GAIT (WALKING PATTERN)

 

Introduction: 

Bipedal walking is an important characteristic of humans. This page presents information about the different phases of the gait cycle,  important functions of the foot while walking and gait analysis which is a key skill for physiotherapists.

Definitions:

Sandra J. Shultz describes gait as: “...someone’s manner of ambulation or locomotion, involves the total body. Gait speed determines the contribution of each body segment. Normal walking speed primarily involves the lower extremities, with the arms and trunk providing stability and balance. The faster the speed, the more the body depends on the upper extremities and trunk for propulsion as well as balance and stability. The legs continue to do the most work as the joints produce greater ranges of motion trough greater muscle responses. In the bipedal system the three major joints of the lower body and pelvis work with each other as muscles and momentum move the body forward. The degree to which the body’s center of gravity moves during forward translation defines efficiency. The body’s center moves both side to side and up and down during gait.”

The gait cycle is a repetitive pattern involving steps and strides. A step is one single step, a stride is a whole gait cycle. The step time is the time between heel strike of one leg and heel strike of the contra-lateral leg. Step width can be described as the medio-lateral space between the two feet.

There are some differences between the gait and run cycle - the gait cycle is one third longer in time, the ground reaction force is smaller in the gait cycle (so the load is lower), and the velocity is much higher. (D) In running, there is also just one stance phase while in stepping there are two. Shock absorption is also much larger in comparison to walking. This explains why runners have more overload injuries.

The Gait Cycle:

The sequences for walking that occur may be summarized as follows:

• Registration and activation of the gait command within the central nervous system
• Transmission of the gait systems to the peripheral nervous system
• Contraction of muscles
• Generation of several forces
• Regulation of joint forces and moments across synovial joints and skeletal segments
• Generation of ground reaction forces

Classification of the gait cycle involves two main phases: the stance phase and the swing phase. The stance phase occupies 60% of the gait cycle while the swing phase occupies only 40% of it. Gait involves a combination of open- and close-chain activities.

A more detailed classification of gait recognizes six phases:

1. Heel Strike
2. Foot Flat
3. Mid-Stance
4. Heel-Off
5. Toe-Off
6. Mid-Swing

An alternative classification of gait involves the following eight phases:

1. Initial Contact
2. Loading Response
3. Midstance
4. Terminal Stance
5. Pre swing
6. Initial Swing
7. Mid Swing
8. Late Swing

Stance phase begins with the heel strike - this is the moment when the heel begins to touch the ground but the toes do not yet touch. In the midstance phase, we can see settlement of the foot at the lateral border. During the change from mid stance to toe off stance, the 5 metacarpophalanges contract. The toe-off phase is also named the propulsive phase.

When the stance phase ends, the swing phase begins. This phase is the phase between the toe off phase and the heel strike phase. In the swing phase we can recognize two extra phases - acceleration and declaration. The acceleration phase goes from toe-off to midswing, while declaration goes from midswing to heel strike. In the acceleration phase, the swing leg makes an accelerated forward movement with the goal of propelling the body weight forward. The declaration phase brakes the velocity of this forward body movement in order to place your foot down with control. Between these two phases, the mid-swing phase occurs. In this phase, both feet are under the body, with the heel next to each other.

Phases of the Gait Cycle:

Heel Strike:

Heel strike, also known as initial contact, is a short period which begins the moment the foot touches the ground and is the first phase of double support. 30° flexion of the hip and full extension in the knee is observed. The ankle moves from a neutral (supinated 5°) position into plantar flexion. After this, knee flexion (5°) begins and increases, just as the plantar flexion of the heel increased. The plantar flexion is allowed by eccentric contraction of the tibialis anterior, extension of the knee is caused by a contraction of the quadriceps, flexion is caused by a contraction of the hamstrings, and the flexion of the hip is caused by the contraction of the rectus femoris.

Foot Flat:

In foot flat, or loading response phase, the body absorbs the impact of the foot by rolling in pronation. The hip moves slowly into extension, caused by a contraction of the adductor magnus and gluteus maximus muscles. The knee flexes to 15° to 20° of flexion. Ankle plantar flexion increases to 10-15°.

Midstance:

In midstance the hip moves from 10° of flexion to extension by contraction of the gluteus medius muscle. The knee reaches maximal flexion and then begins to extend. The ankle becomes supinated and dorsiflexed (5°), which is caused by some contraction of the triceps surae muscles. During this phase, the body is supported by one single leg. At this moment the body begins to move from force absorption at impact to force propulsion forward.

Heel Off:

Heel off begins when the heel leaves the floor. In this phase, the body weight is divided over the metatarsal heads. Here can we see 10-13° of hip hyperextension, which then goes into flexion. The knee becomes flexed (0-5°) and the ankle supinates and plantar flexes.

Toe Off:

In the toe-off/pre-swing phase, the hip becomes less extended. The knee is flexed 35-40° and plantar flexion of the ankle increases to 20°. In toe-off, like the name says, the toes leave the ground.

Early Swing:

In the early swing phase the hip extends to 10° and then flexes due to contraction of the iliopsoas muscle 20° with lateral rotation. The knee flexes to 40-60°, and the ankle goes from 20° of plantar flexion to dorsiflexion, to end in a neutral position.

Mid Swing:

In the midswing phase the hip flexes to 30° (by contraction of the adductors) and the ankle becomes dorsiflexed due to a contraction of the tibialis anterior muscle. The knee flexes 60° but then extends approximately 30° due to contraction of the sartorius muscle. This extension is caused by the quadriceps muscles.

Late Swing:

The late swing/declaration phase begins with hip flexion of 25-30°, a locked extension of the knee and a neutral position of the ankle.

Anatomical Considerations:

The gait cycle involves movement in each part of the leg (and the body).

In the pelvic region there is an anterior-posterior displacement, which alternates from left to right. This displacement facilitates anterior movement of the leg. At each side, there is an anterior-posterior displacement of 4-5°.

In the frontal plane, varus movement is observed in the foot between heel-strike and foot-flat and between heel-off and toe-off. Some valgus movement is also observed between foot-flat and heel off in the feet.In the hip, some varus movement is observed in lateral movements. When the abductors are too weak, a Trendelenburg gait can be observed.

It is important to recognize that the entire body moves while walking. A disorder in any segment of the body can have consequences on the individual's gait pattern, like a reduced knee flexion range in patients with a reconstructed ACL.

Pathological Gait:

Pathological gait is an altered gait pattern due to deformities, weakness or other impairments, for example, loss of motor control or pain. Alterations can broadly be divided into neurological or musculoskeletal causes.

Musculoskeletal Causes:

Pathological gait patterns resulting from musculoskeletal are often caused by soft tissue imbalance, joint alignment or bony abnormalities. Infliction of these on one joint often then impacts on other joints, affecting the gait pattern as a result. The common deviation can be categorized broadly as:

• Hip Pathology
• Knee pathology
• Foot and ankle pathology
• Leg length discrepancy
• Pain

Hip Pathology:

Arthritis is a common cause of pathological gait. An arthritic hip has reduced range of movement during swing phase which causes an exaggeration of movement in the opposite limb ‘hip hiking.

Excessive Hip Flexion can significantly alter gait pattern most commonly due to; • Hip flexion contractures • IT band contractures, • Hip flexor spasticity, • Compensation for excessive knee flexion and ankle DF, • Hip pain • Compensation for excess ankle plantar flexion in mid swing. The deviation of stance phase will occur mainly on the affected side. The result is forward tilt of the trunk and increased demand on the hip extensors or increased lordosis of the spine with anterior pelvic tilt. A person with reduced spinal mobility will adopt a forward flexion position in order to alter their centre of gravity permanently during gait.

Hip Abductor Weakness. The abductor muscles stabilise the pelvis to allow the opposite leg to lift during the swing phase. Weak abductor muscles will cause the hip to drop towards the side of the leg swinging forward. This is also known as Trendelenburg gait.

Hip Adductor Contracture. During swing phase the leg crosses mid line due to the weak adductor muscles, this is known as ‘scissor gait’.

Weak Hip Extensors will cause a person to take a smaller step to lessen the hip flexion required for initial contact, resulting in a lesser force of contraction required from the extensors. Overall gait will be slower to allow time for limb stabilisation. Compensation is increased posterior trunk positioning to maintain alignment of the pelvis in relation to the trunk.

Hip Flexor Weakness results in a smaller step length due to the weakness of the muscle to create the forward motion. Gait will likely be slower and may result in decreased floor clearance of the toes and create a drag.

Knee Pathologies:

Weak Quadriceps. The quadriceps role is to eccentrically control the knee during flexion through the stance phase. If these muscles are weak the hip extensors will compensate by bringing the limb back into a more extended position, reducing the amount of flexion at the knee during stance phase. Alternatively heel strike will occur earlier increasing the ankle of plantar flexion at the ankle, preventing the forward movement of the tibia, to help stabilize the knee joint.

Severe Quadriceps Weakness or instability at the knee joint will present in hyperextension during the initial contact to stance phase. The knee joint will ‘snap’ back into hyperextension as the body weight moves forwards over the limb.

Knee Flexion Contraction will cause a limping type gait pattern. The knee is restricted in extension, meaning heel strike is limited and step length reduced. To compensate the person is likely to ‘toe walk’ during stance phase. Knee flexion contractures of more than 30 degrees will be obvious during normal paced gait. Contractures less then this will be more evident with increased speeds.

Ankle Pathologies:

Ankle Dorsiflexion Weakness results in a lack of heel strike and decreased floor clearance. This leads to an increased step height and prolonged swing phase.

Calf Tightening or Contractures due to a period of immobilisation or trauma will cause reduced heel strike due to restricted dorsiflexion. The compensated gait result will be ‘toe walking’ on stance phase, reduced step length and excessive knee and hip flexion during swing phase to ensure floor clearance.

Foot Pathologies:

Hallux Rigidus results in a lack of dorsiflexion of the great toe.  The MPJ uses the windlass effect to raise the arch and stiffen the foot during dorsiflexion of the hallux. This stiffness increases the efficiency of the propulsion portion of the gait cycle. To be efficient in creating stiffness, the hallux should be able to dorsiflex at least 65 degrees.

Leg Length Discrepancy:

Leg length discrepancy can be as a result of an asymmetrical pelvic, tibia or femur length or for other reasons such as a scoliosis or contractures. The gait pattern will present as a pelvic dip to the shortened side during stance phase with possible ‘toe walking’ on that limb. The opposite leg is likely to increase its knee and hip flexion to reduce its length.

Antalgic Gait:

Antalgic gait due to knee pain presents with decreased weight bearing on the affected side. The knee remains in flexion and possible toe weight bearing occurs during stance phase.

Antalgic gait due to ankle pain may present with a reduced stride length and decreased weight bearing on the affected limb. If the problem is pain in the forefoot then toe off will be avoided and heel weight bearing used. If the pain is more in the heel, toe weight bearing is more likely. General ankle pain may result in weight bearing on the lateral border.

Antalgic gait due to hip pain results in reduced stance phase on that side. The trunk is propelled quickly forwards with the opposite shoulder lifted in an attempt to even the weight distribution over the limb and reduce weight bearing. Swing phase is also reduced.

Common Neurological Causes of Pathological Gait:

Hemiplegic Gait, often seen as a result of a stroke. The upper limb is in a flexed position, adducted and internally rotated at the shoulder. The lower limb is internally rotated, knee extended and the ankle inverted and plantar flexed. The gait is likely to be slow with circumduction or hip hitching of the affected limb to aid floor clearance.

Diplegic Gait. Spasticity is normally associated with both lower limbs. Contractures of the adductor muscles can create a ‘scissor’ type gait with a narrowed base of support. Spasticity in the lower half of the legs results in plantarflexed ankles presenting in ‘tip toe’ walking and often toe dragging. Excessive hip and knee flexion is required to overcome this.

Parkinsonian Gait often seen in Parkinson’s disease or associated with conditions which cause parkinsonisms. Rigidity of joints results in reduced arm swing for balance. A stooped posture and flexed knees are a common presentation. Bradykinesia causes small steps which are shuffling in presentation. There may be occurrences of freezing or short rapid bursts of steps known as ‘festination’ and turning can be difficult.

Ataxic Gait is seen as uncoordinated steps with a wide base of support and staggering/variable foot placement. This gait is associated with cerebellar disturbances and can be seen in patients with longstanding alcohol dependency

People with 'Sensory'Disturbances may present with a sensory ataxic gait. Presentation is a wide base of support, high steps and slapping of feet on the floor in order to gain some sensory feedback. They may also need to rely on observation of foot placement and will often look at the floor during mobility due to lack of proprioception.

Myopathic Gait. Due to hip muscular dystrophy, if it is bilateral the presentation will be a ‘waddling gait’, unilaterally will present as a Trendelenburg Gait.

Neuropathic Gaits. High stepping gait to gain floor clearance often due to foot drop

Gait Analysis:

The analysis of the gait cycle is important in the biomechanical mobility examination to gain information about lower limb dysfunction in dynamic movement and loading. When analyzing the gait cycle, it is best to examine one joint at time. Objective and subjective methods can be used.

Subjective

Our observation of gait is a subjective measure that we can use. We might ask the individual to walk normally, on insides and outsides of feet, in a straight line, running.  All the time looking to compare sides and understanding of "normal".

Objective

An objective approach is quantitative and parameters like time, distance, and muscle activity will be measured. Other objective methods to assess the gait cycle that use equipment include:

• Video Analysis and Treadmill
• Electronic and Computerized Apparatus
• Electronic Pedometers
• Satellite Positioning System

Qualitative methods to assess and analyse gait include:

• Rancho Los Amigos Hospital Rating List
• Ten Meter Walking Test
• 6 Minute Walking Test
• 2 Minute Walking Test
• Dynamic Gait Index
• Emory Functional Ambulation Profile
• Timed Up and Go Test This test is statistically associated with falling in men, but not in women.
• Functional Ambulation Categories
• Tinetti-Test

 

Understanding Phases of the Gait Cycle:

Gait analysis is the study of human locomotion. In order to analyze and quantify how someone walks, it is necessary to isolate the shortest, unique, repeatable task during gait. This task is called the gait cycle. A single gait cycle can be measured from any gait event to the same subsequent event on the same foot, but the conventional tacit model considers gait cycle is measured from one foot strike to the subsequent foot strike of the same foot.

Quantifying aspects of the gait cycle, such as time and spatial measures, allow for analysis of gait symmetry, variability and quality.

Two Primary Phases of the Gait Cycle:

The gait cycle can be broken down into two primary phases, the stance and swing phases, which alternate for each lower limb.

• Stance phase: Consists of the entire time that a foot is on the ground.
• Swing phase: Consists of the entire time that the foot is in the air.

The observation of both the spatial and temporal characteristics of the two lower limbs makes it possible to introduce complementary phases. When both members are simultaneously in the stance phase, we speak of bipedal support or double support (2 times 10%); when only one is in the support phase, one speaks of unipedal support or single support (40%), the second then being in oscillating phase.

The most accurate approach is based on the functional interpretation of events and identifies eight phases that capture three tasks related to walking. We then distinguish (Perry & Burnfield, 2010):

1. Weight acceptance (0-12%):

The objectives of weight acceptance are to stabilize the limb, absorb shock and preserve the progression of the body. This phase can be broken down further into initial contact and loading response. Initial contact consists of the first 3% of the gait cycle. In typical gait, the heel strikes the ground and initiates the rotation over the heel to foot flat to preserve progression. This motion is the first rocker of the gait cycle. Loading response goes from 3-12% of the gait cycle. In this portion, the knee flexes slightly in order to absorb shock as the foot falls flat on the ground, stabilizing in advance of single limb support.

2. Single limb support (12-50%):

Single limb support involves progression of the body over the foot and weight-bearing stability. The first sub-phase of single limb support is midstance, which is seen during the 12-31% of the gait cycle. During midstance, the shank rotates forward over the supporting foot, creating the second rocker motion of the cycle. This maintains the forward progression of gait. The second stage of single support is terminal stance which goes from 31-50% of the gait cycle. During terminal stance, the center of mass advances out in front of the supporting foot. The heel raises of the ground as you roll onto the ball of the foot, creating the third rocker motion of the cycle.

3. Swing phase (50-100%):

The objectives of the swing phase of gait

• Foot clearance over the ground
• Forward swing of the limb
• Preparation of limb for stance

The swing phase can be broken down into 4 sub-phases.

1. Pre-swing takes place during 50-62% of the gait cycle. Pre-swing is the transition phase between stance and swing, in which the foot is pushed and lifted off of the ground.
2. Initial swing goes from 62-75% of the gait cycle. During initial swing, the hip, knee, and ankle are flexed to begin advancement of the limb forward and create clearance of the foot over the ground.
3. Mid-swing goes from 75-87% of the gait cycle. During mid-swing, limb advancement continues and the thigh reaches its peak advancement.
4. Terminal swing is the final phase of the gait cycle going from 87-100% of the cycle. During terminal swing, the final advancement of the shank takes place and the foot is positioned for initial foot contact to start the next gait cycle.

Figure 1. Breakdown of the gait cycle into phases based on the work of Perry and Burnfield (2010)

Figure from: Stöckel, Tino & Jacksteit, Robert & Behrens, Martin & Skripitz, Ralf & Bader, Rainer & Mau-Moeller, Anett. (2015). The mental representation of the human gait in young and older adults. Frontiers in Psychology. 6. 943. 10.3389/fpsyg.2015.00943.

Perry, J., and Burnfield, J. M. (2010). Gait Analysis: Normal and Pathological Function. New York, NY: Slack Inc

 

Gait Training:    

Gait training:

Gait training is a type of physical therapy. It can help improve ability to stand and walk. Physiotherapist may recommend gait training if any illness or injury that affects  ability to get around. It may gain independence in walking, even if need an adaptive device.

Gait training can help:

• strengthen muscles and joints
• improve balance and posture
• build endurance
• develop muscle memory
• retrain legs for repetitive motion
• lower risk of falls, while increasing mobility

It may also lower the risk of other illnesses, such as heart disease and osteoporosis, by increasing physical activity and mobility. Choosing gait training over immobility may help protect and improve overall health.

gait training uses:

Physiotherapist may recommend gait training for immobile patient  due to an injury, illness, or other health condition. For example, the following conditions can lead to difficulties with walking:

• spinal cord injuries
• broken legs or pelvis
• joint injuries or replacements
• lower limb amputations
• strokes or neurological disorders
• muscular dystrophy or other musculoskeletal disorders

Children who require gait therapy often have brain injuries, neurological disorders, or musculoskeletal issues. Their physiotherapist may recommend gait therapy before or after they start walking.

 

 

 Gait training involves:

Physiotherapist  will likely encourage to start gait training as soon as possible after an injury or illness that affects patients  ability to walk. They may recommend other forms of physical therapy and treatments too. It must be healthy enough for physical activity and movement  beginning stage. All joints must also be strong enough to support gait training.

Once patients  healthy enough to start gait training, the process is similar to other physical therapies. It often involves machines that help to  walk safely.  Physiotherapist may also assist in gait training exercises. They can help support body weight, provide stability, and offer other assistance.

Gait training commonly involves walking on a treadmill and completing muscle strengthening activities. Patients  may wear a harness while walking on the treadmill or doing other exercises. Physiotherapist may teach  stepping over objects, lifting legs, sitting down, standing up, or other activities.

The type, intensity, and duration of training will depend on patients  specific diagnosis and physical abilities.

The takeaway:

Gait training can be hard work. If patient have been immobile for a while, the process of walking or relearning to walk may be physically and mentally challenging.  Physical therapist should know about any challenges of patients inability.  And physiotherapist should know about patients specific condition, gait training plan, and long-term outlook.

 THOSE ABOVE ARE COLLECTED FROM SOME BOOKS AND WEBSITES..

THANK YOU,

SRIKUMARAN PHYSIOTHERAPY CLINIC & FITNESS CENTER