It is about the posture and gait cycle, stages. With understanding of crossed syndrome at the end you can manage your treatment plan for stretching of the muscles and strengthening of the other group of muscles

1. Gait Cycle
Hossein Khorrami, Ph.D. DOMP
www.slideshare.net/khorrami4

2. Factors Influencing Gait
• Musculoskletal
– muscle, tendon, ligaments
– Joint, bones
– Soft tissue, fascia
• Neurological issues
– Central, basal ganglia, cerebellum,..
– Peripheral

3. Factors Affect Gait Pattern
• Nervous system, CNS, PNS
• Muscle issues, Tender point, trigger point,
spasm, FM, plantar fasciitis..
• Joint issues, bone, ligament, tendon
• Anatomy
• External
• Other

5. Basic Gait Terms
• Base of gait(walking base,
stride width)
– Standing feet distance or during
walking
– Balance, stability & erect
posture
– 2-4 inches heel to heel

6. Angle of Gait
• Almost 7o
In-toeing Out-toeing

7. • Step length
• Stride length
• Cadence: Steps or strides-cycles/min
• Walking base: Stride width or distance
between line of feet
• Degree of toe out: ~7o, decreases with speed

8. Stride Length vs Step Length
• Stride length: Distance between successive
ground contact of the same foot
– Distance from the heel of right foot (starting
position) to the heel of right foot (ending position)
– Average: 150cm(5ft)
• Step length: distance from the heel of right
foot to the heel of left foot
– Average: 75cm(2.5ft)

9. Gait Phases
• Stance phase: Consists of the entire time
that a foot is on the ground
• Swing phase: Consists of the entire time
that the foot is in the air

11. • gf

13. Stance Phase
• Initial contact(heel strike)
• Foot flat(loading response)
• Mid stance
• Terminal stance(heel off)
• Toe off(pre swing)

14. Stance Intervals
• Initial double support: 10%
• Single support: 40%
• Terminal double support: 10%
• So 40% single & 20% double support

15. Swing Phase
• Initial swing(acceleration)
• Mid swing(vertical tibia)
• Terminal swing(deceleration)

16. Temporal & Spatial Variables

19. Stance Phase
• Initial contact( heel strike)
– Muscular contractions
• Hip extensors to stabilize the hip
• Eccentric contraction of quadriceps
• Isometric & Eccentric contraction of tibialis anterior

20. Stance Phase
• Loading response(initial double limb support)
– occurs after initial contact until elevation of
opposite limb
– bodyweight is transferred on to the supporting
limb
– Eccentric cont. of tibialis ant, dorsiflexion to
control plantar flexion
– Quads contraction to stabilize knee

21. Stance Phase
• Mid stance
– from elevation of opposite limb until both ankles are
aligned in coronal plane
– Concentric contraction of G. Medius & calf muscles
– Eccentric contraction of pelvic & hip flexors

22. Stance Phase
• Terminal phase
– begins when the supporting heel rises from the
ground and continues until the opposite heel
touches the ground
– Toe flexor & tibialis ant, eccentric hip flexor,
concentric plantar flexors

23. Stance Phase
• Pre-swing(second double limb support)
• from initial contact of opposite limb to just
prior to elevation of ipsilateral limb
– Hip flexor to propel advancing limb

24. Swing Phase
• Initial swing ( toe off)
• start of single limb support for opposite
limb
• from elevation of limb to point of maximal
knee flexion
• hip flexors concentrically contract to
advance the swinging leg, concentric
tibialis ant.

25. Swing Phase
• Mid-swing (foot clearance)
• following knee flexion to point where tibia is
vertical
• ankle dorsiflexors contract to ensure foot
clearance

26. Swing Phase
• Terminal swing (tibia vertical)
• from point where tibia is vertical to just prior
to initial contact
• hamstring muscles decelerate forward motion
of thigh

29. Gait Cycle Variables
• Pelvic ant/post tilt
• Pelvic rotation
– pelvis rotates 4 degrees medially on swing side
– lengthens the limb as it prepares to accept weight
• Pelvic tilt
– pelvis drops 4 degrees on swing side
– lowers COG at midstance
• Lateral displacement of pelvis
– pelvis shifts over stance limb

31. Gait Cycle Variables
• Knee flexion in stance
– Lowers COG, decreasing energy expenditure
– Also absorbs shock of heel strike
– Early knee flexion (15 degrees) at loading response
– At midstance, the knee extends as the ankle plantar
flexes and foot supinates
– Restores leg to original length
– Reduces fall of pelvis at opposite heel strike

32. Gait Cycle Variables
• Center of gravity (COG)
– in standing position is 5cm anterior to S2 vertebral
body
– vertical displacement
• during gait cycle COG displaces vertically in a rhythmic
pattern
• the highest point is during midstance phase
• lowest point occurs at the time of double limb support
– horizontal displacement
• COG displaces 5cm horizontally during adult male step

34. Variables
• Ground Reaction Forces(GRF)
– Ankle, knee, hip
• ACL
• Acetabulum
• Upper limb frequency
– Low speed: stepping frequency (2:1 ratio of arm to
leg)
– Higher velocity: stride frequency (1:1 ratio of arm
to leg)

35. Stance Phase
• Initial contract( heel strike)
– Hip external rotation
– Tibia internal rotation (popliteus muscle)
– Ankle- foot, supination, plantar flexion

36. Stance Phase
• Loading response(initial double limb support)
– Hip internal rotation
– Knee flexion, 20 degrees
– Tibia internal rotation
– Ankle- foot, pronation plantarflexion

37. Stance Phase
• Mid stance
– Hip neutral
– Knee extend
– Tibia neutral
– Ankle- foot, almost neutral, 3o dorsiflexion

38. Knee

39. Stance Phase
• Terminal phase
– Hip external rotation
– Tibia external rotation
– Ankle- foot, supination, 15o plantar flexion(max)

40. Stance Phase
• Pre-swing(second double limb support)
– Hip external rotation
– Tibia external rotation
– Ankle- foot, supination, 20o plantarflexion

42. Compensations
• Hip tightness
• To keep stride length compensate with:
• more anterior & posterior pelvis tilt
• Excessive stress of lumbar spine

43. Compensations
• Hi heel shoes
• To keep stride length compensate with:
• more knee flexion
• Excessive stress of knee joint

44. Q-Angle

45. Q- angle
• Normal Q-angle: 10o -15o
• >20o is pathologic
• Male average: 14o
• Female average: 17o

46. • Women naturally have a larger Q-angle than
men
• In addition, women have increased hip
adduction, hip internal rotation, knee valgus,
and the internal rotation during functional
activities such as running and walking as
compared to men

49. Valgus vs Varus

50. Flat Feet
• Congenital
• Asquired, structural changes, occurred over
time
• All babies have flat feet
• Arches typically form by age 6

51. Flat Feet
• Flexible
• Rigid
• Adult Acquired(Fallen arches)
• Vertical Talus

52. Flat Feet, Risk Factors
• Achilles tendon injuries
• Broken bones
• Cerebral Palsy(CP)
• Diabetes
• Down syndrome
• Hi BP
• Obesity
• Pregnancy
• RA
• Soccer, basketball

53. Flat Feet, Causes
• Posterior Tibial Tendon Dysfunction(PTTD)

54. Tarsal Bones
Tarsals: 7 bones
• Calcaneus
• Talus
• Navicular
• Medial cuneiform
• Intermediate cuneiform
• Lateral cuneiform
• Cuboid
• Foot contains:
• 26 bones
• 33 joints
• 100 tendons, muscles & ligaments

56. Flat Feet, Sign & Symptoms
• Leg cramp
• Foot pain, particularly heel and arch area
• Muscular pain
• Toe drift(point outward)

57. Hip Stabilizers

60. G. Medius, dual function

61. Crossed Syndrome
• Dr. Vladamir Janda (1928-2002),
a Czech physician, developed the
“crossed syndrome” theory in
1979

63. Crossed Syndromes
• The postural distortion pattern known as upper crossed syndrome
It involves:
• Thoracic hyperkyphosis
• Hypolordosis of the Cervical Spine
• Hyperextension of the head upon the atlas at the atlanto-occipital joint
• Forward head carriage
• Protraction of the shoulder girdles
• Internal rotation of the arms at the GH joint

65. Common causes of Upper Crossed Syndrome
(history of injury)
• Weakness in the neck flexors
• Weakness in the serratus anterior
• Weakness in the lower trapezius
• Tightness in the upper trapezius
• Tightness in the levator scapulae
• Tightness in the pectoralis major
• Tightness in the sternocleidomastoid

66. Common situations with Upper Crossed
Syndrome
• Discomfort is increased the longer the
body maintains a fixed posture, but it is
relieved when the body is moved
• Only specific movements or angles
generate pain, whereas other movements
do not

67. Muscle symptoms of Upper Crossed Syndrome
• Upper Crossed Syndrome typically involve the following symptoms and a two-aspects evolution stage of strength impact:
• First aspect: symptoms perceived from mild to severe
• Tightness → soreness → soreness and pain → dull pain → stabbing pain → tearing pain → loss of sensation
• Second aspect: muscle strength impact from mild to severe, represented by a scale of 5 to 0, as follows:
• 5 points: can resist gravity, complete all joint range of motion, and resist maximum resistance
• 4 points: can resist gravity, complete all joint range of motion, and resist partial resistance
• 3 points: can resist gravity and complete all joint range of motion
• 2 points: complete all joint range of motion on a flat plane without gravity
• 1 point: no movement, but muscle contraction can be palpated
• 0 points: no movement and no muscle contraction

68. Risk factors for Upper Crossed
Syndrome
• Poor posture; long periods of sitting, bending and hunching
over, habitual side sleeping, inadequate muscle flexibility,
over-exercising, etc
• Structural abnormalities; leg length discrepancies, flat feet,
pelvic misalignment, scoliosis, fractures, trauma, post-
surgery, etc
• Other factors; poor circulation, irregular exercise, tissue
adhesion, scars, etc.

71. • In adaptive shortening of cervical spinal musculature as part of upper crossed syndrome, SCM is
particularly relevant
• SCM crosses middle and lower cervical spinal joints anteriorly so it flexes middle and lower
cervical spine
• But it crosses the upper cervical spinal joints, especially the atlanto-occipital joint, posteriorly, so it
extends the head at the AOJ
• For this reason, the SCM is adaptively shortened and tightened with both the hypolordosis of the
(lower and middle) cervical spine and with the hyperextension of the head at the AOJ

72. Ligament Creep

75. Common causes of Lower Crossed Syndrome
(previous injury)
• Weakness in the rectus abdominis muscle
• Weakness in the transverse abdominis muscle
• Weakness in the oblique muscles
• Weakness in the gluteus maximus muscle
• Weakness in the posterior fibers of the gluteus medius muscle
• Tightness in the anterior fibers of the gluteus medius muscle
• Weakness in the muscles surrounding the tibialis anterior
• Tightness in the erector spinae muscles (including the iliocostalis lumborum, longissimus thoracis, and spinalis thoracis)
• Tightness in the quadratus lumborum muscle
• Tightness in the psoas muscle
• Tightness in the rectus femoris muscle

77. • Tight hip flexor musculature
• excessive anterior tilt of the pelvis
• hyperlordosis of the lumbar spine
• hyperkyphosis of the thoracic spine
• hypolordosis of the lower neck with
hyperextension of the head at the atlanto-
occipital joint
• forward head carriage
• tight posterior neck muscles
• Headache

78. Common situations with Lower Crossed
Syndrome
• Discomfort increases the longer the fixed
posture is maintained, but is relieved to
some extent when the body moves
• Pain is only felt when specific movements
or angles are used, and not with other
movements

79. Muscle symptoms of Lower Crossed Syndrome
• The muscle symptoms of Lower Crossed Syndrome usually have the following symptoms and two-dimensional evolutionary stages of strength impact:
• First aspect: Symptoms go from light to severe
• Tightness → Soreness → Soreness and pain → Dull pain → Stabbing pain → Tearing pain → Numbness
• Second aspect: The impact of muscle strength goes from light to severe, expressed in 5-0 points:
• 5 points: Can resist gravity, complete all joint movements, and resist the greatest resistance
• 4 points: Can resist gravity, complete all joint movements, and resist partial resistance
• 3 points: Can resist gravity, complete all joint movements
• 2 points: Complete all joint movements on a gravity-free plane
• 1 point: No movement on a gravity-free plane, but muscle contraction can be palpated
• 0 points: No movement, and no muscle contraction

80. Risk factors for Lower Crossed Syndrome
• Poor posture, prolonged sitting, bending over, hunchback, habitual side-sleeping,
insufficient muscle flexibility, and overcompensation due to excessive exercise, etc
• Structural abnormalities, leg length discrepancy, flat feet, pelvic misalignment, scoliosis,
fractures, post-surgery, etc.
• Others, poor circulation, irregular exercise, tissue adhesion, scarring, etc.
• Lower Crossed Syndrome is located in the lower torso, and those who lack training,
overuse their iliopsoas muscles (from sitting for long periods), poor posture