This document discusses recognizing features of gait due to bone and joint impairments. It provides information on measuring and visualizing bone deformities such as femoral anteversion and tibial torsion. Examples of gait graphs are presented to analyze impairments like persistent femoral anteversion and abductor weakness that cause increased internal hip rotation throughout the gait cycle. The effects of bone deformities on lever arms and gait compensation strategies are also examined.

1. Recognising features due to
bone and joint impairments
Richard Baker
Professor of Clinical Gait Analysis
1

2. 2

3. How can you visualise the
supplementary data on the graphs?
3

4. Bone and Joint Impairments
4

5. Bone Impairments
Deformations of whole bones:
• Persistent femoral anteversion
• Increased tibial torsion
• Bowing of long bones
Most often treated by osteotomies.
5

6. Joint Impairments
Deformations of joints from local
deformation of bones and/or cartilage and or
pathology in ligamentous constraints.
• Knee flexion contracture
Tend to be treated by osteotomies or guided
growth (eight plates or stapling)
6

7. Joint Impairments
Excludes restrictions in joint range as a
consequence of muscle shortness (which
will be addressed later in course).
7

8. Bony impairments
8

9. “Lever-arm disease”
All bones act mechanically as levers.
“Lever-arm disease” or “dysfunction” really just means
bony abnormality and is not sufficiently specific to be
useful.
Often used to refer to torsional malalignment but the way
that this affects lever mechanisms is particularly poorly
understood.
“Lever-arm disease” is a phrase which is best avoided!
9

10. Femoral anteversion
10

11. Normal femoral Anteversion
11
12°
Knee joint axis

12. Abnormal femoral anteversion
12
40°
40°

13. Measuring anteversion
13

14. Measuring anteversion
14
Passive range of
external rotation
Femoral
anteversion
Passive range of
internal rotation

15. Post-operative?
15
Passive range of
external rotation
Femoral
anteversion
Passive range of
internal rotation

16. Normal femur development
16
Von Lanz T (1953). Z Anat 117:317-45.
Shands A, Steele M (1958). Journal of Bone and Joint Surgery 40-A:803.
Crane L (1959).Journal of Bone and Joint Surgery 41-A:421.
Fabry G, MacEwen GD, Shands AR (1973). Journal of Bone and Joint Surgery 55-A:1726-1738.
0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18
Anteversion(degrees)
Age( years)
Lanz
Shands
Crane
Fabry

17. Femoral anteversion
The reduction in femoral anteversion is
almost certainly a consequence of bone
remodelling of the whole femur and not just
the femoral neck.
17

18. 0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18
Anteversion(degrees)
Age( years)
Bobroff (CP)
CP femur development
18
Bobroff ED, Chambers HG, Sartoris DJ, Wyatt MP, Sutherland DH (1999). Clinical Orthopaedics and Related Research 364:194-204.

19. All children have anteversion
Question is not,
“Do they have anteversion?”
but,
“Is the anteversion affecting the way they walk?”
19

20. Anteversion and the abductors

21. Abductor Moment Arm

22. Anteversion (0 )

23. Anteversion (40 )

24. Anteversion (40 ) + Int. Rot.

25. Anteversion (40 ) + Int. Rot. (40 )

26. Internal rotation gait
Probably a consequence of:
persistent femoral anteversion
and
abductor weakness
26

27. 27
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycleHip abductor strength 3(2) 3(2)
Hip adductor tone (Ashworth) 1 1
Hip internal rotation range 57°int 61°int
External rotation range 8°ext 5°ext
Femoral anteversion 21°int 24°int

28. 28
a
Features: Comments:
a. too much int. hip rotation through cycle bilaterally
Supplementary data: left right Comments:
Hip internal rotation range 57° 61°
Hip external rotation range 8° 5°
Femoral anteversion 21° 24°
Hip abductor strength 3 3
Impairment: Bilateral persistent femoral anteversion Evidence: clear Effect on walking: major
Impairment: Bilateral hip abductor weakness Evidence: clear Effect on walking: major

29. Hemiplegia
29
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
Hip abductor strength 3(1) 5(2)
Hip adductor tone (Ashworth) 1 0
Hip internal rotation range 56°int 44°int
External rotation range 1°ext 33°ext
Femoral anteversion 31°int 15°int
Features: Comments:
Supplementary data: left right Comments:
Impairment: Evidence: Effect on walking:
Impairment: Evidence: Effect on walking:
a. Increased left hip. rot. throughout
a
c. Increased left ext. pel. rot. throughout Compensation for internal hip rot
c
d
d. Inc. bilat. int. foot prog. throughout On left consequence of int. hip rot
On right consequence of int. pel. rot.
b b. Right hip within normal limits
Internal hip rot. range 56 44
External hip rot. range 1 33
Femoral anteversion 31 15
Hip abductor strength 3 5
Left femoral anteversion
Left hip abductor weakness
clear
clear
marked
marked

30. Hemiplegia
30
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
Left femoral derotation
Dobson, F., et al.
J Bone Joint Surg Br, 2005.
87(4): 548-55.

31. Tibial torsion
31

32. Tibial torsion
32
Knee joint axis
12°
Knee joint axis20°

33. Measuring tibial torsion
33
Compare with VICON
measurement if using
medial malleolar markers
in static

34. Normal tibia development
34
Can be increased or decreased in CP suggesting different mechanism to anteversion
Staheli, L.T., et al., J Bone Joint Surg Am, 1985. 67(1):39-47.

35. Knee forward foot out
Is it in the tibia or in the foot?
35
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Anklerotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Anklerotation
% gait cycle
Ankle rotation
normal so
deformity must
be in tibia
Ankle rotation
sufficiently
external to
explain foot
progression

36. -30°
-20°
-10°
0°
10°
20°
30°
1° 11° 21° 31° 41° 51°
Pelvicobliquity
% gait cycle
0°
10°
20°
30°
40°
50°
60°
1° 11° 21° 31° 41° 51°
Pelvictilt
% gait cycle
-20°
-10°
0°
10°
20°
30°
40°
50°
60°
70°
0° 20° 40° 60° 80° 100°
Hipflexion
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
HipAdduction
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
0°
10°
20°
30°
40°
50°
60°
1° 11° 21° 31° 41° 51°
Pelvictilt
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
1° 11° 21° 31° 41° 51°
Pelvicobliquity
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-20°
-10°
0°
10°
20°
30°
40°
50°
60°
70°
0° 20° 40° 60° 80° 100°
Hipflexion
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
HipAdduction
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycle
-15°
-5°
5°
15°
25°
35°
45°
55°
65°
75°
0° 20° 40° 60° 80° 100°
Kneeflexion
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Kneeadduction
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Kneerotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Dorsiflexion(ankle)
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Anklerotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle

37. -30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
37
0°
10°
20°
30°
40°
50°
60°
1° 11° 21° 31° 41° 51°
Pelvictilt
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
1° 11° 21° 31° 41° 51°
Pelvicobliquity
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-20°
-10°
0°
10°
20°
30°
40°
50°
60°
70°
0° 20° 40° 60° 80° 100°
Hipflexion
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
HipAdduction
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Kneerotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Anklerotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle

38. -30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
38
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
Pelvic
rotation

39. 39
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Hiprotation
% gait cycle
Hip
rotation

40. 40
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Kneerotation
% gait cycle
Knee
rotation

41. 41
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Anklerotation
% gait cycle
Ankle
rotation

42. 42
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Pelvicrotation
% gait cycle
-30°
-20°
-10°
0°
10°
20°
30°
0° 20° 40° 60° 80° 100°
Footprogression
% gait cycle
Foot
progression

43. Pelvic rotation
+
Hip rotation = Distal femur rotation
+
Knee rotation = Proximal tibia rotation
+
Tibial torsion = Distal tibia rotation
+
Ankle rotation = Foot progression
43

44. Leg length discrepancy
44

45. Leg length discrepancy
Distance from
anterior superior iliac spine
to
medial malleolus
(via medial epicondyle if
knee cannot be extended)
45

46. Leg length discrepancy
46
Pelvic obliquity and hip ab/adduction are consequences of leg length discrepancy

47. Compensations
• Shorter leg
– Vault
– Toe walking
• Longer leg
– Increased knee flexion
– Increased hip flexion
• Work from ground up!
47

48. Conversion of angle to height
48
0
10
20
30
40
50
60
70
80
90
100
0° 5° 10° 15° 20° 25° 30°
Differenceinhipheight(mm)
Pelvic obliquity
100mm
150mm
200mm
250mm
300mm
pelvic
width
For person with pelvic width of 250mm exhibiting 15° pelvic obliquity
Difference
in hip height
is 47mm

49. Bowing of long bones
49
Not observable
in gait analysis
data

50. Joint contractures
50

51. “True” joint contractures
• Consequence of focal impairment of
bone, cartilage andor ligaments
• Distinguish from limited joint range as a
consequence of short muscles
51

52. 52
Knee flexion is probably the impairment limiting knee flexion
Measured
knee flexion
contracture

53. 53
Measured
knee flexion
contracture
Another impairment is limiting knee extension …
… but if that is corrected then the contracture will be a problem.