knee considerations : A << P viewview

Squat or sit on a stool to observe the Squat or sit on a stool to observe the patient from the level of his/her kneespatient from the level of his/her knees

Varus thrustVarus thrust In single-leg wt-bearing stage of the In single-leg wt-bearing stage of the

diseased limb, it collapses into varus diseased limb, it collapses into varus and its lateral border goesaway from and its lateral border goesaway from midline into a midline into a lateral thrust.lateral thrust.

Advanced O.A; varus from malunited Advanced O.A; varus from malunited tibial plateau #, tibia varumtibial plateau #, tibia varum

Lateral ligamentous laxity usually adds a Lateral ligamentous laxity usually adds a recurvatum thrust, noticeable from side.recurvatum thrust, noticeable from side.

Knee considerations : A << P Knee considerations : A << P viewview

Valgus thrustValgus thrust Opposite of varus thrustOpposite of varus thrust Much less commonMuch less common Patient with bilateral valgus may Patient with bilateral valgus may

circumduct to avoid knocking of knees circumduct to avoid knocking of knees (Knock-Knee gait)(Knock-Knee gait)

Knee considerations : lateral Knee considerations : lateral viewview

Stiff << knee gait << extendedStiff << knee gait << extended The patient keeps the knee extended to The patient keeps the knee extended to

avoid patellofemoral pain, like a stilt. May avoid patellofemoral pain, like a stilt. May also do so to compensate quad weakness by also do so to compensate quad weakness by locking in extension during stance phase locking in extension during stance phase

Stiff << knee in flexionStiff << knee in flexion Even 5º FFD may cause limpEven 5º FFD may cause limp

Short strideShort stride Heel strike is replaced by almost foot-flat to Heel strike is replaced by almost foot-flat to

start stance phasestart stance phase Jerky up-down motion from apparent Jerky up-down motion from apparent

shorteningshortening

Ankle foot considerationsAnkle foot considerations

Equinus contractureEquinus contracture High stepping during swing of affected sideHigh stepping during swing of affected side Abnormally early heel raiseAbnormally early heel raise Hyper extension of same knee in mid Hyper extension of same knee in mid

stance to accommodate the equinusstance to accommodate the equinus Stiff 1Stiff 1stst MTP joint MTP joint

Walks mainly on lateral border of foot (note Walks mainly on lateral border of foot (note the increased wear of lateral border of the the increased wear of lateral border of the shoe, if worn. More sensitive than gait) shoe, if worn. More sensitive than gait)

Hurried push off, directly from the heelHurried push off, directly from the heel

Flat footFlat foot ‘‘Springiness’ of the gait is , it is awkward Springiness’ of the gait is , it is awkward

and stiffand stiff Heel raise is avoided, so the heel and Heel raise is avoided, so the heel and

ball of foot rises togetherball of foot rises together Toes are usually turned outwards (splay Toes are usually turned outwards (splay

foot)foot)

Neurological issuesNeurological issues

Hemi-paretic gaitHemi-paretic gait

MildMild Arm swings lessArm swings less Affected leg is flexed less than normal and Affected leg is flexed less than normal and

more externally rotated in swing phasemore externally rotated in swing phase SevereSevere

Hip, knee, ankle extended and spasticHip, knee, ankle extended and spastic Abduction and circumduction of hip plus Abduction and circumduction of hip plus

tilt of pelvis to opposite side is needed for tilt of pelvis to opposite side is needed for forward swing of the limbforward swing of the limb

Paraparetic gaitParaparetic gait

Both legs are moved in a slow and Both legs are moved in a slow and stiff pattern with circumduction. stiff pattern with circumduction. Scissoring may be presentScissoring may be present Common in spinal cord diseaseCommon in spinal cord disease Also occurs in C PAlso occurs in C P

Steppage gaitSteppage gait

Dorsiflexion of ankle is weak, so the Dorsiflexion of ankle is weak, so the leg must be lifted higher (by more leg must be lifted higher (by more hip and knee flexion) for ground hip and knee flexion) for ground clearanceclearance Unilateral << L5 radiculopathy / sciatic or Unilateral << L5 radiculopathy / sciatic or

peroneal neuropathyperoneal neuropathy Bilateral << distal polyneuropathy / L.S. Bilateral << distal polyneuropathy / L.S.

polyneuropathy polyneuropathy

Waddling gaitWaddling gait

The trunk is thrown from side to side The trunk is thrown from side to side with each step (bilateral with each step (bilateral Trendelenburg)Trendelenburg) Bilateral hip dislocations, coxa varaBilateral hip dislocations, coxa vara Abductor weakness from Abductor weakness from

myopathy myopathy proximal symmetric spinal muscular proximal symmetric spinal muscular

atrophy atrophy Neuromuscular jn. Disease Neuromuscular jn. Disease

Parkinsonian gaitParkinsonian gait

Forward stoop with modearte hip and Forward stoop with modearte hip and knee flexionknee flexion

Shoulder adducted, elbow flexed, Shoulder adducted, elbow flexed, forearm shows pronation-supination forearm shows pronation-supination tremortremor

Gait starts slowly, maintained by short, Gait starts slowly, maintained by short, rapid stepsrapid steps

Pace tends to accelerate (Festination)Pace tends to accelerate (Festination) Falls are commonFalls are common

Apraxic gaitApraxic gait

Bilateral frontal lobe disease Bilateral frontal lobe disease Brain cannot plan and execute Brain cannot plan and execute

sequential movementssequential movements Initiation is difficult << the patient Initiation is difficult << the patient

seems to be glued to the floor for a seems to be glued to the floor for a while before s/he takes a few while before s/he takes a few shuffling steps and pause againshuffling steps and pause again

Cerebellar ataxic /reeling Cerebellar ataxic /reeling gaitgait

Broad- based gaitBroad- based gait Speed and stride varies irregularly Speed and stride varies irregularly

from step to stepfrom step to step Changing position leads to instabilityChanging position leads to instability Patient seems to be unstable, but Patient seems to be unstable, but

balance is maintained with even eyes balance is maintained with even eyes closedclosed Nystagmus and limb ataxia are present in Nystagmus and limb ataxia are present in

cerebellar hemisphere diseasecerebellar hemisphere disease Alcoholism produces same featuresAlcoholism produces same features

Sensory ataxic gaitSensory ataxic gait

Romberg’s sign is positive (patient Romberg’s sign is positive (patient falls with eyes closed)falls with eyes closed)

Broad base like cerebellar ataxicBroad base like cerebellar ataxic

Vestibular problemsVestibular problems

Patient consistently falls to one side Patient consistently falls to one side in walking / standingin walking / standing

Asymmetric nystagmusAsymmetric nystagmus Differentiate from Differentiate from

Unilateral sensory ataxia Unilateral sensory ataxia by normal by normal proprioceptionproprioception

HemiparesisHemiparesis by normal strengthby normal strength

Choreoathetotic gaitChoreoathetotic gait

Intermittent, irregular jerky Intermittent, irregular jerky movements disrupt the smoothness movements disrupt the smoothness of the gaitof the gait

Flexion and extension at hip are Flexion and extension at hip are common but unpredictable, seen as common but unpredictable, seen as pelvic lurchpelvic lurch

Shuffling and slap-foot gaitsShuffling and slap-foot gaits

Loss of proprioception (from posterior Loss of proprioception (from posterior cord syndrome / parkinsonism/ tabes)cord syndrome / parkinsonism/ tabes)

The brain does not know how far the The brain does not know how far the foot has advanced and cannot predict foot has advanced and cannot predict the exact moment of landing (heel the exact moment of landing (heel strike).strike).

Results in eitherResults in either (a) dragging of feet, so there is no true (a) dragging of feet, so there is no true

swing phase (Shuffling gait)swing phase (Shuffling gait) OR OR (b) crash-landing of the foot : violent and (b) crash-landing of the foot : violent and

un-predictable (Slap-foot gait)un-predictable (Slap-foot gait)