Gait

- Muscle-Deficit Gait
1. Antalgic Gait – To reduce pain, there is avoidance of weight bearing (WB) on the affected limb. The
examiner may note a decrease in the stance phase, a reduced step length on the unaffected side, and a
prolonged period of double support.
2. Gastrocnemius Gait – Weak plantar flexors during terminal stance and toe-off prevent adequate heel
lift. To limit the drop in the COG that occurs without heel lift during terminal stance, the step length of
the contralateral leg is shortened. Treatment: A solid or semisolid ankle–foot orthosis (AFO) with a
full-length footplate simulates plantar flexion during terminal stance.
3. Chronic Gastrocnemius Gait (“Go Backward Before You Go Forward” Gait) – Chronic weakness of
the gastrocnemius muscles causes the calcaneus to become more vertical, and a cavus foot may
develop with a large rubbery bursa over the heel. At heel strike, the body’s movement tends to roll the
foot forward over the bursa. As the GRF passes in front of the ankle and the thrust of the leg is directed
backward, the foot will roll backward over the bursa. This rocking movement makes it look as though
one is taking a step backward prior to moving forward. Additionally, the lack of push during the stance
phase may eliminate the heel-off–to–touch-off phase, leading to a lift-off from foot flat stance. There is
also a tendency for a shortened stance phase on the affected leg to avoid unstable collapse of the ankle
into dorsiflexion.
4. Gluteus Medius–Minimus (Trendelenburg) Gait – In an uncompensated Trendelenburg gait. there is
contralateral pelvic drop secondary to the inability of the hip abductors to stabilize the pelvis during
stance. In a compensated Trendelenburg gait, weak abductors are compensated by a lateral lurch over
the affected side to reduce the stress on the weak muscles. Treatment: A cane used in the contralateral
hand widens the base of support and decreases the hip abductor strength needed to keep the pelvis
level. In bilateral abductor weakness, bilateral canes with a four-point gait may be used.
5. Gluteus Maximus (Extensor Lurch) Gait – This may be seen following injury to the inferior gluteal
nerve or a subtrochanteric hip fracture. Weakened hip extensors are unable to decelerate the forward
momentum of the body (hip flexion moment) at heel strike. To compensate, the subject adopts a
prominent posterior lean and locks the hip joint in extension against the iliofemoral ligament, which
keeps the body’s COG behind the hip. Treatment: Two crutches or canes are used for a three-point gait
6. Quadriceps (Back Knee) Gait – With weakness or inhibition of the quadriceps (e.g., distal femoral
fracture), measures will be adopted to prevent buckling of the knee. One compensation is the use of the
hand(s) to force the knee into extension. The trunk may also lurch forward at initial contact and the
ankle plantar flexors strongly contract in order to bring the COG in front of the knee and force it into
extension. Another compensatory technique is external rotation of the leg at initial contact and early
stance to bring the medial collateral ligament anteriorly to prevent knee buckling. Treatment: A knee
brace may be used to provide knee stability at heel strike (Figure 2.6). Also, the use of a rolling walker
promotes trunk flexion to bring COG in front of the knee.
7. Tibialis Anterior Gait – Pretibial muscle weakness that is at least antigravity (≥3/5 grade) may cause
foot slap after heel strike. If the muscles are <3/5 grade, foot slap is generally not heard because a
steppage gait is more likely. The hip and knee are hyperflexed in a steppage gait to clear the foot
during swing phase, which may otherwise drag (Figure 2.7). The affected limb may alternatively be
circumducted during swing phase. Treatment: A standard posterior leaf spring orthosis (PLSO), which
allows plantar flexion and assists in dorsiflexion. An AFO is often used both to prevent foot slap and to
allow clearance of the foot during swing phase. Note, however, that ankle plantar flexion stabilizes the
knee. Thus, a standard hinged AFO (with plantar flexion posterior stop) may destabilize the knee.
- Central Nervous System Gait Deviations
1. Hemiplegic Gait – Persons with extensor synergies will typically ambulate independently. The typical
extensor synergy pattern has a predilection for knee extension, ankle plantar flexion, and inversion.
Therefore, extensor tone effectively makes the plegic limb longer than the nonplegic side. A
circumduction gait compensates via exaggerated hip abduction to allow for toe clearance and ends with
toe strike. Despite the circumduction, there is a decreased step length and swing phase on the plegic
side. Gait speed will be reduced in order to maintain an acceptable rate of energy expenditure.
Treatment: A solid AFO or a hinged AFO with a posterior stop to decrease effective limb length may
be helpful. A small degree of plantar flexion, however, should be maintained to promote knee stability
when there is quadriceps weakness. With genu recurvatum, providing additional plantar flexion at the
ankle via the addition of a heel lift (Figure 2.8D), and/or cutting the footplate just proximal to the
metatarsal heads (Figure 2.8E), moves the COG posteriorly at the knee level, reducing the knee
extension moment compared to the untreated state
2. Parkinsonian Gait – The classic triad of Parkinson’s disease is tremor, bradykinesia, and instability,
with at least the last two affecting gait. While standing, the knees, trunk, and neck are typically flexed
and the body appears stiff. When there is ambulation, there is a characteristic shuffling gait with short
quickening steps, as if the patient were racing after the COG (festination). Turns are made “en bloc.”
Decreased arm swing further compromises balance. Treatment: Heel lifts and assistive devices may
help reduce the tendency to fall backward. Walkers with added weight may provide additional stability.
Physical therapy to address postural issues can be helpful
3. Spastic Paraplegia or Diplegia/Crouched Gait – Often seen in persons with cerebral palsy. While
standing, the hip and knees are flexed and internally rotated and the foot is held in equinovarus. With
ambulation, the increased adductor tone at the thighs causes the knees to scissor in front of each other
with each step. Hip adduction causes short step lengths, making the feet seem like they are sticking to
the floor. Balance may be impaired as a result of a narrowing base of support. To compensate for this,
there is a tendency to lean forward and toward the supporting side. The upper extremities tend to be
semiflexed with elbows held out to the sides. Diagnostic nerve blocks may help establish whether or
not a contracture is present. Treatment: AFOs can be used to address equinovarus. Botulinum toxin
injection therapy may be helpful for addressing adductor scissoring and equinovarus. Use of an
assistive device (e.g., a walker) may provide additional stability.