1. Mitchell L. Goldflies, M.D.

2. Overview  Introduction  Stance  Swing  Normal and Abnormal Gait

3. Introduction

4. Stance  60 % of gait cycle  Foot is in contact with ground  Conversion of potential energy into kinetic energy  During stance phase hip extends and pelvis rotates backward gradually

5. Stance  5 phases: Contact Loading Midstance Terminal Preswing

6. Stance

7. Stance - Contact  Length of stance phase: Begin – contact of the heel to the ground End – remainder of the foot contacts the ground

8. Stance - Contact  Objective of stance phase: Forward progression Shock absorption Adaption to terrain Preparation for loading phase

9. Stance - Contact  At initial ground contact: Knee extended Hip flexed Ankle neutral Foot pronating at subtalar joint Leg internally rotating

10. Stance - Contact  At forefoot contact: Knee flexes Ankle plantarflexes STJ pronates

11. Stance - Contact  Muscles: Long extensors decelerate plantarflexion Tibialis posterior decelerates pronation Gastrocnemius decelerates internal tibial rotation

12. Stance - Contact

13. Stance – Loading  Objective: Initial double-limb support Body weight is transferred onto the stance limb

14. Stance – Loading  Body: Knee flexes 15 ◦ Ankle plantarflexes15 ◦  Muscles: Pretibials – shock absorbers during this phase

15. Stance - Midstance  Objective: Limb and trunk stability Progression over stationary foot  Body: Knee/hip begin extension STJ neutral

16. Stance - Midstance  Muscles: Tibialis posterior/soleus start to supinate STJ Peroneus longus stabilizes first ray Triceps surae decelerate forward displacement of tibia and plantarflex ankle joint

17. Stance - Terminal  Objective: Forward progression Foot becomes rigid lever

18. Stance - Terminal  Body: Knee flexes Ankle plantar flexes STJ supinates, rapidly First ray plantarflexes 1 st MPJ dorsiflexes – toe-off through tip of hallux

19. Stance - Terminal  Muscles: Soleus and tibialis posterior assist heel lift Peroneus longus stabilizes first ray FHL, FHB, AbH, AdH stabilize hallux EHL dorsiflexes hallux

20. Stance - Preswing  Objective: Forward progression Foot becomes “rigid lever” 30 – 60% of gait cycle Second period of double limb support

21. Stance - Preswing

22.  Body: Knee flexes Ankle plantar flexes Subtalar joint rapidly supinates First ray plantarflexes 1 st MPJ dorsiflexes

23. Stance - Preswing  Muscles: Soleus and tibialis posterior assist heel lift Peroneus longus stabilizes first ray FHL, FHB, AbH, AdH stabilize hallux EHL dorsiflexes hallux

24. Swing  Objective: Forward progression Ground clearance

25. Swing  Body: Hip continues to flex Knee extends from flexed position Ankle dorsiflexes STJ slightly pronated at toe-off

26. Swing  Muscles Long extensors dorsiflex foot for toe clearance Tibialis anterior dorsiflexes the first ray

27. Swing  Phases Initial swing: ○ Begins at toe off and continues until maximum knee flexion (60◦) Mid swing: ○ Maximum knee flexion until tibia is vertical/perpendicular to the ground Terminal swing: ○ Beings when tibia is vertical and ends at initial contact

28. Swing  Contraction of quadriceps before toe off Helps to initial leg forward swing Prevents heel from rising to high in the posterior direction  Hamstrings become active before heel strike Decelerate forward swing of leg Controls heel position at foot strike

29. Gait Analysis  Assessment procedures required to properly asses gait: Weight acceptance – initial contact/loading response Stance – midstance/terminal stance Forward progression – terminal stance/preswing Swing – initial swing/midswing/terminal swing

30. Gait Analysis

31. Normal Gait  Used to describe patterns that have been generalized across sex, age, genetic predisposition, and anthropometric variables  Duration of stance/swing phases are the same for each limb

32. Normal Gait  Maximizes center of gravity through: Knee motion Knee flexion after heel strike Pelvic rotation Pelvic tilt Lateral displacement of pelvis Foot and ankle motion

33. Normal Gait

34. Abnormal Gait  Consequence of: Pain Weakness Difference in limb length

35. Abnormal Gait

36.  Antalgic gait Pain common cause of limp Shortened stance phase on affected side In stance phase - with pain in hip joint, trunk motion toward painful side

37. Abnormal Gait  Dorsiflexor gait pattern Swing phase – difficulty in clearing toes

38. Abnormal Gait  Gluteus maximus gait pattern Contracts at moment of heel-strike Slows trunk’s forward motion by stopping flexion of hip and initiating extension Weak gluteus maximus cause trunk to lurch forward at heel strike on weaker side, which interrupts forward motion

39. Abnormal Gait  Gluteus maximus gait pattern

40. Abnormal Gait  Gluteus medius gait pattern Characterized by Trendelenberg gait pattern Stance - opposite side of pelvis tilts downward during toward weaker side resulting from a weakened medius

41. Abnormal Gait  Gluteus medius gait pattern

42. Abnormal Gait  Gluteus medius gait pattern Trunk lurches toward weakened side to compensate Center of gravity shifts to fulcrum on weaker side, which shortens the moment arm from the center of gravity to hip joint, therefore reducing effort required of hip abductors

43. Abnormal Gait  Gluteus medius gait pattern

44. Abnormal Gait  Paralyzed quadriceps gait pattern Gait may appear normal when walking on level surface with a paralyzed quadriceps Quads not necessary for knee joint stability at full extension

45. Abnormal Gait  Paralyzed quadriceps gait pattern Those with paralyzed quads will be unable to run and experience difficulty on rough/inclined surfaces or stairs Long leg knee brace might be needed to support knee joint in full extension  Triceps gait pattern

46. Discussion

47. Conclusion

48. Questions?

49. References  Goldflies, M.L, Andriacchi, T.P., and Galante, J.O. The Relationship Between Varus Deformity and Moments at the Knee During Gait and the Changes at the knee after High Tibial Osteotomy. 27th Annual ORS, Las Vegas Nevada, Feb. 24 - 26, 1981.  Andriacchi, T.P., Goldflies, M.L, Galante, J.O. and Stern, D.S. Moments Exerted on the Lower Extremities During Running. 27th Annual ORS, Las Vegas Nevada, Feb. 24 - 26, 1981.  Andriacchi, T.P., Goldflies, M.L, Galante, J.O. Normal Variation in Joint Moments During Level Walking, 1980.

50. References  http://moon.ouhsc.edu/dthompso/GAIT/TERMS.HTM http://moon.ouhsc.edu/dthompso/GAIT/TERMS.HTM  http://www.drpribut.com/sports/spgait.html http://www.drpribut.com/sports/spgait.html  http://www.emedicine.com/pmr/topic225.htm http://www.emedicine.com/pmr/topic225.htm  http://www.latrobe.edu.au/podiatry/Thegaitcycle.html http://www.latrobe.edu.au/podiatry/Thegaitcycle.html  http://www.oandp.org/jpo/library/1993_02_039.asp http://www.oandp.org/jpo/library/1993_02_039.asp  http://www.oandp.org/jpo/library/1997_02_049.asp http://www.oandp.org/jpo/library/1997_02_049.asp

51. References  http://www.wheelessonline.com/ortho/gait http://www.wheelessonline.com/ortho/gait  http://www.wheelessonline.com/ortho/stance_phase_of_gait http://www.wheelessonline.com/ortho/stance_phase_of_gait  http://www.wheelessonline.com/ortho/swing_phase_of_gait http://www.wheelessonline.com/ortho/swing_phase_of_gait

52. Image Sources  http://www.newscientist.com/blog/shortsharpscience/2007_0 5_01_archive.html http://www.newscientist.com/blog/shortsharpscience/2007_0 5_01_archive.html  www.foot-fixer.com/contactus.html www.foot-fixer.com/contactus.html  http://www.northcoastfootcare.com/footcare-info/foot- problems.html http://www.northcoastfootcare.com/footcare-info/foot- problems.html  web.techwalking.com:462/gait_lab.html web.techwalking.com:462/gait_lab.html  http://www.stepfamilytalk.com/walk-a-little-slower-daddy/ http://www.stepfamilytalk.com/walk-a-little-slower-daddy/  http://www.nature.com/nrn/journal/v3/n10/fig_tab/nrn939_F1. html http://www.nature.com/nrn/journal/v3/n10/fig_tab/nrn939_F1. html

53. Image Sources  www.dubinchiro.com/features/shin1.html www.dubinchiro.com/features/shin1.html  http://www.hopkins-arthritis.org/physician-corner/radiology- rounds/radiology_14/images/slide1.jpg http://www.hopkins-arthritis.org/physician-corner/radiology- rounds/radiology_14/images/slide1.jpg  http://www.aboutjoints.com/physicianinfo/topics/anatomyhip/ anatomyhipimages/hipfigure1.33.jpg http://www.aboutjoints.com/physicianinfo/topics/anatomyhip/ anatomyhipimages/hipfigure1.33.jpg  http://storybridge.org/wordpress/wp- content/uploads/female_screenshot.png http://storybridge.org/wordpress/wp- content/uploads/female_screenshot.png

54. Image Sources  http://i164.photobucket.com/albums/u38/oscarandy122586/F OOTPRINTS.jpg http://i164.photobucket.com/albums/u38/oscarandy122586/F OOTPRINTS.jpg  http://www.drpribut.com/sports/spgait.html http://www.drpribut.com/sports/spgait.html