Chapter 13

Gait and posture analysis

Overview

It is not clear whether gait is

learned or is pre-programmed at
the spinal cord level. However,
once mastered, gait allows us to
move around our environment in an
efficient manner, requiring little in
the way of conscious thought, at
least in familiar surroundings.

The Gait Cycle

Walking involves the alternating action

of the two lower extremities
The walking pattern is studied as a gait
cycle
The gait cycle is defined as the interval of
time between any of the repetitive events
of walking. Such an event could include
the point when the foot initially contacts
the ground, to when the same foot contacts
the ground again

The Gait Cycle

The gait cycle consists of two periods:

stance and swing
The stance period

Constitutes approximately 60% of the gait cycle

Describes the entire time the foot is in contact
with the ground and the limb is bearing weight
Begins with the initial contact of the foot on the
ground, and concludes when the ipsilateral foot
leaves the ground
The stance period takes about 0.6 sec during an
average walking speed

The Gait Cycle

Swing period
Constitutes approximately 40% of
the gait cycle
Describes the period when the foot
is not in contact with the ground
Begins as the foot is lifted from the
ground and ends with initial contact
with the ipsilateral foot

Stance Period

Within the stance period, two tasks

and four intervals are recognized
The two tasks include weight
acceptance and single limb support
The four intervals include loading
response, mid stance, terminal
stance and pre-swing

Stance Period

Weight acceptance
The weight acceptance task occurs
during the first 10% of the stance
period

The loading response interval begins as

one limb bears weight while the other leg
begins to go through its swing period.
This interval may be referred to as the
initial double stance period and consists
of the first 0-10% of the gait cycle

Stance Period

Single Leg Support

The middle 40% of the stance period is divided
equally into mid stance and terminal stance

The mid stance interval representing the first half of

the single limb support task, begins as one foot is
lifted, and continues until the body weight is aligned
over the forefoot
The terminal stance interval is the second half of the
single limb support task. It begins when the heel of the
weight bearing foot lifts off the ground and continues
until the contralateral foot strikes the ground

Stance Period

Limb Advancement
Pre-swing. This interval begins with
initial contact of the contralateral
limb and ends with ipsilateral toeoff. As both feet are on the floor at
the same time during this interval,
double support occurs for the
second time in the gait cycle.

Swing Period

Within the swing period, one task

and four intervals are recognized
The task involves limb
advancement
The four intervals include preswing, initial swing, mid-swing,
and terminal swing

Swing Period

Limb Advancement
Pre-swing. In addition to representing the
final portion of the stance period and
single limb support task, the pre-swing
interval is considered as part of the swing
period
Initial swing. This interval begins with the
lift of the foot from the floor and ends
when the swinging foot is opposite the
stance foot.

Swing Period

Limb Advancement
Mid-swing. This interval begins as the
swinging limb is opposite the stance
limb, and ends when the swinging
limb is forward and the tibia is
vertical
Terminal swing. This interval begins
with a vertical tibia of the swing leg
with respect to the floor, and ends
the moment the foot strikes the floor

Gait parameters

Cadence
Cadence is defined as the number of
separate steps taken in a certain time
Normal cadence is between 90 and 120
steps per minute
The cadence of women is usually 6-9 steps
per minute slower than that of men
Cadence is also affected by age, with
cadence decreasing from the age of 4 to the
age of 7, and then again in advancing years

Gait parameters

Stride length
Step length is measured as the distance
between the same point of one foot on
successive footprints (ipsilateral to the
contralateral foot fall).
Stride length, on the other hand, is the
distance between successive points of
foot-to-floor contact of the same foot

A stride is one full lower extremity cycle

Two step lengths added together make the
stride length

Characteristics of
Normal Gait

Gait involves the displacement of body

weight in a desired direction utilizing a
coordinated effort between the joints of
the trunk and extremities and the
muscles that control or produce these
motions
Any interference that alters this
relationship may result in a deviation or
disturbance of the normal gait pattern

Normal Gait

Five priorities of normal gait:

Stability of the weight bearing foot
throughout the stance period
Clearance of the non-weight bearing foot
during the swing period
Appropriate pre-positioning (during terminal
swing) of the foot for the next gait cycle
Adequate step length
Energy conservation

Center of Gravity
(COG)

During the gait cycle, the COG is

displaced both vertically and
laterally

Joint Motions in Gait

Trunk and Upper Extremities

During the gait cycle:

The swing of the arms is out of phase with the legs

As the upper body moves forward, the trunk twists
about a vertical axis
The thoracic spine and the pelvis rotate in opposite
directions to each other to enhance stability and
balance
The lumbar spine tends to rotate with the pelvis
The shoulders and trunk rotate out of phase with
each other during the gait cycle

Joint Motions in Gait

Pelvis
For normal gait to occur, the pelvis
must both rotate and tilt

Joint Motions in Gait

Sacroiliac Joint
As the right leg moves through the swing period,
the position of the right innominate changes from
one of extreme anterior rotation at the point of
pre-swing to a position of posterior rotation at the
point of initial contact
As the right extremity moves through the loading
response to mid stance, the ilium on that side
begins to convert from a posteriorly rotated
position to a neutrally rotated position. From mid
stance to terminal stance, the ilium rotates
anteriorly, achieving maximum position at
terminal stance

Joint Motions in Gait

Sacroiliac Joint
The sacrum rotates forward around
a diagonal axis during the loading
response, reaching its maximum
position at mid stance (e.g., right
rotation on a right oblique axis at
right mid stance), and then begins
to reverse itself during terminal
stance

Joint Motions in Gait

Hip
Hip motion occurs in all three planes
during the gait cycle

Knee
The knee flexes twice and extends
twice during each gait cycle: once
during weight bearing and once
during non-weight bearing

Joint Motions in Gait

Foot and ankle

Ankle joint motion during the gait cycle occurs
primarily in the sagittal plane

At initial contact with the ground the ankle is dorsiflexed

During the loading response interval, plantar flexion
occurs at the talocrural joint, with pronation occurring at
the subtalar joint
At the end of the mid stance interval, the talocrural joint
is maximally dorsiflexed, and the subtalar joint begins to
supinate
From the mid stance to the terminal stance interval the
foot is in supination
Once the ankle is fully close-packed, the heel is lifted by a
combination of passive force and contraction from the
taut gastrocnemius, and the soleus

Muscle Actions in Gait

Spine and pelvis

During the swing period, the semispinalis,
rotatores, multifidus, and external oblique
muscles are active on the side toward which
the pelvis rotates
The erector spinae and internal oblique
abdominal muscles are active on the opposite
side
The psoas major and quadratus lumborum
help to support the pelvis on the side of the
swinging limb, while the contralateral hip
abductors also provide support

Muscle Actions in Gait

Knee
During the swing period, there is very little
activity from the knee flexors
The knee extensors contract slightly at the
end of the swing period prior to initial
contact. During level walking the quadriceps
achieve peak activity during the loading
response interval (25% maximum voluntary
contraction) and are relatively inactive by
mid stance as the leg reaches the vertical
position and locks, making quadriceps
contraction unnecessary

Muscle Actions in Gait

Hip
During the early to mid portion of the swing
phase, the iliopsoas is the prime mover with
assistance from the rectus femoris, sartorius,
gracilis, adductor longus, and possibly the tensor
fascia latae, pectineus, and the short head of the
biceps femoris during the initial swing interval
In terminal swing, there is no appreciable action
of the hip flexors when ambulating on level
ground. Instead the hamstrings and gluteus
maximus are strongly active to decelerate hip
flexion and knee extension

Muscle Actions in Gait

Hip
The adductor magnus muscle supports hip
extension and also rotates the pelvis
externally toward the forward leg
In mid stance, coronal plane muscle activity
is greatest as the abductors stabilize the
pelvis. The muscle activity initially is
eccentric as the pelvis shifts laterally over
the stance leg. The gluteus medius and
minimus remain active in terminal stance for
lateral pelvic stabilization

Muscle Actions in Gait

Knee
Hamstring involvement is also important
to normal knee function. The co
activation of the antagonist muscles
about the knee during the loading
response aid the ligaments in
maintaining joint stability, by equalizing
the articular surface pressure
distribution, and controlling tibial
translation.

Muscle Actions in Gait

Foot and ankle

During the beginning of the swing
period, the tibialis anterior, extensor
digitorum longus (EDL), extensor
hallucis longus (EHL), and possibly
the peroneus tertius contract
concentrically with slight to moderate
intensity tapering off during the
middle of the swing period

Muscle Actions in Gait

Foot and ankle

At the point where the leg is
perpendicular to the ground during
the swing period, the tibialis
anterior, EDL and EHL group of
muscles contract concentrically to
dorsiflex and invert the foot in
preparation for the initial contact

Muscle Actions in Gait

Foot and ankle

Following initial contact, the anterior tibialis
works eccentrically to lower the foot to the
ground during the loading response interval
Calcaneal eversion is controlled by the eccentric
activity of the posterior tibialis, and the anterior
movement of the tibia and talus is limited by the
eccentric action of the gastrocnemius and soleus
muscle groups as the foot moves towards mid
stance
Pronation occurs in the stance period to allow for
shock absorption, ground terrain changes, and
equilibrium

Muscle Actions in Gait

Foot and ankle

The triceps surae become active again from mid
stance to the late stance period contracting
eccentrically to control ankle dorsiflexion as the
COG continues to move forward
In late stance period the Achilles tendon is
stretched as the triceps surae contracts and the
ankle dorsiflexes
At this point the heel rises off the ground and
the action of the plantar flexors changes from
one of eccentric contraction, to one of
concentric contraction

Influences on Gait

Pain
Posture
Flexibility and the amount of available joint
motion
Endurance - economy of mobility
Base of Support
Interlimb coordination
Leg-length
Gender
Pregnancy

Influences on Gait

Obesity
Age
Lateral and vertical displacement of
the COG
Properly functioning reflexes
Vertical Ground Reaction Forces
Medial-Lateral Shear Forces
Anterior-Posterior Shear Forces

Specific Deviations of
Individual Joints

Hip
Inadequate power
Inadequate or inappropriate range of
motion
Malrotation

Specific Deviations of
Individual Joints

Knee
The common problem at the knee
during the stance period is excessive
flexion. During the swing period, the
most common error is due to
inadequate motion

Specific Deviations of
Individual Joints

Foot and ankle

There are three broad types of errors
of the foot and ankle in the stance
and swing periods:
Malrotation
Varus or valgus deformity
Abnormal muscle moments

Abnormal Gait
Syndromes

In general gait deviations fall

under four headings:
Those caused by weakness
Those caused by abnormal joint
position or range of motion
Those caused by muscle contracture
Those caused by pain

Abnormal Gait
Syndromes

Antalgic Gait
The antalgic gait pattern can result from
numerous causes including joint
inflammation or an injury to the muscles
tendons and ligaments of the lower extremity
The antalgic gait is characterized by a
decrease in the stance period on the involved
side in an attempt to eliminate the weight
from the involved leg and use of the injured
body part as much as possible

Abnormal Gait
Syndromes

Equinus Gait
Equinus gait (toe-walking), one of
the more common abnormal
patterns of gait of patients with
spastic diplegia, is characterized by
forefoot strike to initiate the cycle
and premature plantar flexion in
early stance to midstance

Abnormal Gait
Syndromes

Gluteus maximus Gait

The gluteus maximus gait, which results
from weakness of the gluteus maximus, is
characterized by a posterior thrusting of
the trunk at initial contact in an attempt to
maintain hip extension of the stance leg
The hip extensor weakness also results in
forward tilt of the pelvis, which eventually
translates into a hyperlordosis of the spine
to maintain posture

Abnormal Gait
Syndromes

Quadriceps Gait
Quadriceps weakness can result from a
peripheral nerve lesion (femoral), a spinal
berve root lesion, from trauma, or from
disease (muscular dystrophy)
Quadriceps weakness requires that forward
motion be propagated by circumducting each
leg. The patient leans the body toward the
other side to balance the center of gravity,
and the motion is repeated with each step

Abnormal Gait
Syndromes

Spastic Gait
A spastic gait may result from either
unilateral or bilateral upper motor neuron
lesions

Spastic hemiplegic (hemiparetic) gait . This type of

gait results from a unilateral upper motor neuron
lesion and is frequently seen following a
completed stroke
Spastic paraparetic gait. This type of gait results
from bilateral upper motor neuron lesions (e.g.,
cervical myelopathy in adults and cerebral palsy
in children)

Abnormal Gait
Syndromes

Ataxic Gait
The ataxic gait is seen in two
principal disorders: cerebellar
disease (cerebellar ataxic gait) and
posterior column disease (sensory
ataxic gait)

Abnormal Gait
Syndromes

Steppage Gait
This type of gait occurs in patients with a foot
drop
A foot drop is the result of weakness or
paralysis of the dorsiflexor muscles due to an
injury to the muscles, their peripheral nerve
supply, or the nerve roots supplying the
muscles
The patient lifts the leg high enough to clear
the flail foot off the floor by flexing
excessively at the hip and knee, and then
slaps the foot on the floor

Abnormal Gait
Syndromes

Trendelenburg Gait
This type of gait is due to weakness of the
hip abductors (gluteus medius and
minimus)
The normal stabilizing affect of these
muscles is lost and the patient
demonstrates an excessive lateral list in
which the trunk is thrust laterally in an
attempt to keep the center of gravity over
the stance leg

Abnormal Gait
Syndromes

Parkinsonian Gait
The parkinsonian gait is characterized by a
flexed and stooped posture with flexion of
the neck, elbows, metacarpophalangeal
joints, trunk, hips, and knees
The patient has difficulty initiating
movements and walks with short steps
with the feet barely clearing the ground.
This results in a shuffling type of gait with
rapid steps

Abnormal Gait
Syndromes

Hysterical Gait
The hysterical gait is non-specific and bizarre
It does not conform to any specific organic
pattern with the abnormality varying from
moment to moment and from one
examination to another
There may be ataxia, spasticity, inability to
move, or other types of abnormality
The abnormality is often minimal or absent
when the patient is unaware of being
watched or when distracted

Posture

Good posture is a subjective term

reflecting what the clinician
believes to be correct based on
ideal models.
Generally speaking muscles can
be subdivided into:
Postural muscles
Phasic muscles

Posture

The ability to main correct posture

is related to a number of factors,
which includes but is not limited to:

Energy cost
Strength and flexibility
Structural deformities
Disease
Pain