Gait involves complex coordination between the brain, spinal cord, and muscles. Abnormalities can arise from issues anywhere in this system. Common gait abnormalities include antalgic gait due to pain minimizing, Trendelenburg's gait from abductor weakness, and hemiparetic gait from neurological injury causing stiff, circumducted movement. Analysis of stance, swing, pelvis position, and limb mechanics can localize neurological or orthopedic problems causing impaired walking.

1. GaitGait
For DNBFor DNB
PGT’sPGT’s
GaitGait
For DNB PGT’sFor DNB PGT’s
G G KarG G Kar

2. ‘‘Walking is one of the mostWalking 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 (andFrom cerebral cortex to skin of the sole (and
almost everything in-between and beyond) canalmost everything in-between and beyond) can
affect normal, smooth, cyclic bipedal ambulation.affect normal, smooth, cyclic bipedal ambulation.
Lumbosacral spinal cord centers are responsibleLumbosacral spinal cord centers are responsible
for the cyclical stepping movements and theyfor the cyclical stepping movements and they
are modified by cerebral cortex, basal ganglia,are modified by cerebral cortex, basal ganglia,
brainstem and cerebellum.brainstem and cerebellum.

3. Gait cycleGait cycle
 The series of events taking place betweenThe series of events taking place between
the time a foot touches the ground andthe time a foot touches the ground and
when the same foot returns to the groundwhen the same foot returns to the ground
once againonce again
 This is arbitrary, because gait is a cyclicThis is arbitrary, because gait is a cyclic
process.process.
 The whole body takes part in gaitThe whole body takes part in gait

4. Two basic phasesTwo basic phases
 Stance phase for a limbStance phase for a limb
 Some part of the foot is touching the groundSome part of the foot is touching the ground
 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 two ofthere is significant overlap of these two of
the two limbs in walkingthe two limbs in walking

5. Stance phase (60%)Stance phase (60%)
 Heel strikeHeel strike
 Foot flatFoot flat
 MidstanceMidstance
 Push offPush off
 Heel offHeel off
 Toes offToes off

6. Swing phaseSwing phase
 AcclerationAccleration
 Mid-swingMid-swing
 DecelarationDecelaration

7. Orthopedic issues in gaitOrthopedic issues in gait

8. Antalgic gaitAntalgic gait
 Self – protecting adaptation of the gait toSelf – protecting adaptation of the gait to
minimize pain during weight bearingminimize pain during weight bearing
 Cause may be anywhere in the lower extremityCause may be anywhere in the lower extremity
 Removes the weight from affected side asRemoves the weight from affected side as
quickly as possible ̶̶ stance phase of thisquickly as possible ̶̶ stance phase of this
side and swing phase of the normal side areside and swing phase of the normal side are
lessened,lessened,
 So, stride length and velocity areSo, stride length and velocity are
decreased.decreased.

9. Short limb gaitShort limb gait
 Pelvis tilt down to the affected side (‘Hip-Pelvis tilt down to the affected side (‘Hip-
hiking)hiking)
 Compensates lengthCompensates length
 Allows ground clearance of the longer limbAllows ground clearance of the longer limb
 In supra-trochanteric shortening with abductorIn supra-trochanteric shortening with abductor
insufficiency, walking becomes difficultinsufficiency, walking becomes difficult
 Foot may supinate or patient may walk onFoot may supinate or patient may walk on
toes to compensatetoes to compensate
 Normal limb may compensate by flexion atNormal limb may compensate by flexion at
hip / kneehip / knee

10. Pelvis and hip considerations :Pelvis and hip considerations :
Anterior ̶̶ Posterior assessmentAnterior ̶̶ Posterior assessment
 Abductor mechanism function (normal)Abductor mechanism function (normal)
 Normally, CG is in midlineNormally, CG is in midline
 In swing phase of a limb, body tends to f allIn swing phase of a limb, body tends to f all
towards the same side like a car leanstowards the same side like a car leans
towards the side with two flat tyrestowards the side with two flat tyres
 Gluteus medius and minimus abduct the hipGluteus medius and minimus abduct the hip
to shift CG towards midlineto shift CG towards midline

11. An X-ray in (Lt) stance phaseAn X-ray in (Lt) stance phase
 Distance form the midlineDistance form the midline
to femoral head is almostto femoral head is almost
twice that betweentwice that between
abductor and femoralabductor and femoral
headhead
 Abductor pull is aboutAbductor pull is about
double the wt of upperdouble the wt of upper
bodybody
Generates tremendous
compressive forces across the
hip weight-bearing area
About 3 times of upper body weight

12. Trendelenburg’s gaitTrendelenburg’s gait
 Abductor mechanism fails to lift up theAbductor mechanism fails to lift up the
opposite hemi-pelvisopposite hemi-pelvis
 Pelvis droops toward the floor in thePelvis droops toward the floor in the
stance phase of the diseased limbstance phase of the diseased limb
 Exaggerated up-down motion of pelvisExaggerated up-down motion of pelvis
 Bilateral pathology leads to waddlingBilateral pathology leads to waddling

13. Abductor lurch / limpAbductor lurch / limp
most of the modern books do not tear hair over differences betweenmost of the modern books do not tear hair over differences between
limp and lurchlimp and lurch
 If the abductor mechanism is furtherIf the abductor mechanism is further
weakened, trunk muscles come into play.weakened, trunk muscles come into play.
The entire body moves (and the shoulderThe entire body moves (and the shoulder
tilts) towards the diseased side in stancetilts) towards the diseased side in stance
phase of that limb. This is abductor lurch.phase of that limb. This is abductor lurch.

14. Abductor lurch / limpAbductor lurch / limp
 Same thing can occur in painful hip even ifSame thing can occur in painful hip even if
abductors are normalabductors are normal
 By tilting the body to the affected side, theBy tilting the body to the affected side, the
CG is shifted near the femoral head center :CG is shifted near the femoral head center :
 And by that, the reaction force is reduced, inAnd by that, the reaction force is reduced, in
an attempt to reduce the painan attempt to reduce the pain

15. Pelvis and hip considerations :Pelvis and hip considerations :
lateral viewlateral view
 Gluteus maximus lurchGluteus maximus lurch
 Normally, the gluteus maximus preventsNormally, the gluteus maximus prevents
toppling forwards in stance phase as the CGtoppling forwards in stance phase as the CG
is anterior to the hipis anterior to the hip
 In GMax weakness, this toppling is preventedIn GMax weakness, this toppling is prevented
by trunk muscles, thrusting the pelvisby trunk muscles, thrusting the pelvis
forwards and the trunk backwards to bring CGforwards and the trunk backwards to bring CG
posterior. This results in GMax or extensorposterior. This results in GMax or extensor
lurch.lurch.

16. 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

17. Knee considerations : A ̶̶ P viewKnee considerations : A ̶̶ P view
 Squat or sit on a stool to observe the patientSquat or sit on a stool to observe the patient
from the level of his/her kneesfrom the level of his/her knees
 Varus thrustVarus thrust
 In single-leg wt-bearing stage of the diseasedIn single-leg wt-bearing stage of the diseased
limb, it collapses into varus and its laterallimb, it collapses into varus and its lateral
border goesaway from midline into aborder goesaway from midline into a laterallateral
thrust.thrust.
 Advanced O.A; varus from malunited tibialAdvanced O.A; varus from malunited tibial
plateau #, tibia varumplateau #, tibia varum
 Lateral ligamentous laxity usually adds aLateral ligamentous laxity usually adds a
recurvatum thrust, noticeable from side.recurvatum thrust, noticeable from side.

18. Knee considerations : A ̶̶ P viewKnee considerations : A ̶̶ P view
 Valgus thrustValgus thrust
 Opposite of varus thrustOpposite of varus thrust
 Much less commonMuch less common
 Patient with bilateral valgus may circumduct toPatient with bilateral valgus may circumduct to
avoid knocking of knees (Knock-Knee gait)avoid knocking of knees (Knock-Knee gait)

19. Knee considerations : lateral viewKnee considerations : lateral view
 Stiff ̶̶ knee gait ̶̶ extendedStiff ̶̶ knee gait ̶̶ extended
 The patient keeps the knee extended to avoidThe patient keeps the knee extended to avoid
patellofemoral pain, like a stilt. May also do so topatellofemoral pain, like a stilt. May also do so to
compensate quad weakness by locking incompensate quad weakness by locking in
extension during stance phaseextension 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 startHeel strike is replaced by almost foot-flat to start
stance phasestance phase
 Jerky up-down motion from apparent shorteningJerky up-down motion from apparent shortening

20. 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 stanceHyper extension of same knee in mid stance
to accommodate the equinusto accommodate the equinus
 Stiff 1Stiff 1stst
MTP jointMTP joint
 Walks mainly on lateral border of foot (noteWalks mainly on lateral border of foot (note
the increased wear of lateral border of thethe 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

21.  Flat footFlat foot
 ‘‘Springiness’ of the gait is , it is awkward andSpringiness’ of the gait is , it is awkward and
stiffstiff
 Heel raise is avoided, so the heel and ball ofHeel raise is avoided, so the heel and ball of
foot rises togetherfoot rises together
 Toes are usually turned outwards (splay foot)Toes are usually turned outwards (splay foot)

22. Neurological issuesNeurological issues

23. Hemi-paretic gaitHemi-paretic gait
 MildMild
 Arm swings lessArm swings less
 Affected leg is flexed less than normal andAffected 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 tilt ofAbduction and circumduction of hip plus tilt of
pelvis to opposite side is needed for forwardpelvis to opposite side is needed for forward
swing of the limbswing of the limb

24. Paraparetic gaitParaparetic gait
 Both legs are moved in a slow and stiffBoth legs are moved in a slow and stiff
pattern with circumduction. Scissoringpattern with circumduction. Scissoring
may be presentmay be present
 Common in spinal cord diseaseCommon in spinal cord disease
 Also occurs in C PAlso occurs in C P

25. Steppage gaitSteppage gait
 Dorsiflexion of ankle is weak, so the legDorsiflexion of ankle is weak, so the leg
must be lifted higher (by more hip andmust be lifted higher (by more hip and
knee flexion) for ground clearanceknee flexion) for ground clearance
 Unilateral ̶̶ L5 radiculopathy / sciatic orUnilateral ̶̶ L5 radiculopathy / sciatic or
peroneal neuropathyperoneal neuropathy
 Bilateral ̶̶ distal polyneuropathy / L.S.Bilateral ̶̶ distal polyneuropathy / L.S.
polyneuropathypolyneuropathy

26. Waddling gaitWaddling gait
 The trunk is thrown from side to side withThe trunk is thrown from side to side with
each step (bilateral Trendelenburg)each step (bilateral Trendelenburg)
 Bilateral hip dislocations, coxa varaBilateral hip dislocations, coxa vara
 Abductor weakness fromAbductor weakness from
 myopathymyopathy
 proximal symmetric spinal muscular atrophyproximal symmetric spinal muscular atrophy
 Neuromuscular jn. DiseaseNeuromuscular jn. Disease

27. Parkinsonian gaitParkinsonian gait
 Forward stoop with modearte hip andForward stoop with modearte hip and
knee flexionknee flexion
 Shoulder adducted, elbow flexed, forearmShoulder adducted, elbow flexed, forearm
shows pronation-supination tremorshows pronation-supination tremor
 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

28. Apraxic gaitApraxic gait
 Bilateral frontal lobe diseaseBilateral frontal lobe disease
 Brain cannot plan and execute sequentialBrain cannot plan and execute sequential
movementsmovements
 Initiation is difficult ̶̶ the patient seems toInitiation is difficult ̶̶ the patient seems to
be glued to the floor for a while beforebe glued to the floor for a while before
s/he takes a few shuffling steps and pauses/he takes a few shuffling steps and pause
againagain

29. Cerebellar ataxic /reeling gaitCerebellar ataxic /reeling gait
 Broad- based gaitBroad- based gait
 Speed and stride varies irregularly fromSpeed and stride varies irregularly from
step to stepstep to step
 Changing position leads to instabilityChanging position leads to instability
 Patient seems to be unstable, but balancePatient seems to be unstable, but balance
is maintained with even eyes closedis maintained with even eyes closed
 Nystagmus and limb ataxia are present inNystagmus and limb ataxia are present in
cerebellar hemisphere diseasecerebellar hemisphere disease
 Alcoholism produces same featuresAlcoholism produces same features

30. Sensory ataxic gaitSensory ataxic gait
 Romberg’s sign is positive (patient fallsRomberg’s sign is positive (patient falls
with eyes closed)with eyes closed)
 Broad base like cerebellar ataxicBroad base like cerebellar ataxic

31. Vestibular problemsVestibular problems
 Patient consistently falls to one side inPatient consistently falls to one side in
walking / standingwalking / standing
 Asymmetric nystagmusAsymmetric nystagmus
 Differentiate fromDifferentiate from
 Unilateral sensory ataxiaUnilateral sensory ataxia by normalby normal
proprioceptionproprioception
 HemiparesisHemiparesis by normal strengthby normal strength

32. Choreoathetotic gaitChoreoathetotic gait
 Intermittent, irregular jerky movementsIntermittent, irregular jerky movements
disrupt the smoothness of the gaitdisrupt the smoothness of the gait
 Flexion and extension at hip are commonFlexion and extension at hip are common
but unpredictable, seen as pelvic lurchbut unpredictable, seen as pelvic lurch

33. Shuffling and slap-foot gaitsShuffling and slap-foot gaits
 Loss of proprioception (from posterior cordLoss of proprioception (from posterior cord
syndrome / parkinsonism/ tabes)syndrome / parkinsonism/ tabes)
 The brain does not know how far the footThe brain does not know how far the foot
has advanced and cannot predict thehas advanced and cannot predict the
exact moment of landing (heel strike).exact moment of landing (heel strike).
 Results in eitherResults in either
 (a) dragging of feet, so there is no true swing(a) dragging of feet, so there is no true swing
phase (Shuffling gait)phase (Shuffling gait) OROR
 (b) crash-landing of the foot : violent and un-(b) crash-landing of the foot : violent and un-
predictable (Slap-foot gait)predictable (Slap-foot gait)