Gait Deviations Secondary to Specific Impairments

Deviation observed @ the ankle/foot: initial contact with forefoot (heel never makes contact w/ ground)

Impairment: Heel pain plantar flexion contracture spasticity of ankle plantar flexors Pathologic Precursor: Calcaneal Fx, plantar fasciitis UMN lesion/CP/CVA Rationale/Compensation: purposeful strategy to avoid WB on the heel to maintain the weight over the foot, the knee & hip are kept in flexion throughout stance, leading to a "crouched gait"; requires short steps

Deviation observed @ the knee: Flexed position of the knee during stance & lack of knee extension during terminal swing

Impairment: Knee Flexion contracture >10° (genu felxum) Hamstring overactivity (spasticity) Knee pain/joint effusion Pathologic Precursor: UMN Lesion Trauma Arthritis Rationale/Compensation: Associated increase in hip flexion& ankle dorsiflexion during stance Knee kept in flexion since this is the position of lowest intra-articular pressure

Deviation observed @ the ankle/foot: Supinated foot position n& WB on the lateral aspect of the foot during stance

Impairment: Pes cavus deformity Pathologic Precursor: congenital structural deformity Rationale/Compensation: a high medial longitudinal arch is noted w/ reduced midfoot mobility throughout swing & stance

Deviation observed @ the ankle/foot: Excessive foot pronation occurs during stance w/ failure of the foot to supinate in mid stance; normal medial longitudinal arch noted during swing

Impairment: Rearfoot varus and/or forefoot varus Pathologic Precursor: Congenital or acquired structural deformity Rationale/Compensation: Excessive foot pronation & associated flattening of the medial longitudinal arch may be accompanied by a general medial rotation of the LE during stance

Deviation observed @ the knee: Reduced or absent knee flexion during swing

Impairment: Spasticity of knee extensors Knee extension contracture Pathologic Precursor: UMN Lesion Immobilization/surgical fixation Rationale/Compensation: Compensatory hip hiking and/or hip circumduction could be noted

Deviation observed @ the knee: rapid extension of knee (knee extensor thrust) immediately after initial contact

Impairment: Spasticity of the quads Pathologic Precursors: UMN Lesion Rationale/Compenstations: Depending on the status of the posterior structures of the knee, may occur with or without knee hyperextension

Deviation observed @ the ankle/foot: Heel remains in contact with the ground late in terminal stance

Impairment: Weakness or flaccid paralysis of plantar flexors or w/ or w/out a fixed dorsiflexed position of the ankle Pathologic Precursor: Peripheral or central nervous system disorder Excessive surgical lengthening of achilles tendon Rationale/Compensation: excessive ankle dorsiflexion results in prolonged heel contact, reduced push off, and a shorter step length

Deviation observed @ the hip/pelvis/trunk: excessive lordosis in terminal stance

Impairment: hip flexion contracture Pathologic Precursor: arthritis Rationale/Compensation: compensation for lack of hip extension

Deviation observed @ the hip/pelvis/trunk: forward bending of trunk during mid & terminal stance as the hip is moving over the foot

Impairment: hip flexion contracture or hip pain Pathologic Precursor: hip OA Rationale/Compensation: compensation for lack of hip extension; alternate adaptation could be excessive lordosis. Keeping hip @ 30° flexion minimizes intraarticular pressure

Deviation observed @ the hip/pelvis/trunk: posterior tilt of the pelvis during initial swing

Impairment: hip flexor weakness Pathologic Precursor: L2-3 nerve root compression Rationale/Compensation: abdominals are used during initial swing to advance the swing leg

Deviation observed @ the hip/pelvis/trunk: trunk lurches backward & toward the unaffected stance leg from heel off to mid swing

Impairment: hip flexor weakness Pathologic Precursor: L2-3 nerve root compression Rationale/Compensation: hip flexion is passively generated by a backward movement of the trunk

Deviation observed @ the hip/pelvis/trunk: hip circumduction

Impairment: hip flexor weakness Pathologic Precursor: L2-3 nerve root compression Rationale/Compensation: semicircular movement combining hip flexion, ABDuction, & forward rotation of the pelvis

Deviation observed @ the ankle/foot: premature elevation of the heel in midstance or terminal stance

Impairment: lack of dorsiflexion Pathologic Precursor: congenital or acquired muscular tightness of ankle plantar flexors Rationale/Compensation: characteristic bouncing gait pattern

Deviation observed @ the knee: Varus thrust during stance

Impairment: laxity of the posterior & lateral ligamentous joint structures of the knee Pathologic Precursor: Trauma or progressive laxity Rationale/Compensation: Rapid varus deviation of the knee during midstance, typically accompanied by knee hyperextension

Deviation observed @ the ankle/foot: foot flat

Impairment: marked weakness of ankle dorsiflexors Pathologic Precursor: Common peroneal N palsy Distal peripheral neuropathy Rationale/Compensation: sufficient strength of dorsiflexors to partially dorsiflex the ankle during swing; normal dorsiflexion occurs during stance as long as the ankle has normal ROM

Deviation observed @ the ankle/foot: Foot slap

Impairment: mild weakness of dorsiflexors Pathologic Precursor: Common peroneal N palsy Distal peripheral neuropathy Rationale/Compensation: Ankle dorsiflexors have sufficient strength to dorsiflex ankle during swing but not enough to control ankle plantar flexion after heel contact

Deviation observed @ the hip/pelvis/trunk: trendelenberg

Impairment: mild weakness of glute med of stance leg Pathologic Precursor: Guillian-Barre, Poliomyelitis Rationale/Compensation: compensated trendelenberg gait is often seen in severe weakness of ABDuctors

Deviation observed @ the ankle/foot: excessive inversion & plantar flexion of the foot & ankle occurs during swing & @ initial contact

Impairment: pes equinovarus d/t spasticity of the plantar flexors & invertors Pathologic Precursor: UMN lesion (CP, CVA) Rationale/Compensation: contact with the ground is made w/ the lateral border of the forefoot; weight bearing on the lateral border of the foot during stance

Deviation observed @ the ankle/foot: initial contact with forefoot, heel is brought to the ground by a posterior displacement of the tibia @ midstance

Impairment: plantar flexion contracture spasticity of ankle plantar flexors Pathologic Precursor: UMN Lesion (CP/CVA) Ankle fusion in plantar flexed position Rationale/Compensation: knee hyperextension occurs during stance owing to the inability of the tibia to move forward over the foot; hip flexion & excessive forward trunk lean during terminal stance occur to shift the weight of the body over the foot

Deviation observed @ the knee: genu recurvatum during stance

Impairment: quad weakness Pathologic Precursor: Poliomyelitis Rationale/Compensation: S/t progressive stretching of the posterior capsule of the knee

Deviation observed @ the ankle/foot: initial contact with forefoot followed by the heel

Impairment: severe weakness of ankle dorsiflexors Pathologic Precursor: Common peroneal N palsy Distal peripheral neuropathy Rationale/Compensation: No active ankle dorsiflexion is possible during swing; likely requires excessive knee & hip flexion during swing to avoid catching toes on the ground

Deviation observed @ the hip/pelvis/trunk: Lateral trunk lean toward stance leg (aka compensated trendelenburg or waddling gait if B/L)

Impairment: significant weakness of hip ABDuctors or hip pain Pathologic Precursor: Guillian-Barre, Poliomyelitis, arthritis Rationale/Compensation: shifting trunk over the support limb reduces the demand on ABDuctors & reduces compressive force of ABDuctors @ hip joint

Deviation observed @ the hip/pelvis/trunk: Backwards trunk lean during loading response

Impairment: weak hip extensors Pathologic Precursors: Paralysis of poliomyelitis Mechanical Rationale/Associated Compensations: This action moves COM behind the hip & reduces the need for hip extension

Deviation observed @ the knee: Knee remains extended during the loading response, but there is no extensor thrust

Impairment: weak quads Pathologic Precursors: Femoral N Palsy, L3-4 compression neuropathy Rationale/Compenstations: Knee remains fully extended throughout stance; an associated anterior trunk lean in the early part of stance moves the line of gravity of the trunk, slightly anterior to the axis of rotation of the knee; this keeps the knee extended w/out action of the knee extensors; this gait deviation may lead to an excessive stretching of the posterior capsule of the knee & eventual knee hyperextension during stance (genu recurvatum) Knee is kept in extension to reduce the need for quad activity & associated compressive forces; it may be accompanied by na antalgic gait pattern characterized by a reduced stance time & shorter step length

Deviation observed @ the ankle/foot: ankle remains plantar flexed during swing & can be associated w/ dragging of the toes, typically called drop foot

Impairment: weakness of dorsiflexors and/or pes equinus deformity Pathologic Precursor: Common peroneal N palsy Rationale/Compensation: Hip hiking, hip circumduction, or excessive hip & knee flexion of the swing leg or vaulting of the stance leg may be noted to lift the toes off the ground & prevent dragging during swing

Deviation observed @ the ankle/foot: Excessive foot pronation w/ weight bearing on the medial portion of the foot during stance; the medial longitudinal arch remains absent during swing

Impairments: Weakness (paralysis) of ankle invertors Pes planus deformity Pathologic Precursor: UMN lesion (CP, CVA) Congenital structural deformity Rationale/Compensation: an overall excessive medial rotation of the LE during stance is possible