GaitGait
For DNBFor DNB
PGT’sPGT’s
GaitGait
For DNB PGT’sFor DNB PGT’s
G G KarG G Kar
‘‘Walking is one of the mostWalking is one of the most
complicated motor activities’complicated motor activities’
Olney, A...
Gait cycleGait cycle
 The series of events taking place betweenThe series of events taking place between
the time a foot ...
Two basic phasesTwo basic phases
 Stance phase for a limbStance phase for a limb
 Some part of the foot is touching the ...
Stance phase (60%)Stance phase (60%)
 Heel strikeHeel strike
 Foot flatFoot flat
 MidstanceMidstance
 Push offPush off...
Swing phaseSwing phase
 AcclerationAccleration
 Mid-swingMid-swing
 DecelarationDecelaration
Orthopedic issues in gaitOrthopedic issues in gait
Antalgic gaitAntalgic gait
 Self – protecting adaptation of the gait toSelf – protecting adaptation of the gait to
minimi...
Short limb gaitShort limb gait
 Pelvis tilt down to the affected side (‘Hip-Pelvis tilt down to the affected side (‘Hip-
...
Pelvis and hip considerations :Pelvis and hip considerations :
Anterior ̶̶ Posterior assessmentAnterior ̶̶ Posterior asses...
An X-ray in (Lt) stance phaseAn X-ray in (Lt) stance phase
 Distance form the midlineDistance form the midline
to femoral...
Trendelenburg’s gaitTrendelenburg’s gait
 Abductor mechanism fails to lift up theAbductor mechanism fails to lift up the
...
Abductor lurch / limpAbductor lurch / limp
most of the modern books do not tear hair over differences betweenmost of the m...
Abductor lurch / limpAbductor lurch / limp
 Same thing can occur in painful hip even ifSame thing can occur in painful hi...
Pelvis and hip considerations :Pelvis and hip considerations :
lateral viewlateral view
 Gluteus maximus lurchGluteus max...
Pelvis and hip considerations :Pelvis and hip considerations :
lateral viewlateral view
 Flexion contracture of hip /knee...
Knee considerations : A ̶̶ P viewKnee considerations : A ̶̶ P view
 Squat or sit on a stool to observe the patientSquat o...
Knee considerations : A ̶̶ P viewKnee considerations : A ̶̶ P view
 Valgus thrustValgus thrust
 Opposite of varus thrust...
Knee considerations : lateral viewKnee considerations : lateral view
 Stiff ̶̶ knee gait ̶̶ extendedStiff ̶̶ knee gait ̶̶...
Ankle foot considerationsAnkle foot considerations
 Equinus contractureEquinus contracture
 High stepping during swing o...
 Flat footFlat foot
 ‘‘Springiness’ of the gait is , it is awkward andSpringiness’ of the gait is , it is awkward and
st...
Neurological issuesNeurological issues
Hemi-paretic gaitHemi-paretic gait
 MildMild
 Arm swings lessArm swings less
 Affected leg is flexed less than normal a...
Paraparetic gaitParaparetic gait
 Both legs are moved in a slow and stiffBoth legs are moved in a slow and stiff
pattern ...
Steppage gaitSteppage gait
 Dorsiflexion of ankle is weak, so the legDorsiflexion of ankle is weak, so the leg
must be li...
Waddling gaitWaddling gait
 The trunk is thrown from side to side withThe trunk is thrown from side to side with
each ste...
Parkinsonian gaitParkinsonian gait
 Forward stoop with modearte hip andForward stoop with modearte hip and
knee flexionkn...
Apraxic gaitApraxic gait
 Bilateral frontal lobe diseaseBilateral frontal lobe disease
 Brain cannot plan and execute se...
Cerebellar ataxic /reeling gaitCerebellar ataxic /reeling gait
 Broad- based gaitBroad- based gait
 Speed and stride var...
Sensory ataxic gaitSensory ataxic gait
 Romberg’s sign is positive (patient fallsRomberg’s sign is positive (patient fall...
Vestibular problemsVestibular problems
 Patient consistently falls to one side inPatient consistently falls to one side i...
Choreoathetotic gaitChoreoathetotic gait
 Intermittent, irregular jerky movementsIntermittent, irregular jerky movements
...
Shuffling and slap-foot gaitsShuffling and slap-foot gaits
 Loss of proprioception (from posterior cordLoss of propriocep...
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Gait for dnb

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Gait for dnb

  1. 1. GaitGait For DNBFor DNB PGT’sPGT’s GaitGait For DNB PGT’sFor DNB PGT’s G G KarG G Kar
  2. 2. ‘‘Walking is one of the mostWalking is one of the most complicated motor activities’complicated motor activities’ Olney, Aminoff : Harrison’s Principles of Int MedOlney, Aminoff : Harrison’s Principles of Int Med From cerebral cortex to skin of the sole (andFrom cerebral cortex to skin of the sole (and almost everything in-between and beyond) canalmost everything in-between and beyond) can affect normal, smooth, cyclic bipedal ambulation.affect normal, smooth, cyclic bipedal ambulation. Lumbosacral spinal cord centers are responsibleLumbosacral spinal cord centers are responsible for the cyclical stepping movements and theyfor the cyclical stepping movements and they are modified by cerebral cortex, basal ganglia,are modified by cerebral cortex, basal ganglia, brainstem and cerebellum.brainstem and cerebellum.
  3. 3. Gait cycleGait cycle  The series of events taking place betweenThe series of events taking place between the time a foot touches the ground andthe time a foot touches the ground and when the same foot returns to the groundwhen the same foot returns to the ground once againonce again  This is arbitrary, because gait is a cyclicThis is arbitrary, because gait is a cyclic process.process.  The whole body takes part in gaitThe whole body takes part in gait
  4. 4. Two basic phasesTwo basic phases  Stance phase for a limbStance phase for a limb  Some part of the foot is touching the groundSome part of the foot is touching the ground  Swing phase of the limbSwing phase of the limb  The foot is off the groundThe foot is off the ground there is significant overlap of these two ofthere is significant overlap of these two of the two limbs in walkingthe two limbs in walking
  5. 5. Stance phase (60%)Stance phase (60%)  Heel strikeHeel strike  Foot flatFoot flat  MidstanceMidstance  Push offPush off  Heel offHeel off  Toes offToes off
  6. 6. Swing phaseSwing phase  AcclerationAccleration  Mid-swingMid-swing  DecelarationDecelaration
  7. 7. Orthopedic issues in gaitOrthopedic issues in gait
  8. 8. Antalgic gaitAntalgic gait  Self – protecting adaptation of the gait toSelf – protecting adaptation of the gait to minimize pain during weight bearingminimize pain during weight bearing  Cause may be anywhere in the lower extremityCause may be anywhere in the lower extremity  Removes the weight from affected side asRemoves the weight from affected side as quickly as possible ̶̶ stance phase of thisquickly as possible ̶̶ stance phase of this side and swing phase of the normal side areside and swing phase of the normal side are lessened,lessened,  So, stride length and velocity areSo, stride length and velocity are decreased.decreased.
  9. 9. Short limb gaitShort limb gait  Pelvis tilt down to the affected side (‘Hip-Pelvis tilt down to the affected side (‘Hip- hiking)hiking)  Compensates lengthCompensates length  Allows ground clearance of the longer limbAllows ground clearance of the longer limb  In supra-trochanteric shortening with abductorIn supra-trochanteric shortening with abductor insufficiency, walking becomes difficultinsufficiency, walking becomes difficult  Foot may supinate or patient may walk onFoot may supinate or patient may walk on toes to compensatetoes to compensate  Normal limb may compensate by flexion atNormal limb may compensate by flexion at hip / kneehip / knee
  10. 10. Pelvis and hip considerations :Pelvis and hip considerations : Anterior ̶̶ Posterior assessmentAnterior ̶̶ Posterior assessment  Abductor mechanism function (normal)Abductor mechanism function (normal)  Normally, CG is in midlineNormally, CG is in midline  In swing phase of a limb, body tends to f allIn swing phase of a limb, body tends to f all towards the same side like a car leanstowards the same side like a car leans towards the side with two flat tyrestowards the side with two flat tyres  Gluteus medius and minimus abduct the hipGluteus medius and minimus abduct the hip to shift CG towards midlineto shift CG towards midline
  11. 11. An X-ray in (Lt) stance phaseAn X-ray in (Lt) stance phase  Distance form the midlineDistance form the midline to femoral head is almostto femoral head is almost twice that betweentwice that between abductor and femoralabductor and femoral headhead  Abductor pull is aboutAbductor pull is about double the wt of upperdouble the wt of upper bodybody Generates tremendous compressive forces across the hip weight-bearing area About 3 times of upper body weight
  12. 12. Trendelenburg’s gaitTrendelenburg’s gait  Abductor mechanism fails to lift up theAbductor mechanism fails to lift up the opposite hemi-pelvisopposite hemi-pelvis  Pelvis droops toward the floor in thePelvis droops toward the floor in the stance phase of the diseased limbstance phase of the diseased limb  Exaggerated up-down motion of pelvisExaggerated up-down motion of pelvis  Bilateral pathology leads to waddlingBilateral pathology leads to waddling
  13. 13. Abductor lurch / limpAbductor lurch / limp most of the modern books do not tear hair over differences betweenmost of the modern books do not tear hair over differences between limp and lurchlimp and lurch  If the abductor mechanism is furtherIf the abductor mechanism is further weakened, trunk muscles come into play.weakened, trunk muscles come into play. The entire body moves (and the shoulderThe entire body moves (and the shoulder tilts) towards the diseased side in stancetilts) towards the diseased side in stance phase of that limb. This is abductor lurch.phase of that limb. This is abductor lurch.
  14. 14. Abductor lurch / limpAbductor lurch / limp  Same thing can occur in painful hip even ifSame thing can occur in painful hip even if abductors are normalabductors are normal  By tilting the body to the affected side, theBy tilting the body to the affected side, the CG is shifted near the femoral head center :CG is shifted near the femoral head center :  And by that, the reaction force is reduced, inAnd by that, the reaction force is reduced, in an attempt to reduce the painan attempt to reduce the pain
  15. 15. Pelvis and hip considerations :Pelvis and hip considerations : lateral viewlateral view  Gluteus maximus lurchGluteus maximus lurch  Normally, the gluteus maximus preventsNormally, the gluteus maximus prevents toppling forwards in stance phase as the CGtoppling forwards in stance phase as the CG is anterior to the hipis anterior to the hip  In GMax weakness, this toppling is preventedIn GMax weakness, this toppling is prevented by trunk muscles, thrusting the pelvisby trunk muscles, thrusting the pelvis forwards and the trunk backwards to bring CGforwards and the trunk backwards to bring CG posterior. This results in GMax or extensorposterior. This results in GMax or extensor lurch.lurch.
  16. 16. Pelvis and hip considerations :Pelvis and hip considerations : lateral viewlateral view  Flexion contracture of hip /kneeFlexion contracture of hip /knee  Increased lumbar lordosis / stoopingIncreased lumbar lordosis / stooping  Short stride lengthShort stride length
  17. 17. Knee considerations : A ̶̶ P viewKnee considerations : A ̶̶ P view  Squat or sit on a stool to observe the patientSquat or sit on a stool to observe the patient from the level of his/her kneesfrom the level of his/her knees  Varus thrustVarus thrust  In single-leg wt-bearing stage of the diseasedIn single-leg wt-bearing stage of the diseased limb, it collapses into varus and its laterallimb, it collapses into varus and its lateral border goesaway from midline into aborder goesaway from midline into a laterallateral thrust.thrust.  Advanced O.A; varus from malunited tibialAdvanced O.A; varus from malunited tibial plateau #, tibia varumplateau #, tibia varum  Lateral ligamentous laxity usually adds aLateral ligamentous laxity usually adds a recurvatum thrust, noticeable from side.recurvatum thrust, noticeable from side.
  18. 18. Knee considerations : A ̶̶ P viewKnee considerations : A ̶̶ P view  Valgus thrustValgus thrust  Opposite of varus thrustOpposite of varus thrust  Much less commonMuch less common  Patient with bilateral valgus may circumduct toPatient with bilateral valgus may circumduct to avoid knocking of knees (Knock-Knee gait)avoid knocking of knees (Knock-Knee gait)
  19. 19. Knee considerations : lateral viewKnee considerations : lateral view  Stiff ̶̶ knee gait ̶̶ extendedStiff ̶̶ knee gait ̶̶ extended  The patient keeps the knee extended to avoidThe patient keeps the knee extended to avoid patellofemoral pain, like a stilt. May also do so topatellofemoral pain, like a stilt. May also do so to compensate quad weakness by locking incompensate quad weakness by locking in extension during stance phaseextension during stance phase  Stiff ̶̶ knee in flexionStiff ̶̶ knee in flexion  Even 5º FFD may cause limpEven 5º FFD may cause limp  Short strideShort stride  Heel strike is replaced by almost foot-flat to startHeel strike is replaced by almost foot-flat to start stance phasestance phase  Jerky up-down motion from apparent shorteningJerky up-down motion from apparent shortening
  20. 20. Ankle foot considerationsAnkle foot considerations  Equinus contractureEquinus contracture  High stepping during swing of affected sideHigh stepping during swing of affected side  Abnormally early heel raiseAbnormally early heel raise  Hyper extension of same knee in mid stanceHyper extension of same knee in mid stance to accommodate the equinusto accommodate the equinus  Stiff 1Stiff 1stst MTP jointMTP joint  Walks mainly on lateral border of foot (noteWalks mainly on lateral border of foot (note the increased wear of lateral border of thethe increased wear of lateral border of the shoe, if worn. More sensitive than gait)shoe, if worn. More sensitive than gait)  Hurried push off, directly from the heelHurried push off, directly from the heel
  21. 21.  Flat footFlat foot  ‘‘Springiness’ of the gait is , it is awkward andSpringiness’ of the gait is , it is awkward and stiffstiff  Heel raise is avoided, so the heel and ball ofHeel raise is avoided, so the heel and ball of foot rises togetherfoot rises together  Toes are usually turned outwards (splay foot)Toes are usually turned outwards (splay foot)
  22. 22. Neurological issuesNeurological issues
  23. 23. Hemi-paretic gaitHemi-paretic gait  MildMild  Arm swings lessArm swings less  Affected leg is flexed less than normal andAffected leg is flexed less than normal and more externally rotated in swing phasemore externally rotated in swing phase  SevereSevere  Hip, knee, ankle extended and spasticHip, knee, ankle extended and spastic  Abduction and circumduction of hip plus tilt ofAbduction and circumduction of hip plus tilt of pelvis to opposite side is needed for forwardpelvis to opposite side is needed for forward swing of the limbswing of the limb
  24. 24. Paraparetic gaitParaparetic gait  Both legs are moved in a slow and stiffBoth legs are moved in a slow and stiff pattern with circumduction. Scissoringpattern with circumduction. Scissoring may be presentmay be present  Common in spinal cord diseaseCommon in spinal cord disease  Also occurs in C PAlso occurs in C P
  25. 25. Steppage gaitSteppage gait  Dorsiflexion of ankle is weak, so the legDorsiflexion of ankle is weak, so the leg must be lifted higher (by more hip andmust be lifted higher (by more hip and knee flexion) for ground clearanceknee flexion) for ground clearance  Unilateral ̶̶ L5 radiculopathy / sciatic orUnilateral ̶̶ L5 radiculopathy / sciatic or peroneal neuropathyperoneal neuropathy  Bilateral ̶̶ distal polyneuropathy / L.S.Bilateral ̶̶ distal polyneuropathy / L.S. polyneuropathypolyneuropathy
  26. 26. Waddling gaitWaddling gait  The trunk is thrown from side to side withThe trunk is thrown from side to side with each step (bilateral Trendelenburg)each step (bilateral Trendelenburg)  Bilateral hip dislocations, coxa varaBilateral hip dislocations, coxa vara  Abductor weakness fromAbductor weakness from  myopathymyopathy  proximal symmetric spinal muscular atrophyproximal symmetric spinal muscular atrophy  Neuromuscular jn. DiseaseNeuromuscular jn. Disease
  27. 27. Parkinsonian gaitParkinsonian gait  Forward stoop with modearte hip andForward stoop with modearte hip and knee flexionknee flexion  Shoulder adducted, elbow flexed, forearmShoulder adducted, elbow flexed, forearm shows pronation-supination tremorshows pronation-supination tremor  Gait starts slowly, maintained by short,Gait starts slowly, maintained by short, rapid stepsrapid steps  Pace tends to accelerate (Festination)Pace tends to accelerate (Festination)  Falls are commonFalls are common
  28. 28. Apraxic gaitApraxic gait  Bilateral frontal lobe diseaseBilateral frontal lobe disease  Brain cannot plan and execute sequentialBrain cannot plan and execute sequential movementsmovements  Initiation is difficult ̶̶ the patient seems toInitiation is difficult ̶̶ the patient seems to be glued to the floor for a while beforebe glued to the floor for a while before s/he takes a few shuffling steps and pauses/he takes a few shuffling steps and pause againagain
  29. 29. Cerebellar ataxic /reeling gaitCerebellar ataxic /reeling gait  Broad- based gaitBroad- based gait  Speed and stride varies irregularly fromSpeed and stride varies irregularly from step to stepstep to step  Changing position leads to instabilityChanging position leads to instability  Patient seems to be unstable, but balancePatient seems to be unstable, but balance is maintained with even eyes closedis maintained with even eyes closed  Nystagmus and limb ataxia are present inNystagmus and limb ataxia are present in cerebellar hemisphere diseasecerebellar hemisphere disease  Alcoholism produces same featuresAlcoholism produces same features
  30. 30. Sensory ataxic gaitSensory ataxic gait  Romberg’s sign is positive (patient fallsRomberg’s sign is positive (patient falls with eyes closed)with eyes closed)  Broad base like cerebellar ataxicBroad base like cerebellar ataxic
  31. 31. Vestibular problemsVestibular problems  Patient consistently falls to one side inPatient consistently falls to one side in walking / standingwalking / standing  Asymmetric nystagmusAsymmetric nystagmus  Differentiate fromDifferentiate from  Unilateral sensory ataxiaUnilateral sensory ataxia by normalby normal proprioceptionproprioception  HemiparesisHemiparesis by normal strengthby normal strength
  32. 32. Choreoathetotic gaitChoreoathetotic gait  Intermittent, irregular jerky movementsIntermittent, irregular jerky movements disrupt the smoothness of the gaitdisrupt the smoothness of the gait  Flexion and extension at hip are commonFlexion and extension at hip are common but unpredictable, seen as pelvic lurchbut unpredictable, seen as pelvic lurch
  33. 33. Shuffling and slap-foot gaitsShuffling and slap-foot gaits  Loss of proprioception (from posterior cordLoss of proprioception (from posterior cord syndrome / parkinsonism/ tabes)syndrome / parkinsonism/ tabes)  The brain does not know how far the footThe brain does not know how far the foot has advanced and cannot predict thehas advanced and cannot predict the exact moment of landing (heel strike).exact moment of landing (heel strike).  Results in eitherResults in either  (a) dragging of feet, so there is no true swing(a) dragging of feet, so there is no true swing phase (Shuffling gait)phase (Shuffling gait) OROR  (b) crash-landing of the foot : violent and un-(b) crash-landing of the foot : violent and un- predictable (Slap-foot gait)predictable (Slap-foot gait)
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