“ALTERED GAIT SYNDROME” MYTH OR REALITY? Alexander Sapega, M.D. New Jersey / PA Knee & Shoulder Centers

THE “SHORT” ANSWER: Altered Gait Reality “Syndrome” Myth

THE “LONG” ANSWER: Pretty much the same as the short answer, but with a few “complexities”

COROLLARY QUESTION: Can a problem in one knee cause symptoms in its mate?

“SHORT” ANSWER: NO! “LONG” ANSWER: NO! (except in special circumstances)

PATIENT: “My good knee began hurting because of my bad knee.” WHY DO PHYSICIANS HEAR THIS TO SO OFTEN?

REASON #1 First knee problem does often make patients modify their gait to some extent.

REASON #2 Patients’ worry and concern over their first knee problem makes them acutely attuned to even the slightest discomfort in their other knee

REASON #3 Most people over 40 with a symptomatic degenerative condition in one knee also have an asymptomatic one in their opposite knee, which can become symptomatic at any time…. and when it does, most patients will intuitively assign blame to the first knee!

UNDERSTANDING NORMAL GAIT

“I have been bearing more weight on my good knee because of my bad knee.” IS THIS REALLY TRUE?

THE HUMAN KNEE WAS BUILT TO ROUTINELY HANDLE 100% OF BODY WEIGHT (it’s “all-natural”)

THE ONLY WAY ONE CAN REALLY “BEAR MORE WEIGHT” THAN NORMAL ON A KNEE IS TO PICK UP A LOAD AND CARRY IT!

“DYNAMIC” vs. “STATIC” ANALYSIS: Accounting for inertial forces by way of biomechanical: GAIT ANALYSIS

SO WHAT CAN WE LEARN FROM GAIT ANALYSIS STUDIES? Absolute load Loading rate Support time during stride cycle

CONTEXT: “LIMPING” (Favoring/Dis-Favoring) Paralytic Limp Short Leg Limp Antalgic Limp (pain on one side)

ABSOLUTE PEAK KNEE LOAD IS RELATED TO: Body Weight Stride Length Gait Speed GAIT SPEED KNEE LOAD

KNEE PAIN CAUSES: Shorter stride length Slower gait LOWER LOAD ON BOTH KNEES!

KNEE PAIN / LIMP DOES NOT CAUSE: Significantly higher peak load in the opposite knee (at any given gait velocity) Messier, et al: Arch. Phys. Med & Rehab. 1992

KNEE PAIN / LIMP DOES CAUSE: Modest increase in loading rate of opposite knee, a benign phenomenon Messier, et al: Arch. Phys. Med. & Rehab. 1992

KNEE PAIN / LIMP DOES CAUSE: Slight prolongation of time spent by opposite knee in stance phase of stride cycle (support time, or “duty cycle”) Harrington: British J. Bone & Jt. Surg. 1984

“DUTY CYCLE” EFFECT ON OPPOSITE KNEE ( loading time during gait) vs. ACTIVITY LEVEL EFFECT ON OPPOSITE KNEE ( total load time and often amount of load)

KEY POINT! LIGHT DUTY / NO DUTY CAN: Reduce the amount of load, and Reduce total loading time seen by opposite knee, despite antalgic gait.

SUMMARY OF KNEE PAIN EFFECT ON OPPOSITE LEG: Slower gait & shorter stride REDUCE LOAD Antalgic Gait No significant in load but slight in loading rate and duty cycle Light / No Duty Lower total loading time & often lower load

USE OF CRUTCHES CANE: No increased load or known adverse effect on opposite leg/knee (shoulders = different story!)

NET EFFECT OF A KNEE PROBLEM THAT CAUSES GAIT CHANGES AND A DECREASE IN ACTIVITY LEVEL: o pposite knee almost always sees less total overall work-load, not more!

SPECIAL CIRCUMSTANCES: Frequent stair-climbing with one leg only patellofemoral overuse syndromes Knee buckling FALL which injures opposite knee

“In the days when limping from poliomyelitis was common, complaints in the opposite leg attributable to limping were unknown. In fact, the commonest complaint related to limping was backache, not pain in the normal leg.” Harrington, 2005 / Burke et al, 1978

TAKE HOME POINT: “Altered Gait Syndrome” with very few exceptions, is nothing more than a modern “Urban Legend”

NJ / PA Knee & Shoulder Centers Mt. Laurel, NJ * Havertown, PA THANK YOU !