Gait is described as a series of rhythmic, alternating movements of the limbs and trunks that result in

the forward progression of the center of gravity.

Gait is dependent on input from several systems, including the visual, vestibular, cerebellar, motor, and
sensory systems

The basic unit of walking is the gait cycle, which is recorded from the time one foot strikes the ground
until that episode recurs and starts the next cycle.
In one gait cycle, the body goes a distance of one stride.
A stride is made up of one step by each foot, and these two steps are normally symmetrical in length.
Cadence (steps/min) is known as the frequency of stepping.
The speed of walking is calculated as the cadence times the step length.
Walking speed is computed by recording the time a person completes a measured distance

The gait cycle is divided into 2 major phases.

Each lower limb supports the body during its stance phase and then leaves the floor in the swing phase.
The stance phase us the period of time that the foot is one the ground. During stance, the leg accepts
body weight and provides lower limb support
The period of time that the foot leaves the ground and moves forward is called the swing phase.

A double-limb stance (DLS) occurs between each step.

During DLS, the weight is transferred from one foot to the other in a coordinated pattern which is
known as weight acceptance (or loading) and weight release (preswing) for each of the respective limbs

The stance phase of gait which is 60% of the gait cycle, begins with the initial contact or period of weight
acceptance, when the foot touches the ground.
Weight acceptance, also called loading, is a decelerating portion of the gait cycle where the foot stops
after traveling at about 4 m/s during the end of swing phase.
This sudden stop requires controlled braking involving simultaneous
action of the ankle, knee, and hip.
(At the same time, the left leg is involved in lifting off the foot to initiate
its swing phase.)
The ankle is in a slight dorsiflexion upon heel strike and then rapidly plantar flexes under the control of
the anterior tibialis muscle in an eccentric/lengthening contraction, as well as the lesser dorsiflexors,
until the foot is flat on the ground.

loading response marks the beginning of the initial double limb stance. This occurs after initial contact
until elevation of opposite limb. bodyweight is transferred on to the supporting limb

Simultaneously, the knee begins to flex under the eccentric control of the quadriceps
the trunk reaches its lowest point during the
cycle.
The hip, which was flexed at heel strike, begins to extend on the pelvis as the trunk smoothly continues
forward.
The forward momentum of the trunk is controlled by contraction of the hip extensors, gluteus maximus
and the long hamstrings,
Which results in controlled hip extension as the trunk moves forward.
The hip and pelvis rotate opposite to one another at the same time, there is internal hip rotation of the
stance limb.

Single limb support phase (midstance)

The left foot leaves the ground, the right hip continues to rotate internally as that limb enters the single-
limb support portion of stance phase.
The right ankle begins to passively dorsiflex as the tibia tilts forward and the pelvis lowers on the
left in a Trendelenburg tilt.
The pelvis is also moving laterally to the right so that the center of mass (COM) of the body is aligned
over the right foot for balance.
During this period, the pelvis and COM of the body are rising.
To achieve this, some of the kinetic energy of forward motion
is converted into potential energy as the trunk rises against the
force of gravity

In the middle of single-limb stance (SLS) phase, the right ankle reaches maximum dorsiflexion and the
heel begins to rise from the floor.
This heel rise will signal a shift in the right leg’s function in the gait cycle as it ends its decelerating role
and begins to serve as the acceleration for its step phase.
The foot now rocks over to the forefoot as the knee extends, and the pelvis rotates externally and the
right hip maximally extends to prepare for opposite heel strike.
The left lower limb is fully stretched out for its heel strike so that the pelvis is supported and the drop of
the COM of the body is minimized
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From its weight release phase, the right will now shift to weight support to the left lower limb while
accelerating the right leg for its forward propulsion or swing phase
The weight-release phase on the right must now shift
weight support to the left lower limb while accelerating the
right leg for its forward propulsion or swing phase.
During the weight release or terminal stance, the ankle is actively plantar flexed by concentric action of
the gastrocnemius, soleus, posterior tibialis, and lesser plantar flexors.
At the same time, right hip flexion is being produced by the iliacus, psoas, and tensor fascia
lata muscles
The left hip internal rotators are causing forward rotation of the right pelvis. These left hip muscles
contribute to the horizontal forces or forward movement of the right lower limb.
The toe finally leaves the ground as a result of this combined push and pull on the right lower limb.
the swing phase is initiated, causing a step to occur.

During the beginning of swing phase, the right leg continues to accelerate as hip flexion, knee flexion,
and ankle dorsiflexion combine to cause the toe to pass over the ground.
Usually, the toe reaches a minimum height of less than 2.5 cm. at the middle of the swing phase.
This minimal elevation conserves energy by reducing the work done to elevate body parts against
gravity.
This closeness to the ground can also be a safety problem, causing stumbles on uneven ground,
but the gains of energy efficiency caused by reducing the step height are important enough for this
safety risk.
The energy conserving nature of the gait cycle, in part attributable to these
mechanics and its highly repetitive and symmetrical nature,
will be discussed in more detail, but most of us have experienced
the rapid fatigue caused by high stepping (“steppage
gait”) when traversing deep snow or the lack of repetitive steps
when walking on very uneven ground.

The second half of the swing phase returns the right leg into a role of decelerating as the forward
motion is slowed in preparation for heel strike.
The ankle is in dorsiflexion while the hip flexes and the knee extends.
This combination, along with the forward rotation of the right pelvis and external rotation of the right
hip, results in maximal length of the step.
Injury or dysfunction of a joint or muscle-tendon that reduces the step length will have a major impact
on the efficiency of walking.
At the end of swing, the hip extensors function to brake the forward flexion of the hip;
At faster gait speeds, the hamstrings slow and control the knee extension.
The speed of the leg and foot must be controlled to prevent slipping at heel strike.

The vertical displacement of the body is minimized by a number of factors that are known as the
determinants of gait
There are 6 determinants which operate independently but simultaneously to produce a smooth
sinusoidal vertical and horizontal path, which has one vertical peak and trough for
each step.
There is also one lateral sinusoid, or curve, for each stride as the body moves toward the supporting foot
during each cycle.
To illustrate the effects of the determinants of gait, they are
they are removed and replaced in models of the gait cycle as
shown in Figures 5-4 to 5-8. This “compass gait” analysis was
restudied by Della Croce et al. (6) with the inclusion of data
recorded in a contemporary gait lab, largely reaffirming the
model.
The first determinant of gait is the rotation of the pelvis.
During each step, the pelvis rotates forward on the side of the swinging limb. The axis of this rotation is
the hip joint of the stance leg, which undergoes internal rotation.
As the pelvis forms a bridge between the two hips, it reduces the angle of intersection of the thighs to
reduce the vertical descent of the trunk.

To better understand this, Delisa has models to illustrate the determinants of gait.
Hypothetical compass gait. The pelvis
is represented by a single bar with a small cuboid representing
the body’s COM. The legs are rigid bars articulating only at the hip.
No foot, ankle, or knee joints are present. The pathway of the COM is a series of interconnecting
arcs.
The picture shows the effect of pelvic rotation in the transverse plane. The slight rotation of the pelvis in
the transverse plane during double-limb support reduces the elevation needed by the COM when
passing over the weight-bearing leg during midstance.

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The pelvic Trendelenburg motion, or pelvic list, is the

second determinant.
The pelvis drops a few degrees so that the hip of the leg in swing phase is lower than the hip
of the stance limb.
This reduces the vertical rise of the COM of the trunk and reduces the work of lifting this mass.
But this reduces the space for toe clearance
Pelvic list, as well as rotation, has been shown to decrease at slower speeds.
This fact, and the data that reveal that these motions are less important modifiers
of the vertical movement of the COM, suggests that these
movements are important to the control of the momentum
during forward propulsion.
Knee flexion in stance phase is an important determinant of gait because it provides a shock-absorbing
mechanism at the beginning of the stance phase.
The reduction of the shock of foot impact on the floor helps maintain
momentum which reduces energy loss of stopping and restarting the gait cycle.
Also, the knee flexion in stance reduces the height of the hip joint in midstance. This additional height
reduction prevents energy loss from lifting the body but at the cost of quadriceps muscle work.

Lateral displacement of the pelvis also occurs during each step. The pelvis and trunk must move to the
stance side to balance the COM of the trunk above the stance foot and align the tibia into the vertical
position during stance.
This determinant of gait is a net loss of energy since it
causes upward movement of the body, but it is necessary for
balance in bipedal gait.

The trunk and shoulder rotate during normal gait in a direction opposite to the pelvic rotation. This 180-
degree phase shift of total trunk movement balances the angular acceleration so that balance and
forward momentum are maintained. Smooth, coordinated movement here is an
energy advantage.

Next determinant is The obliquity of the subtalar joint which provides a unique relationship between the
motion of the foot and the shank.
Dorsiflexion of the foot causes lateral movement of the forefoot and also vice versa.
During stance, the passive dorsiflexion of the ankle, causes internal rotation of the tibia to
partially match that similar movement in the hip.
This combined rotation is then reversed during the end of stance or weight release.

Sagittal plane foot and ankle movement is referred to as the three “rockers.”
The three components happen during heel strike, during foot flat, and during toe-off.
For the first rocker, the dorsiflexion of the foot causes the heel to stick out and
produce a net lengthening of leg length to maximize the length of the step.
This extra length is lost during weight acceptance, when it is no longer needed.
Also during this time, the resisting ankle dorsiflexion muscles provide a
shock-absorbing descent of the forefoot.

During the second rocker, dorsiflexion of the foot occurs during midstance. This
serves to reduce the length of the leg until the pelvis passes in front of the ankle. As the heel rises after
midstance, the third rocker occurs.
The elevation of the heel increases the leg length during push-off and so the amount of drop that is in
the pelvis is limited.

The rockers of the heel, midfoot and forefoot are useful in minimizing the vertical
work of the body movement. It also provides a rolling-like mechanism of foot during stance so that
momentum is preserved.
According to Delisa, that heel rise and forefoot support may be the most important determinant of gait

Gait Examination
To examine a patient, we ask the patient to walk across the room in a straight line. We can also observe
the patient as he walks from the waiting area into the examination room
We also ask the patient to stand from a chair, walk across the room and come back toward the
examiner.

When we examine the gait of the patient we pay attention to the following
Ease of arising from a seated position.
We assess if the patient easily arise from a sitting position. Because difficulty with standing up from
sitting may indicate proximal muscle weakness, movement disorders with difficulty initiating
movements, or a balance problem.
Next we assess the patient’s balance
Does the patient lean to one side? Because they may be an indication of cerebellar dysfunction.
Patients with medullary lesions and cerebellar lesions tend to push towards the side of the lesion.
Diffuse disease affecting both cerebellar hemispheres can cause a generalized loss of balance.
Patients with cerebellar disorders usually have balance issues with or without their eyes open.

Next we assess the Walking speed of the patient

Patients with Parkinson disease will have problems initiating movements, but then lose their balance
once they are in motion.
Patients with pain, such as knee or hip arthritis, often have limitations of ROM which affects their gait
speed.
It has also been shown that a self-selected gait speed of less than 0.8 m/sec is a risk factor for falls in the
stroke population.
The speed of walking remains stable until about age 70 years when there is a 15% decline per decade.
Gait speed is lower because elderly people take shorter steps.

Next we also look at the Stride and step length.

Does the patient take a small step or shuffle while walking?
Patients with normal pressure hydrocephalus and Parkinson disease usually take small steps or
shuffle, which means that they have a decreased step and stride length.
Stride length is the linear distance between successive corresponding points of heel contact of the
same foot, whereas step length is the distance between corresponding successive contact points
of opposite feet.
An antalgic gait as seen in the image, is characterized with the patient spending more time in stance
phase on one leg. This is because of pain in the other leg.
An average step length is approximately 2 feet for women and 2.5 feet for men.

Lastly, we evaluate the Attitude of arms and legs.

How does the patient hold his or her arms and legs?
Loss of movement as in a spastic or contracted patient should be assessed.
Patients with knee extension weakness might swing their knees into terminal extension, thereby locking
their knee (genu recurvatum).

The patient is then asked to also walk heel to toe in a straight line by putting one heel of one foot
directly in front of the toe of the other.
This is also called tandem gait and is a test of higher balance.
Tandem gait can be difficult for older patients and in some other medical conditions (even without
neurologic disease).

Other tests to assess gait function include observing patients walk on their toes and heels.
Patients with a Trendelenburg gait tend to sway toward the leg in stance phase because of abductor
weakness. Balance can also be assessed by asking patients to hop in place and to do a shallow knee
bend.
Gait disorders have stereotypical patterns that reflect injury to parts of the neurologic system.
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This is a summary of the usual gait patterns and diseases associated with them. They will be discussed in
the nxt slides.

Patients with Hemiplegic Gait have Unilateral upper motor neuron lesions with spastic hemiplegia
The affected lower limb is difficult to move, and knee is held in extension.
With ambulation, the leg swings away from the center of the body, and the hip moves upward to
prevent the toes and foot from striking the floor. This is known as “circumduction.”
If the upper limb is involved, there may be decreased arm swing with ambulation.
The upper limb has a flexor synergy pattern resulting in shoulder adduction, elbow and wrist flexion,
and a clinched fist.

In patients with a Scissoring gait, Bilateral corticospinal tract lesions are often the cause, which is seen
in patients with cerebral palsy, incomplete spinal cord injury, and multiple sclerosis.
Hypertonia in the legs and hips results in flexion and the appearance of a crouched stance. The hip
adductors are overactive causing the knees and thighs to touch or cross in a “scissor-like” movement.
In cerebral palsy, there can be associated ankle plantar flexion forcing the patient to tiptoe walk. The
step length is shortened by the severe adduction or scissoring of the hip muscles.

Ataxic Gait is observed in patients with cerebellar dysfunction or severe sensory loss such as tabes
dorsalis.
Ataxic gait is characterized by a broad-based stance TO MAINTAIN BALANCE and irregular step and
stride length AND SWAYING
In ataxic gait from proprioceptive dysfunction such as in tabes dorsalis), gait will worsen with the eyes
closed.
There is a tendency to sway, whereas watching the floor usually helps guide the uncertain steps.
Ataxic gait from cerebellar dysfunction will not worsen with eyes closed.
Movement of the advancing limb starts slowly, and then there is an erratic movement forward or
laterally. The patient will try to correct the error but usually overcompensates. Tandem gait exacerbates
cerebellar ataxia.

Myopathic gait is caused by myopathies which cause weakness of the proximal leg muscles.
Myopathies result in a broad-based gait and a “waddling-type” appearance as the patient tries to
compensate for pelvic instability.
Patients will have problems with climbing stairs or rising from a chair without using their arms.
When going from floor to standing, the patient will use their arms and hands to climb up their legs—
known as Gowers sign.1

Trendelenberg gait is Caused by weakness of the abductor muscles (gluteus medius and gluteus
minimus) as seen in superior gluteal nerve injury, poliomyelitis, or myopathy
During the stance phase, the abductor muscle allows the pelvis to tilt down on the opposite side.
To compensate, the trunk moves to the weakened side to maintain the pelvis level during the gait cycle.
This results in a waddling-type gait with an exaggerated compensatory sway of the trunk toward the
weight-bearing side.
It is important to understand that the pelvis sags on the opposite side of the weakened abductor
muscle.
IN THE VIDEO WE CAN SEE WHENEVER THE PERSON LOADS WEIGHT ON THE LEFT FOOT, THE RIGHT HIP
DROPS DOWN TOWARDS THE AFFECTED SIDE. POSITIVE TRENDELENBERG. LEFT HIP ABDUCTOR GLUT
MEDI AND MINIMUS NOT WORKING PROPERLY.

Parkinsonian gait is seen in patients with parkinson disease and other diseases of the basal ganglia
Patients have a stooped posture, narrow base of support, and a shuffling gait with small steps.
As the patient starts to walk, the movements of the legs are usually slow with the appearance of the
feet sticking to the floor.
They might lean forward while walking so the steps become hurried, resulting in shuffling of the feet
(festination.
Starting, stopping, or changing directions quickly is difficult, and there is a tendency for retropulsion
(falling backward when standing). The whole body moves rigidly requiring many short steps and there is
loss of normal arm swing. There can be a “pill-rolling” tremor while the patient walks

Steppage gait is seen with Diseases of the peripheral nervous system including L5 radiculopathy, lumbar
plexopathies, and peroneal nerve palsy.
AS SEEN IN THE VIDEO, THE PATIENT HAS DIFFICULTY DORSIFLEXING THE FOOT RIGHT. THIS CAUSES A
HIGH STEPPAGE GAIT. THE PATIENT COMPENSATES BY LIFTING THE RIGHT LEG HIGHER THAN NORMAL.
The patient with foot drop will have difficulty dorsiflexing the ankle. The patient compensates for the
foot drop by lifting the affected extremity higher than normal to avoid dragging the foot.

Apraxic gait is seen in patients who experience gait impairment but there is no evidence of sensory loss,
weakness, vestibular dysfunction, or cerebellar deficit; seen in frontal lobe injuries, such as a stroke, and
traumatic brain injury.
Despite difficulty with ambulation, patients can perform complex coordinated activities with the lower
limbs

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