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1 s2.0 S1877132720300397 Main
1 s2.0 S1877132720300397 Main
Terminal stance: as the heel begins to lift off the floor, so be-
gins terminal stance. During this phase loading of the foot
moves distally towards the metatarsal heads. As the knee is
Kanishk Shah BMSc (Hons) MRCS (Ed) Orthoapaedic Registrar, Royal fully extended the gastrocnemius muscle is at peak tension and
Surrey County Hospital, Guildford, UK. Conflicts of interest: none able to generate a powerful ankle plantar flexion force for
declared. propulsion.
Matthew Solan FRCS (Tr&Orth) Consultant Foot and Ankle Surgeon,
Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: Pre-swing follows terminal stance and is the point where the
none declared. limb begins to leave the ground, or ‘toe-off’. The ipsilateral hip
Edward Dawe BSc (Hons) FRCS (Tr&Orth) Dip (Sports Med) Consultant Foot flexes which in turn flexes the knee allowing the foot to clear the
and Ankle Surgeon, St Richard’s Hospital, Chichester, UK. Conflicts ground in preparation for swing phase. Clearance of the foot is
of interest: none declared. further facilitated through ankle dorsiflexion via concentric
ORTHOPAEDICS AND TRAUMA 34:3 153 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
BASIC SCIENCE
Figure 1 Schematic representation of gait under normal circumstances. Stance is subdivided into: initial contact, loading response, mid-stance,
and pre-swing. Swing is subdivided into: initial swing, mid-swing and terminal-swing. One completed ‘gait cycle’ is referred to as a ‘stride’. The two
periods of double support are also illustrated which occur during initial contact, the loading response and pre-swing. Reproduced from reference
13.
tibialis anterior contraction (concentric contraction e muscle the ground reaction force of bodyweight that is exerted on the
contraction whilst the muscleetendon unit shortens). foot (and limb). The heel effectively acts like fulcrum around
which the foot ’rotates’ with respect to forward movement or
Swing phase rolling into plantar flexion. The centre of rotation of the knee
Initial, mid- and terminal swing: the swing phase of gait is during this stage also sits anterior to the ground reaction force
divided into three sub-phases: initial swing, mid-swing and ter- arising from bodyweight. There is therefore a plantar flexion
minal swing. As the name would imply, the limb ‘swings’ though moment exerted across the ankle and a flexion moment exerted
this phase and movement is driven primarily under momentum across the knee. The plantar flexion moment at the ankle is
generated during the stance phase. During swing phase, there controlled through eccentric contraction of tibialis anterior and
must be adequate flexion of both the hip and the knee. This is the toe extensors and the flexion moment across the knee
achieved through concentric contraction of the hip flexors in through eccentric contraction of the quadriceps as the cycle
conjunction with knee flexors (hamstrings) and a small contri- progresses towards mid-stance. The ground reaction force at this
bution from the gastrocesoleus complex. The result is flexion of stage passes through the centre of rotation of the hip joint
the hip and knee during the initial and the mid-swing sub-phases. therefore the hip is essential rotationally neutral during this
Adequate dorsiflexion of the ankle is also required in terminal stage.
swing to achieve foot clearance from the ground. This is achieved As the heel strikes the ground, it is passively pushed into
through concentric contraction of tibialis anterior. valgus which unlocks the Chopart joint. This allows the foot to be
flexible and so 1) accommodate uneven surfaces and 2) absorb
The three rockers of gait the shock of landing. This means the centre of gravity of the body
The gait cycle can also be considered in terms of three functional does not have to rise, which optimizes energy efficiency.
rocker units, as described by Perry.1 Each rocker has a different
fulcrum and the rockers are another way of considering the Mid-stance e the second rocker: next, the limb moves over the
sub-phases of stance (Figure 2). foot and the ankle undergoes passive dorsiflexion. Consequently,
the vector of the ground reaction force across the lower limb
Initial contact and loading response e the first rocker: during changes and now passes directly through the ankle joint. The
the first rocker the centre of rotation of the ankle sits anterior to ankle is now acting as the fulcrum. The centre of rotation of the
ORTHOPAEDICS AND TRAUMA 34:3 154 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
BASIC SCIENCE
Figure 2 (a) Shows where the ground reaction force passes in each rocker with respect the centre of rotation of each of the joints. Dependent on
the joint and where the joint reaction force passes, a flexion or extension moment is created. If the ground reaction force passes through the centre
of rotation, a moment about the joint is not created. (b) Shows the three rockers but with respect to the foot and the relevant muscle contractions in
each of the rockers. Adapted from reference 14.
knee and hip passes posterior to the ground reaction force and band of connective tissue that originates at the medial calcaneal
therefore there are extension moments exerted across both of tubercle and spans out to insert onto the base of the proximal
these joints. The knee and hip are both maintained in extension phalanges of the toes. Within the foot this effectively creates a
with minimal contribution from the musculature which further ’truss’ like structure between the calcaneum and the metatarsal
serves to conserve energy. Forward movement of the ankle (i.e. heads (Figure 3).
dorsiflexion) is controlled through eccentric contraction of the Extension of the big toe results in the plantar fascia being
gastrocnemiusesoleus complex. pulled distally. This shortens distance between the calcaneum
and the metatarsal heads, shortening the truss, with rotation
Terminal stance e the third and final rocker: as forward mo- occurring about the talonavicular joint. This results in raising of
mentum continues, passive dorsiflexion of the ankle progresses the medial longitudinal arch. The origin and insertion of the
until the limit of the joint is reached. At that point, concentric plantar facia forms the windlass mechanism around the meta-
contraction of the gastrocnemiusesoleus complex occurs and tarsophalangeal joints (MTPJs). This is the basis of the Jack test,
causes the heel to raise off the floor. The fulcrum point now by which the medial longitudinal arch is recreated by dorsi-
moves to the metatarsal heads. As the hip remains extended and flexion of the hallux.
the ankle begins to plantarflex, the centre of rotation of the ankle When the heel is in valgus (first rocker), the axes of the
joint passes posteriorly to the ground reaction force and anteri- talonavicular and calcaneocuboid joints (Chopart joint) are par-
orly to the centre of rotation of the knee, resulting in knee allel and the foot is supple and flexible, allowing it to adapt to
flexion. Tibialis posterior contracts concentrically and induces uneven surfaces. As the MTPJs dorsiflex and the plantar fascia is
heel varus. This has the effect of locking the mid-tarsal joints and tensioned recreating the medial longitudinal arch, the axes of
transforms the foot from a flexible structure into a rigid lever these two joints diverge. This ‘locks’ the Chopart joint and the
which can propel the body forward. foot becomes a rigid structure.
It is this transient rigidity that allows rotation of the foot and
The plantar fascia and the windlass mechanism ankle to occur around the metatarsal heads. This in turn results
The final rocker relies upon the plantar fascia and the effect that in the ability to ‘toe-off’ and continue moving through gait
extension of the big toe has upon it. The plantar fascia is a thick cycle.
ORTHOPAEDICS AND TRAUMA 34:3 155 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
BASIC SCIENCE
Antalgic gait
An antalgic pattern of gait is a compensatory mechanism to
reduce pain. The pain may be arising from anywhere within the
affected lower limb. Common to all forms of antalgic gait is the
reduced amount of time spent in single stance on the affected
side e the goal being to minimize the time the affected limb is
under load. Consequently, the amount of time spent in double
support increases and swing phase of the unaffected contra-
lateral leg is also reduced. The type of antalgic gait that is
observed will differ dependent on which part of the lower limb is
affected; therefore, it is possible to determine the cause of ant-
algic gait through careful observation.
Pathological gait
Pathological gait can be thought of as secondary to either
M R
neuromuscular disorders or musculoskeletal disorders (bone,
joints, or soft tissues).
My Ry
A B
ORTHOPAEDICS AND TRAUMA 34:3 156 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
BASIC SCIENCE
ORTHOPAEDICS AND TRAUMA 34:3 157 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
BASIC SCIENCE
Gait and limb length discrepancy arthrodesis of the ankle.10 One assumes this occurs secondary to
The list of causes of a limb length discrepancy includes other joints in the foot being ‘allowed to reach their full potential’
congenital disorders such as dysplasia of the hip, disorders of the as the pain in the tibiotalar joint is resolved thus improving
spine, particularly scoliosis, and degenerative conditions of the overall sagittal plane movement. As a result of this improvement,
hip such as osteoarthritis. Limb length discrepancies can also the time the unaffected limb spends in support reduces (i.e. the
arise as a result of surgery such as total hip replacement. Surgical affected limb can ‘properly go through’ terminal stance), which
scars provide clues as to whether or not the cause is post- in turn helps to normalize or improve stride length10
operative. In summary both treatment options for ankle arthritis can lead
Limb length discrepancies can be classified as either structural to some restoration of more normal biomechanics and gait.9,10
or functional. In structural causes the constituent parts of the An arthritic ankle adversely affects gait by reducing the dura-
limb have been affected so that there has been a change in the tion of terminal stance and reducing stride length.
length of the bones. In functional discrepancies the posture of the
lower limb contributes to an apparent change in length of the Steppage gait and weakness of ankle dorsiflexion (drop foot
limb. One such example would be a flexion contracture of the and slapping gait): steppage gait is a pattern of gait character-
knee. ized by an equinus position of the ankle. There is loss of normal
In a patient with a flexion contracture of the knee, the knee heel strike and loss of normal heel to toe progression. As a result
cannot extend and so heel strike is compromised. This effectively hip and knee flexion need to be exaggerated during the swing
reduces stride length. In addition, the patient may toe-walk phase of gait so that the toes clear the ground, because there is an
during stance phase on the affected side. effective increase in the length of the limb.3 Common causes of a
Studies have attempted to quantify the extent of limb length steppage gait include equinus contractures, foot drop, trauma
discrepancy resulting in clinically relevant sequalae. If the limb and immobilization of the ankle.3
length discrepancy is within 3% there are no associated Weakness of the ankle dorsiflexors may occur with stroke,
compensatory mechanisms involved. Above 5.5% the longer nerve injury (commonly after pelvic or spinal trauma/surgery) or
limb needs to do more mechanical work since there is greater neurological conditions such as hereditary sensory motor neu-
vertical displacement of the centre of gravity. Clinically this is ropathy (CharcoteMarieeTooth disease). There is loss of eccen-
manifested by the pelvis dipping towards the shorter side during tric contraction of these muscles and therefore loss of control of
the swing phase, and toe-walking on the shorter of the two limbs plantar flexion during the first rocker of gait which can result in a
during stance i.e. an absence of heel strike or initial contact. On ‘foot slap’. If this weakness is extreme or there is complete pa-
occasion this can also manifest as circumduction of the shorter ralysis of the anterior compartment, then the foot adopts a plan-
limb or hip hiking to accommodate the longer leg.8 tarflexed position earlier than normal i.e. in the swing phase
resulting in ’foot drop’. One compensatory mechanism for the toes
Foot and ankle and gait disturbance to clear the ground is for the limb to adopt steppage gait as
Painful conditions of the foot and ankle result in an antalgic described above. Other patients may circumduct the longer limb
pattern of gait dependant on which part is involved. Aetiologies to accommodate the extra functional length. The young and
include osteoarthritis, inflammatory arthritis, trauma and infec- flexible may, over time, develop pelvic obliquity to compensate.
tion. As a result of pain the foot will contact the ground abnor-
mally and patients may preferentially choose to bear weight on The gastrocesoleus complex and its effect on gait/foot
the heel, the forefoot or along the lateral border of the foot during biomechanics: if there is weakness of the gastrocesoleus com-
the stance phase as a result of protective supination. plex, there will be loss of ankle plantarflexion and loss of control
of ankle dorsiflexion. As a result, there is no power in the lever
Osteoarthritis of the ankle: patients who have painful arthritic that normally ‘pushes the foot off the floor’. Toe-off is effectively
ankles spend less time in the stance phase of gait. In addition, inhibited, which limits forward propulsion. The stride length on
stride length and walking speed are also reduced and these may the unaffected side is shortened to compensate. Common con-
be a way to reduce the load across the joint. Predictably the ditions such as rupture of the Achilles tendon, radiculopathy or
biggest loss of range of movement of an arthritic ankle is in the peripheral neuropathy, can result in this pattern of gait.
sagittal plane. Conversely, tightness of the gastrocesoleus complex can also
As stance progresses through the first and second rocker a lead to alterations in biomechanics of the foot and ankle, and
reduced range of movement of the tibiotalar joint shortens the subtle alterations in the gait cycle.
amount of time spent in terminal stance. If there is tightness of the gastrocesoleus complex the ankle is
Common treatment modalities for end stage arthritis of the unable to ‘fully unwind’ and it becomes harder to achieve full
ankle include fusion of the joint or total ankle arthroplasty. Total dorsiflexion of the ankle. This affects the second and third
ankle arthroplasty has been shown to improve gait characteris- rockers of gait where the gastroc muscle is at maximum tension
tics with restoration back to normal parameters at 1-year follow- because of knee extension. Toe-off has to begin earlier and this
up.9 Therefore, in suitable patients, total ankle arthroplasty may overloads the fulcrum of the third rocker (the metatarsal heads).
be a suitable treatment option to help restore normal ankle The plantar aspect of the forefoot will display characteristic cal-
movements and therefore gait. losities when examined. In addition, Silfverskio €ld’s test is likely
One would expect the gait characteristics in a fused ankle to to be positive since isolated gastrocnemius tightness is more
be markedly worse but interestingly movement in the sagittal common than contracture of both the gastrocnemius and the
plane has been shown to significantly improve following soleus.
ORTHOPAEDICS AND TRAUMA 34:3 158 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
BASIC SCIENCE
The different patterns of gait in cerebral palsy and the overriding muscle forces. The ‘alpha’ angle foot position effectively
describes the position the foot will adopt with respect to the lower leg. The appropriate orthotic is also described15
Foot position ( ) Overriding muscle forces Orthotic required
Table 2
Tightness of the gastrocnemius leads to forefoot overload and of the hip and the knee in early stance followed by extension
gives rise to conditions such as a metatarsalgia and Morton’s to variable degrees as the gait cycle progresses. The pelvis
neuroma. Patients who suffer from these conditions benefit from again adopts a normal position or may be tilted anteriorly.
rocker shoes, which will reduce forefoot pressures during the There are gait deviations at multiple joints and treatment op-
third rocker of gait. tions should be considerate towards treating underlying
spasticity. Given that all three joints are involved in this
Hallux rigidus: degenerative changes at the first MTPJ result in pattern, the hip, knee and ankle plantar flexors are all affected
pain and loss of range of movement, particularly dorsiflexion of to a certain degree.
the big toe. Approximately 65 of dorsiflexion is required to Both true equinus and jump gait patterns have similar orthotic
achieve normal gait. Reduced dorsiflexion of the big toe restricts requirements because the second rocker of gait is inhibited. A
forward propulsion and affects the toe-off sub-phase of gait and hinged ankle foot orthosis may be of benefit as it prevents
third rocker.11 Patients avoid moving the big toe and during gait excessive plantar flexion. Consequently the ground reaction force
this usually results in the foot adopting a position of protective now passes anterior to the knee and is normalized.12
supination, with the lateral border of the foot being preferentially
loaded11 through external rotation of the hip. Toe-off now occurs Apparent equinus: in apparent equinus, the range of movement
from the lesser metatarsal heads and may commonly result in is preserved at the ankle but there is excessive flexion of the hip
lesser metatarsal stress fractures or other causes of lateral fore- and the knee throughout stance with normal or an anterior tilt to
foot pain such as Morton’s neuroma.11 the pelvis.12
Gait disturbances in cerebral palsy
Crouch gait: with this pattern there is excessive dorsiflexion of
Numerous classifications for the gait patterns seen in cerebral
the ankle throughout stance, and excessive flexion of the knee
palsy have been described using qualitative data. Rodda et al. in
and the hip. The pelvis remains within normal limits or may
2004 described these gait abnormalities by combining pattern
adopt a posterior pelvic tilt. Due to the position of the foot, the
recognition and kinematic data.12
calcaneum remains in contact with the floor for a prolonged
They described five different patterns based on the position of
period of time.
the ankle followed by the knee, the hip and the pelvis respectively.
The force of the hamstrings and the psoas dominates in both
1) True equinus
apparent equinus and crouch gait. There is prolongation of the
2) Jump gait
second rocker and therefore a solid foot and ankle orthosis helps
3) Apparent equinus
pass the ground reaction force anteriorly more quickly facili-
4) Crouch gait
tating gait progression.12
5) Asymmetrical gait
The key muscle groups that were found to be affected by
Asymmetric gait: as the name would suggest there is asym-
spasticity or contracture were the flexors of the hip and knee and
metry between the two legs. Each leg may fall into different
the plantar flexors of the ankle.12
categories; for instance one leg may fall into the category of
apparent equinus and the other in the category of jump gait12
True equinus: in true equinus the ankle adopts an equinus po-
(see Table 2).
sition. There is full extension of the knee and hip and the pelvis
remains within the normal range. As with other gait abnormal-
Conclusion
ities where the ankle is in equinus, there is lack of heel strike and
patients may ‘toe-walk’. The ability to walk upright is functionally important, irrespective
Spasticity of the calves overrides the force of the hamstrings of age and occupation. Disease processes and pathologies can
and psoas and this is a pattern seen more in younger children. often alter gait and significantly impact on activities of daily
These children are prime candidates for botulinium injections. living. Careful evaluation and observation of the gait cycle helps
Older children tend to be affected by disease driven primarily by to identify the pathologies that the patient has presented with. An
contractures of the heel cord.12 appreciation of the normal gait cycle and how certain disease
processes might affect it can help to achieve a diagnosis, often
Jump gait: in this pattern of gait, the ankle again adopts an before the patient has even volunteered their history, and can aid
equinus position. There is abnormal and exaggerated flexion with the selection of an appropriate treatment option. A
ORTHOPAEDICS AND TRAUMA 34:3 159 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.
BASIC SCIENCE
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ORTHOPAEDICS AND TRAUMA 34:3 160 Crown Copyright Ó 2020 Published by Elsevier Ltd. All rights reserved.