GAIT PATTERNS IN HIPGAIT PATTERNS IN HIPDISORDERSDISORDERS

Dr. K.K. CHANDRABABU,Dr. K.K. CHANDRABABU,

Professor of Orthopaedics,Professor of Orthopaedics,

Medical College,ThiruvananthapuramMedical College,Thiruvananthapuram..

Normal gaitNormal gait Definition Definition

Gait analysisGait analysis

Pathological gaitPathological gait Spastic gaitSpastic gait

Antalgic gaitAntalgic gait

Trendelenberg gaitTrendelenberg gait

Short limb gaitShort limb gait

Gluteus maximus Gluteus maximus gaitgait

gait in bilateral hip gait in bilateral hip problemsproblems

Normal GaitNormal Gait

DefinitionDefinition

Human gait is bipedal, Human gait is bipedal,

biphasic,biphasic, forward forward propulsion of centre of propulsion of centre of gravitygravity,,in which there is alternate in which there is alternate sinuous movement of head sinuous movement of head and body, and body, with least expenditure with least expenditure

of energyof energy

Normal GaitNormal GaitDefinitionDefinition

Human gait is bipedal, Human gait is bipedal, biphasic, forward propulsion of biphasic, forward propulsion of centre of gravity, in which there centre of gravity, in which there is alternate sinuous movement is alternate sinuous movement of head and body, with least of head and body, with least expenditure of energy.expenditure of energy.

Normal walking Normal walking requirementsrequirements

EquilibriumEquilibrium-ability to assume upright-ability to assume upright posture and maintain balance.posture and maintain balance.

LocomotionLocomotion-ability to initiate and maintain -ability to initiate and maintain rhythmic stepping.rhythmic stepping.

MuskuloskeletalMuskuloskeletal integrityintegrity--normal bone normal bone joint and muscle function.joint and muscle function.

NeurologicalNeurological controlcontrol--visual ,auditory visual ,auditory vestibular and sensory motor inputvestibular and sensory motor input

GAIT ANALYSISGAIT ANALYSIS

Study of human locomotionStudy of human locomotion Walking consists of a series of gait Walking consists of a series of gait

cyclescycles A single gait cycle is known as a A single gait cycle is known as a

STRIDESTRIDE

GAIT CYCLEGAIT CYCLEA single gait cycle or stride is defined:A single gait cycle or stride is defined:Period when ONE foot contacts the ground Period when ONE foot contacts the ground

to when that same foot contacts the to when that same foot contacts the ground againground again

Each stride has 2 phases:Each stride has 2 phases:Stance PhaseStance Phase -60% of the gait cycle -60% of the gait cycle

Foot in contact with the groundFoot in contact with the groundSwing PhaseSwing Phase -40% of the gait cycle -40% of the gait cycle

Foot NOT in contact with the groundFoot NOT in contact with the ground

Stance Phase of GaitStance Phase of GaitWhen the foot is in When the foot is in contact with the ground contact with the ground

Stance phase has 5 Stance phase has 5 parts:parts:1.Initial Contact1.Initial Contact (Heel (Heel

Strike) Strike)

2.Loading Response2.Loading Response (Foot Flat) (Foot Flat)

3.Midstance 3.Midstance

4.Terminalstance4.Terminalstance(heel (heel raise) raise)

5.Pre-Swing5.Pre-Swing(toe off)(toe off)1 2 3 4 5

Initial ContactInitial Contact

Phase 1Phase 1 The moment when The moment when

the the redred heel just heel just touches the floor,touches the floor,

The first double The first double stance period beginsstance period begins

Blue leg is at the end Blue leg is at the end of terminal stance of terminal stance

Loading ResponseLoading ResponsePhase 2Phase 2 Rest of the Rest of the redred foot comes foot comes

down to contact the down to contact the groundground

The double stance period The double stance period continuescontinues

Full body weight is Full body weight is transferred onto the transferred onto the redred leg. leg.

Blue leg is in pre swing Blue leg is in pre swing (toe off)(toe off)

MidstanceMidstance Phase 3Phase 3 single limb supportsingle limb support

interval. interval. Begins with the Begins with the

lifting of the blue lifting of the blue foot and continues foot and continues until the centre of until the centre of mass(body wt) is mass(body wt) is directly over the directly over the red red ankleankle

Terminal StanceTerminal Stance

Phase 4Phase 4 Begins when the Begins when the redred

heel rises and heel rises and continues until the continues until the heel of the blue foot heel of the blue foot hits the ground.hits the ground.

Centre of mass(body Centre of mass(body wt) progresses wt) progresses beyond the red footbeyond the red foot

Pre swingPre swingPhase 5Phase 5 Begins with the initial Begins with the initial

contact of the blue foot contact of the blue foot and ends with and ends with redred toe-off. toe-off.

The second double stance The second double stance interval in the gait cycle interval in the gait cycle

Transfer of body weight Transfer of body weight from ipsilateral to from ipsilateral to opposite limb takes place.opposite limb takes place.

Stance Phase Stance Phase CharacteristicsCharacteristics

During a single stride, there are 2 During a single stride, there are 2 periods of double limb support periods of double limb support Initial double limb stance- initial contact Initial double limb stance- initial contact

&Loading response ®&Loading response ®Terminal double limb stance-pre swing Terminal double limb stance-pre swing

®®

IC LR MSt TSt PSw ISw MSw TSw

Swing PhaseSwing Phase

When foot is NOT contacting the When foot is NOT contacting the groundground

Limb advancement phaseLimb advancement phase

3 parts of swing phase:3 parts of swing phase:

-Initial swing-Initial swing

-Midswing-Midswing

-Terminal swing-Terminal swing

Initial SwingInitial Swing

Phase 6Phase 6 Begins when the red Begins when the red

foot is lifted from the foot is lifted from the floor and ends when floor and ends when the red swinging foot the red swinging foot is opposite the blue is opposite the blue stance foot. stance foot.

The blue leg is in The blue leg is in mid-stance.mid-stance.

MidswingMidswingPhase 7Phase 7 Starts at the end of the Starts at the end of the

initial swing and initial swing and continues until the red continues until the red swinging limb is in front swinging limb is in front of the body of the body

Advancement of the red Advancement of the red legleg

The blue leg is in late The blue leg is in late mid-stance.mid-stance.

Terminal SwingTerminal SwingPhase 8Phase 8 Begins at the end of Begins at the end of

midswing and ends midswing and ends when the foot when the foot touches the floor. touches the floor.

Limb advancement Limb advancement is completed at the is completed at the end of this phase.end of this phase.

parts of a gait cycleparts of a gait cycle

0-10% 10-30% 30-50% 50-60% 60-73% 73-87% 87-100%

Initial double limb stance

single limb stance

Terminaldouble limbstance

Gait ProgressionGait Progression

R leg

L leg

R STANCE

L SINGLE1st

DOUBLE SUPPORT

2nd DOUBLE

SUPPORT

DOUBLE SUPPORTR SINGLE

L SWING L STANCE

R SWINGR STANCE

Tasks and divisions of gait Tasks and divisions of gait cyclecycle

Gait parameters(cadence Gait parameters(cadence parametersparameters))

Step lengthStep length –distance between two feet –distance between two feet during double limb support.it is during double limb support.it is measured from the heel of one foot to measured from the heel of one foot to heel of contralateral footheel of contralateral foot

Stride lengthStride length -distance one limb travels -distance one limb travels during the stance and swing phase.it is during the stance and swing phase.it is measured from the point of foot measured from the point of foot contact at the beginning of stance contact at the beginning of stance phase to the point of contact by the phase to the point of contact by the

same same foot at the end of swing phasefoot at the end of swing phase

gait parametersgait parameters

Stride length

L step lengthR step length

LL

R

Walking base

8cm8cm

70-82 cm

35-40cm35-40cm

Cadence parameters Cadence parameters contd..contd..

Step timeStep time –amount of time used to –amount of time used to

complete one step lengthcomplete one step length

CadenceCadence –number of steps taken per –number of steps taken per

minuteminute

Walking velocityWalking velocity -distance -distance traveled per traveled per

minuteminute

90-120 steps

CENTRE OF MASSCENTRE OF MASS

Center of mass (COM) is located just Center of mass (COM) is located just anterior to the second sacral vertebraanterior to the second sacral vertebra

COM deviates from the straight line in COM deviates from the straight line in verticalvertical and and lateral lateral sinusoidal sinusoidal displacementsdisplacements

Displacement in the plane of Displacement in the plane of progressionprogression

Pelvis and trunk Pelvis and trunk shift 1-2 inch shift 1-2 inch laterally laterally during gait during gait cyclecycle

width of a N base measures2-4 inches and step length 15 inches

CoG deviates 2 inches vertically during gait cycle

in swing phase CoG oscillates 40 degree forward

Energy expenseEnergy expense

Efficient gait Efficient gait reduces the amount reduces the amount of energy required of energy required to ambulateto ambulate

heel strike mid stance toe off

goals-to reduce the maximum ht of body CoM at goals-to reduce the maximum ht of body CoM at mid stance,to increase the minimum ht of body mid stance,to increase the minimum ht of body CoM at heel strike and toe offCoM at heel strike and toe off

the locomotor system the locomotor system has several methods has several methods to try to reduce its to try to reduce its amplitudeamplitude

heel strike mid stance toe off

Determinants of gaitDeterminants of gait

Pelvic rotationPelvic rotation

Pelvic tiltPelvic tilt

Stance phase knee flexionStance phase knee flexion

Transverse rotation of leg Transverse rotation of leg segment segment

Normal valgus alignment of Normal valgus alignment of kneeknee

Ankle rockersAnkle rockers

Muscle activity during gaitMuscle activity during gait

Concentric contraction-generates power Concentric contraction-generates power and accelerates body forwardand accelerates body forward

-gastrocsoleus contracts to lift the -gastrocsoleus contracts to lift the

heel off the groundheel off the ground

-iliopsoas contracts flexing the hip -iliopsoas contracts flexing the hip

and pulling the stance phase limb and pulling the stance phase limb

off the groundoff the ground

Muscle activity during gaitMuscle activity during gait

Eccentric contraction-slows down and Eccentric contraction-slows down and stabilises joint motionstabilises joint motion

-tibialis anterior-contracts at initial-tibialis anterior-contracts at initial contact ,firing during plantar flexion contact ,firing during plantar flexion as the foot is lowered to ground.as the foot is lowered to ground. so the foot is gently lowered to groundso the foot is gently lowered to ground -gastrocsoleus-contracts eccentrically -gastrocsoleus-contracts eccentrically through the stance phase controlling through the stance phase controlling

the the rate of dorsiflexion of ankle rate of dorsiflexion of ankle

KINEMATICSKINEMATICS

Denotes the motion observed and Denotes the motion observed and measured at pelvis,hip,knee,ankle and measured at pelvis,hip,knee,ankle and footfoot

Done in three planesDone in three planes

-sagittal plane-hip flexion ,extension-sagittal plane-hip flexion ,extension

-coronal plane-hip -coronal plane-hip abduction,adductionabduction,adduction

-transverse plane-rotation -transverse plane-rotation hip,tibia,feet hip,tibia,feet

CLINICAL GAIT ANALYSISCLINICAL GAIT ANALYSIS

OBSERVATIONAL GAIT ANALYSISOBSERVATIONAL GAIT ANALYSIS

3D GAIT ANALYSIS3D GAIT ANALYSIS

Obsevational gait analysisObsevational gait analysis

Pt should be viewed from the front, Pt should be viewed from the front, side, and behindside, and behind

hyperlordosis . ankle plantarflexion hyperlordosis . ankle plantarflexion

dorsi flexion, knee flexion extension, dorsi flexion, knee flexion extension, and hip flexion extension. pelvic and hip flexion extension. pelvic abduction or adduction. abduction or adduction.

Observational gait analysis-Observational gait analysis-what to look forwhat to look for

The head position.The head position.Shoulders - depressed, elevated, protracted, or retracted.Shoulders - depressed, elevated, protracted, or retracted.Amount of arm swing - normal, increased, or decreasedAmount of arm swing - normal, increased, or decreasedThe trunk - forward or backward lurch or a list to the R or L The trunk - forward or backward lurch or a list to the R or L The pelvis -hiked, level, dropped, or fixed.The pelvis -hiked, level, dropped, or fixed.The hip - extension, flexion, rotation, circumduction, or an The hip - extension, flexion, rotation, circumduction, or an adducted or abducted posture.adducted or abducted posture.The knee - flexion, extension, and general stability The knee - flexion, extension, and general stability The ankle- plantarflexion and dorsiflexion, eversion and The ankle- plantarflexion and dorsiflexion, eversion and inversion. inversion. The foot - proper push off and pronation and supination The foot - proper push off and pronation and supination Pain-where and whenPain-where and whenCadence,base width,stride lengthCadence,base width,stride length

3D gait analysis3D gait analysis

THIS IS DONE IN A GAIT LABORATARYTHIS IS DONE IN A GAIT LABORATARY

3D gait analysis3D gait analysis

Kinematics -movement Kinematics -movement

Kinetics -forces related to movements Kinetics -forces related to movements Ground reaction forces (GRF) Ground reaction forces (GRF) Moment or torque - a turning force that results in Moment or torque - a turning force that results in

angular change of position of a segment/joint angular change of position of a segment/joint Power - a function of joint angular velocity and joint Power - a function of joint angular velocity and joint

moment; rate of doing work moment; rate of doing work

Electromyography (EMG) -recording of Electromyography (EMG) -recording of myoelectrical activitymyoelectrical activity

Gait Patterns in Cerebral PalsyGait Patterns in Cerebral Palsy

Geographic classificationGeographic classificationHemiplegia (one side; UL>LL)Hemiplegia (one side; UL>LL)Diplegia (both sides; LL>UL)Diplegia (both sides; LL>UL)Triplegia (both LL+1UL)Triplegia (both LL+1UL)Quadriplegia (both UL+both Quadriplegia (both UL+both

LL+trunk)LL+trunk)

Common: Spastic hemiplegia or Common: Spastic hemiplegia or diplegia(91%)diplegia(91%)

Cerebral PalsyCerebral Palsy

Spastic Diplegia /quadriplegiaSpastic Diplegia /quadriplegia(Sutherlands and Davids)(Sutherlands and Davids)

True EquinusTrue Equinus -distal spasticity -distal spasticityGastrosoleus spasticity EquinusGastrosoleus spasticity Equinus

±Genu recurvatum±Genu recurvatum Jump GaitJump Gait

Spasticity of hamstrings and hip flexors and calfSpasticity of hamstrings and hip flexors and calfEquinus +hip and knee in flexion ,ant. pelvic tiltEquinus +hip and knee in flexion ,ant. pelvic tilt

+ exaggerated lumbar lordosis+ knee stiff (rectus femoris)+ exaggerated lumbar lordosis+ knee stiff (rectus femoris) Crouch gaitCrouch gait

Excessive dorsiflexion or calcaneus at ankle +excessive flexion at knee Excessive dorsiflexion or calcaneus at ankle +excessive flexion at knee and hip +ant. pelvic tiltand hip +ant. pelvic tilt

may bemay be Iatrogenic Iatrogenic due to isolated lengthening of TA (w/o correcting due to isolated lengthening of TA (w/o correcting hamstring & iliopsoas spasmhamstring & iliopsoas spasm))

Crouch gait Jump gait

Scissoring gaitScissoring gait Adductor musculature spasmAdductor musculature spasm Flexion +int. rotn deformityFlexion +int. rotn deformity TFL is the main deforming forceTFL is the main deforming force Can bring the swing limb up toCan bring the swing limb up to

the stance limbthe stance limb Cadence parameters are grossly Cadence parameters are grossly

decreaseddecreased

ANTALGIC GAITANTALGIC GAIT

Pain in Pain in

lower limb lower limb

backback

----hip pain hip pain Lurch to affected sideLurch to affected side

Reduce abductor force on hipReduce abductor force on hip

No pelvic dropNo pelvic dropNo gluteal weaknessNo gluteal weakness

ANTALGIC GAITANTALGIC GAIT

Short steppingShort stepping Asymmetrical step lengthAsymmetrical step length Step length on affected side lessStep length on affected side less Unaffected limb is brought Unaffected limb is brought

forward more quickly than forward more quickly than normal in swing phasenormal in swing phase

Duration of stance phase Duration of stance phase increased on normal sideincreased on normal side

ANTALGIC GAITANTALGIC GAIT

InfectiveInfectiveInflammatoryInflammatoryEarly perthesEarly perthesAcute silpAcute silpTraumaTrauma

Abductor muscle functionAbductor muscle function Two limb stanceTwo limb stance One limb stanceOne limb stance Cog to wt bearing head = Cog to wt bearing head =

c o h to abductor c o h to abductor x 2x 2

compressive force on wt bearing compressive force on wt bearing head =head =

3x wt of upper 3x wt of upper bodybody

In 1895 Fredrich Trendelenburg described a clinical sign useful for detecting the function of hip abductor muscle with special referance to CDH and progressive muscular dystrophy

TRENDELENBERG GAITTRENDELENBERG GAIT

Functional weakening of abductor Functional weakening of abductor mechanism.mechanism.

Abductor muscles at mechanical Abductor muscles at mechanical disadvantagedisadvantage

Standing on affected side pelvis drop to Standing on affected side pelvis drop to normal sidenormal side

To compensate pt lurch to affected sideTo compensate pt lurch to affected side

steppage gaitsteppage gait

No need to compensate – tilt to opposite No need to compensate – tilt to opposite sideside

TRENELENBURG GAITTRENELENBURG GAIT

UNCOMPENSATEDUNCOMPENSATED

COMPENSATEDCOMPENSATED

TRENDELENBERG GAITTRENDELENBERG GAIT

Fulcrum – Fulcrum – hip joint – DDHhip joint – DDH

arthritis arthritis

Lever arm -Lever arm - head,neck,and shaft head,neck,and shaft

Congenital coxa vara,Congenital coxa vara,

#neck, malunited # trochanter#neck, malunited # trochanter Power -Power - abductorsabductors

polio, myopathy etc.polio, myopathy etc.

SHORT LEG GAITSHORT LEG GAIT

Shift to same sideShift to same sidePelvis tilt downward with dipPelvis tilt downward with dipEqual period on each sideEqual period on each sideSupinate foot or toe walkSupinate foot or toe walkFlex knee and hip on normal sideFlex knee and hip on normal sideRaise pelvis on normal side in Raise pelvis on normal side in

swing phase – swing phase – hip hikinghip hiking – to – to clear groundclear ground

GL. MAXIMUSGL. MAXIMUS WEAKNESS GAIT WEAKNESS GAIT

GL. MAXIMUSGL. MAXIMUS Terminal swing- opposite side – gluteus maximus Terminal swing- opposite side – gluteus maximus

locks hip in extension on wt bearing side locks hip in extension on wt bearing side Weakness- Weakness- pelvis thrust forward and trunk backwardpelvis thrust forward and trunk backward shift COG backwards– shift COG backwards– no force GM need to lockno force GM need to lock increased lordosisincreased lordosis lurch back &forth over the hipslurch back &forth over the hips Gowers’ signGowers’ sign

Gait after arthrodesisGait after arthrodesisPt will not tilt to sidePt will not tilt to side

Body moves forwards & backwardsBody moves forwards & backwards

Excessive anterior pelvic tilt & lumbar lordosis Excessive anterior pelvic tilt & lumbar lordosis were necessary to extend the femur on the involved were necessary to extend the femur on the involved side while the normal limb was being advancedside while the normal limb was being advanced

Transverse pelvic rotation about the Transverse pelvic rotation about the contralateral hip increasedcontralateral hip increased

walking speed 84 per cent of normal walking speed 84 per cent of normal

Gait in bilateral hip Gait in bilateral hip diseasesdiseases

Waddling gaitWaddling gait

Bilateral Bilateral trendelenbergtrendelenberg

CDHCDH

COXA VARACOXA VARA

Gait in bilateral ankylosisGait in bilateral ankylosisAnkylosis in abductionAnkylosis in abduction Weight on one sideWeight on one side Lift other side Lift other side Foot as fulcrumFoot as fulcrum Rotate the whole bodyRotate the whole body Advance opp legAdvance opp leg Repeat on other sideRepeat on other side

‘‘a curious clockwork gait’–a curious clockwork gait’– Herbert Herbert SeddenSedden

Ankylosis in adductionAnkylosis in adduction

Knee close

cannot lift leg walking not possible

Gait in bilateral ankylosisGait in bilateral ankylosis

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