Gait | NPTE-PTA Musculoskeletal system

A gait cycle is the repetitive pattern of foot movements that occur when walking or running. It’s defined as the time between when the heel of one foot touches the ground and when it touches the ground again. There are 2 phases of gait with 8 sub-phases. The sub-phases can be classified further into the Rancho Los Amigos or traditional terminology.

Definitions

Step length: Distance between 2 successive contact points on opposite feet (Normal: approx. 72cm/28 in.).
Stride length: Distance between successive points of foot-to-foot contact of the same foot, or 1 complete gait cycle of that extremity. (Decreases with age, pain, disease, and fatigue).

Normal patterns of gait

Phases of the gait cycle

Stance phase - 60% of the cycle
Swing phase - 40% of the cycle

Stance phase (will be denoted as traditional/Rancho Los Amigos terminology)

Heel strike/initial contact
- The beginning of the stance phase, when the heel or another part of the foot contacts the ground
- Joint positions: hip flexion, knee extension, ankle 0 degrees dorsiflexion
- Muscles activated
  - Erector spinae - eccentric
  - Gluteus maximus - concentric
  - Quadriceps - eccentric
  - Hamstrings - concentric
  - Anterior tibialis - eccentric
  - Extensor digitorum longus - eccentric
  - Flexor digitorum longus - eccentric
Foot flat/loading response
- The portion of the first double support period of the stance phase from the initial contact until the contralateral extremity leaves the ground
- Joint positions: hip flexion, knee flexion, ankle 15 degrees plantarflexion
- Muscles activated
  - Erector spinae - concentric
  - Gluteus maximus - concentric
  - Gluteus medius/minimus/tensor fasciae latae - eccentric (closed chain to control the drop of the opposite side of the pelvis as that leg begins to swing).
  - Quadriceps - eccentric
  - Anterior tibialis - eccentric (to lower the foot and prevent foot slap)
  - Extensor digitorum longus - eccentric
  - Flexor digitorum longus - eccentric
Midstance
- The portion of the single limb support stance phase that begins when the contralateral extremity leaves the ground & ends when the body is directed over the supporting limb
- Joint positions: hip extension, knee extension, ankle 0 degrees dorsiflexion (allows for the highest point in the gait cycle).
- Muscles activated
  - Iliopsoas - eccentric
  - Gluteus medius/minimus/TFL - isometric (closed chain to hold the pelvis level for opposite side swing phase)
  - Hamstrings - eccentric
  - Gastrocnemius - eccentric
Heel off/terminal stance
- The last portion of the single limb support stance phase that begins with heel rise and continues until the contralateral extremity contacts the ground
- Joint positions: hip hyperextension, knee extension, ankle 15 degrees dorsiflexion
- Muscles activated
  - Iliopsoas - eccentric
  - Gluteus medius/minimus/TFL - concentric (closed chain to stabilize pelvis for opposite side swing phase)
  - Hamstrings - concentric
  - Gastrocnemius - concentric
Toe off/preswing
- The portion of stance that begins the second double support period from the initial contact of the contralateral extremity to lift off the reference extremity
- Joint positions: hip about 10 degrees hyperextension moving toward neutral, knee flexion (about 35-40 degrees), ankle 20 degrees plantarflexion
- Muscles activated
  - Iliopsoas - concentric
  - Adductor magnus - concentric
  - Hamstrings - concentric
  - Quadriceps - eccentric
  - Anterior tibialis - concentric
  - Gastrocnemius - concentric

Swing phase (will be denoted as traditional/Rancho Los Amigos terminology)

Acceleration/initial swing
- The portion of swing from the point when the reference extremity leaves the ground to the maximum knee flexion of the same extremity
- Joint positions: hip flexion, knee flexion (approx. 60-65 degrees, maximum knee flexion), ankle 0 degrees plantarflexion
- Muscles activated
  - Iliopsoas - concentric
  - Hamstrings - concentric
  - Quadriceps - eccentric
  - Anterior tibialis - concentric
Mid-swing
- Portion of the swing phase from maximum knee flexion of the reference extremity to a vertical tibial position
- Joint positions: hip flexion, knee flexion decreasing from maximum toward about 25-30 degrees, ankle 0 degrees plantarflexion (maximal shortening of the limb for ground clearance).
- Muscles activated
  - Iliopsoas - concentric
  - Hamstrings - eccentric
  - Anterior tibialis - concentric
Deceleration/terminal swing
- The portion of the swing phase from a vertical position of the tibia of the reference extremity to just before initial contact
- Joint positions: hip flexion, knee extension, ankle 0 degrees plantarflexion
- Muscles activated
  - Iliopsoas - concentric
  - Hamstrings - eccentric
  - Anterior tibialis - concentric

Gait assessment

A gait assessment is a systematic evaluation of an individual’s walking or running pattern used to identify abnormalities or inefficiencies that may indicate an underlying issue.

PTA role: During a gait assessment, you collect gait data and identify observed deviations from normal patterns, then communicate those findings to the supervising PT. Interpreting the findings and diagnosing the underlying cause is the PT’s responsibility, not yours. Stop gait training and notify the PT immediately if the patient reports new dizziness, shows an abnormal vital-sign response, or has a near-fall.

Keys to a thorough gait assessment

Observe the patient walking: Watch them walk towards and away from you, noting their overall gait pattern, speed, and stability.
Look for abnormalities: Pay attention to any deviations from normal gait, such as:
- Uneven stride length: One leg appears to take shorter or longer steps than the other.
- Foot placement: Observe how the heel and toes make contact with the ground.
- Arm swing: Note the presence and symmetry of arm movement.
- Pelvic movement: Look for any unusual or excessive pelvic tilting or rotation.
- Trunk sway: Observe excessive or abnormal trunk movement during walking.
Assess balance, speed, and endurance: Observe how the patient maintains balance during walking and turning, whether their speed is normal, and whether they show fatigue over distance.

Primary gait muscles and actions

Muscle activation by phase was described above; their primary actions are below.

Definitions

Erector spinae: Extensors of the lumbar spine
Gluteus maximus: Extension of the hip
Gluteus medius: Leveling of pelvis; hip abductor
Iliopsoas: Flexion of the hip
Adductor magnus: Adduction of the hip
Quadriceps femoris: Extension of the knee; hip flexion (rectus femoris only)
Hamstring: Extension of the hip; flexion of the knee
Gastrocnemius: Flexion of the knee; plantarflexion of the ankle
Tibialis anterior: Dorsiflexion and inversion
Tibialis posterior: Plantarflexion and inversion

Example: identifying the muscle behind a gait deviation

While observing a patient walk, you notice the foot slaps down right after heel strike, and the toes drag along the ground during swing. Which muscle is most likely weak, and why?

Answer: The anterior tibialis. It contracts eccentrically right after heel strike to lower the foot to the ground under control, and it contracts concentrically during swing to dorsiflex the ankle and clear the toes. Weakness here produces both the foot slap at initial contact and the toe drag during swing.

Important gait terms

Femoral anteversion: medial rotation of femur
- Can be related to the medial rotation of the tibia, toe in
Femoral retroversion: lateral rotation of femur
- Can be related to lateral rotation of the tibia, toe out
Internal tibial torsion: medial rotation of the tibia
- Can be related to toe in
External tibial torsion: lateral rotation of the tibia
- Can be related to toe out
Genu valgum: knock-knees
- Can be related to external tibial torsion
Genu varum: bowlegged
- Can be related to internal tibial torsion
Base of support: the distance between the two feet during standing or walking
Cadence: the number of steps taken per minute

Abnormal gait

Common swing phase compensation
- Result of apparent or actual leg length discrepancies.
- Hip hike or shrug
- Hip circumduction
- Steppage gait
Common stance phase compensation
- Result of apparent or actual leg length discrepancies.
- Vaulting (hyperextending the knee and plantarflexing the ankle)

Antalgic (painful) gait

Result of injury to the pelvis, hip, knee, ankle, or foot.
The stance phase on the affected leg is shorter than that on the unaffected leg, because the patient attempts to remove weight from the affected leg as quickly as possible.
- Example: L knee pain - the stance phase of L is shortened.
  - This causes a shortened step length of the R (unaffected) leg, because the R leg swings through quickly to unload the painful L leg.
  - The stance time on the R (unaffected) leg is longer than on the L

Ataxic gait

Results from neurological deficits resulting in abnormal walking patterns characterized by poor coordination and balance, most often associated with cerebellar dysfunction
- Typically presents with clumsy, staggering movements with a wide-based gait
- Vestibular dysfunction, by contrast, produces an unsteady gait with a tendency to veer toward one side, usually with vertigo or dizziness

Trendelenburg (gluteus medius) gait

Weakness of the gluteus medius causes an abnormal gait pattern. The weakness always involves the stance leg with an inability to stabilize the pelvis and a drop of the pelvis on the swing leg, or compensated by leaning over the weak stance leg.
- Increased lateral lean over the affected side
- Pelvis drops on the unaffected (swing) side

Three examples of Trendelenburg gait showing normal, positive, and compensated walking positions. — Trendelenburg test

Hemiplegic or hemiparetic gait

Results from weakness and/or spasticity on one side of the body, typically from a UMN lesion such as stroke, leading to various gait deficits
- Examples of hemiparetic gait patterns are: hip flexor weakness or extensor spasticity may cause circumduction gait during the swing phase of gait, or anterior tibialis weakness could cause foot slap gait during the initial contact of gait

Steppage or drop foot gait

Weak or paralyzed anterior tibialis leaves the foot unable to dorsiflex (drop foot). The patient compensates with steppage: exaggerated hip and knee flexion during swing to clear the toes.
- Inability to clear the ground during the mid-swing phase of gait because of loss of control of the anterior tibialis muscle due to weakness or denervation.

UMN vs LMN gait patterns: Hemiplegic/hemiparetic gait typically results from an upper motor neuron (UMN) lesion (e.g., stroke) - the extremity is spastic, so the patient compensates with hip circumduction or hip hiking to clear the foot during swing. Steppage/drop foot gait typically results from a lower motor neuron (LMN) lesion (e.g., peroneal nerve injury) - the anterior tibialis is flaccid, so the patient increases hip and knee flexion during swing to clear the dragging foot.

Other common gait deviations

Parkinsonian (festinating) gait: Shuffling steps, reduced arm swing, and a flexed trunk and hips, with progressively faster, shorter steps as the patient tries to “catch up” to their own center of mass.
Scissoring gait: Hip adductor spasticity (e.g., cerebral palsy, spinal cord injury) pulls the thighs and knees together during swing, narrowing or crossing the base of support.
Gluteus maximus lurch: Weak hip extensors cause the trunk to lurch posteriorly at initial contact on the involved side, using momentum to substitute for hip extension in early stance.
Quadriceps-weakness gait: Weak quadriceps cause the patient to push the knee into hyperextension or lean the trunk forward over the knee during stance to keep the knee from buckling.
Peripheral neuropathy gait: Peripheral neuropathy can cause a steppage gait when distal weakness produces foot drop, or an unsteady gait when loss of proprioception forces the patient to watch their feet to avoid tripping; the sensory loss makes balance worse with eyes closed or in the dark.

Definitions

Step length: Distance between 2 successive contact points on opposite feet (Normal: approx. 72cm/28 in.).
Stride length: Distance between successive points of foot-to-foot contact of the same foot, or 1 complete gait cycle of that extremity. (Decreases with age, pain, disease, and fatigue).

Normal patterns of gait

Phases of the gait cycle

Stance phase - 60% of the cycle
Swing phase - 40% of the cycle

Stance phase (will be denoted as traditional/Rancho Los Amigos terminology)

Heel strike/initial contact
- The beginning of the stance phase, when the heel or another part of the foot contacts the ground
- Joint positions: hip flexion, knee extension, ankle 0 degrees dorsiflexion
- Muscles activated
  - Erector spinae - eccentric
  - Gluteus maximus - concentric
  - Quadriceps - eccentric
  - Hamstrings - concentric
  - Anterior tibialis - eccentric
  - Extensor digitorum longus - eccentric
  - Flexor digitorum longus - eccentric
Foot flat/loading response
- The portion of the first double support period of the stance phase from the initial contact until the contralateral extremity leaves the ground
- Joint positions: hip flexion, knee flexion, ankle 15 degrees plantarflexion
- Muscles activated
  - Erector spinae - concentric
  - Gluteus maximus - concentric
  - Gluteus medius/minimus/tensor fasciae latae - eccentric (closed chain to control the drop of the opposite side of the pelvis as that leg begins to swing).
  - Quadriceps - eccentric
  - Anterior tibialis - eccentric (to lower the foot and prevent foot slap)
  - Extensor digitorum longus - eccentric
  - Flexor digitorum longus - eccentric
Midstance
- The portion of the single limb support stance phase that begins when the contralateral extremity leaves the ground & ends when the body is directed over the supporting limb
- Joint positions: hip extension, knee extension, ankle 0 degrees dorsiflexion (allows for the highest point in the gait cycle).
- Muscles activated
  - Iliopsoas - eccentric
  - Gluteus medius/minimus/TFL - isometric (closed chain to hold the pelvis level for opposite side swing phase)
  - Hamstrings - eccentric
  - Gastrocnemius - eccentric
Heel off/terminal stance
- The last portion of the single limb support stance phase that begins with heel rise and continues until the contralateral extremity contacts the ground
- Joint positions: hip hyperextension, knee extension, ankle 15 degrees dorsiflexion
- Muscles activated
  - Iliopsoas - eccentric
  - Gluteus medius/minimus/TFL - concentric (closed chain to stabilize pelvis for opposite side swing phase)
  - Hamstrings - concentric
  - Gastrocnemius - concentric
Toe off/preswing
- The portion of stance that begins the second double support period from the initial contact of the contralateral extremity to lift off the reference extremity
- Joint positions: hip about 10 degrees hyperextension moving toward neutral, knee flexion (about 35-40 degrees), ankle 20 degrees plantarflexion
- Muscles activated
  - Iliopsoas - concentric
  - Adductor magnus - concentric
  - Hamstrings - concentric
  - Quadriceps - eccentric
  - Anterior tibialis - concentric
  - Gastrocnemius - concentric

Swing phase (will be denoted as traditional/Rancho Los Amigos terminology)

Acceleration/initial swing
- The portion of swing from the point when the reference extremity leaves the ground to the maximum knee flexion of the same extremity
- Joint positions: hip flexion, knee flexion (approx. 60-65 degrees, maximum knee flexion), ankle 0 degrees plantarflexion
- Muscles activated
  - Iliopsoas - concentric
  - Hamstrings - concentric
  - Quadriceps - eccentric
  - Anterior tibialis - concentric
Mid-swing
- Portion of the swing phase from maximum knee flexion of the reference extremity to a vertical tibial position
- Joint positions: hip flexion, knee flexion decreasing from maximum toward about 25-30 degrees, ankle 0 degrees plantarflexion (maximal shortening of the limb for ground clearance).
- Muscles activated
  - Iliopsoas - concentric
  - Hamstrings - eccentric
  - Anterior tibialis - concentric
Deceleration/terminal swing
- The portion of the swing phase from a vertical position of the tibia of the reference extremity to just before initial contact
- Joint positions: hip flexion, knee extension, ankle 0 degrees plantarflexion
- Muscles activated
  - Iliopsoas - concentric
  - Hamstrings - eccentric
  - Anterior tibialis - concentric

Gait assessment

A gait assessment is a systematic evaluation of an individual’s walking or running pattern used to identify abnormalities or inefficiencies that may indicate an underlying issue.

Keys to a thorough gait assessment

Observe the patient walking: Watch them walk towards and away from you, noting their overall gait pattern, speed, and stability.
Look for abnormalities: Pay attention to any deviations from normal gait, such as:
- Uneven stride length: One leg appears to take shorter or longer steps than the other.
- Foot placement: Observe how the heel and toes make contact with the ground.
- Arm swing: Note the presence and symmetry of arm movement.
- Pelvic movement: Look for any unusual or excessive pelvic tilting or rotation.
- Trunk sway: Observe excessive or abnormal trunk movement during walking.
Assess balance, speed, and endurance: Observe how the patient maintains balance during walking and turning, whether their speed is normal, and whether they show fatigue over distance.

Primary gait muscles and actions

Muscle activation by phase was described above; their primary actions are below.

Definitions

Erector spinae: Extensors of the lumbar spine
Gluteus maximus: Extension of the hip
Gluteus medius: Leveling of pelvis; hip abductor
Iliopsoas: Flexion of the hip
Adductor magnus: Adduction of the hip
Quadriceps femoris: Extension of the knee; hip flexion (rectus femoris only)
Hamstring: Extension of the hip; flexion of the knee
Gastrocnemius: Flexion of the knee; plantarflexion of the ankle
Tibialis anterior: Dorsiflexion and inversion
Tibialis posterior: Plantarflexion and inversion

Example: identifying the muscle behind a gait deviation

While observing a patient walk, you notice the foot slaps down right after heel strike, and the toes drag along the ground during swing. Which muscle is most likely weak, and why?

Answer: The anterior tibialis. It contracts eccentrically right after heel strike to lower the foot to the ground under control, and it contracts concentrically during swing to dorsiflex the ankle and clear the toes. Weakness here produces both the foot slap at initial contact and the toe drag during swing.

Important gait terms

Femoral anteversion: medial rotation of femur
- Can be related to the medial rotation of the tibia, toe in
Femoral retroversion: lateral rotation of femur
- Can be related to lateral rotation of the tibia, toe out
Internal tibial torsion: medial rotation of the tibia
- Can be related to toe in
External tibial torsion: lateral rotation of the tibia
- Can be related to toe out
Genu valgum: knock-knees
- Can be related to external tibial torsion
Genu varum: bowlegged
- Can be related to internal tibial torsion
Base of support: the distance between the two feet during standing or walking
Cadence: the number of steps taken per minute

Abnormal gait

Common swing phase compensation
- Result of apparent or actual leg length discrepancies.
- Hip hike or shrug
- Hip circumduction
- Steppage gait
Common stance phase compensation
- Result of apparent or actual leg length discrepancies.
- Vaulting (hyperextending the knee and plantarflexing the ankle)

Antalgic (painful) gait

Result of injury to the pelvis, hip, knee, ankle, or foot.
The stance phase on the affected leg is shorter than that on the unaffected leg, because the patient attempts to remove weight from the affected leg as quickly as possible.
- Example: L knee pain - the stance phase of L is shortened.
  - This causes a shortened step length of the R (unaffected) leg, because the R leg swings through quickly to unload the painful L leg.
  - The stance time on the R (unaffected) leg is longer than on the L

Ataxic gait

Results from neurological deficits resulting in abnormal walking patterns characterized by poor coordination and balance, most often associated with cerebellar dysfunction
- Typically presents with clumsy, staggering movements with a wide-based gait
- Vestibular dysfunction, by contrast, produces an unsteady gait with a tendency to veer toward one side, usually with vertigo or dizziness

Trendelenburg (gluteus medius) gait

Weakness of the gluteus medius causes an abnormal gait pattern. The weakness always involves the stance leg with an inability to stabilize the pelvis and a drop of the pelvis on the swing leg, or compensated by leaning over the weak stance leg.
- Increased lateral lean over the affected side
- Pelvis drops on the unaffected (swing) side

Hemiplegic or hemiparetic gait

Results from weakness and/or spasticity on one side of the body, typically from a UMN lesion such as stroke, leading to various gait deficits
- Examples of hemiparetic gait patterns are: hip flexor weakness or extensor spasticity may cause circumduction gait during the swing phase of gait, or anterior tibialis weakness could cause foot slap gait during the initial contact of gait

Steppage or drop foot gait

Weak or paralyzed anterior tibialis leaves the foot unable to dorsiflex (drop foot). The patient compensates with steppage: exaggerated hip and knee flexion during swing to clear the toes.
- Inability to clear the ground during the mid-swing phase of gait because of loss of control of the anterior tibialis muscle due to weakness or denervation.

Other common gait deviations

Parkinsonian (festinating) gait: Shuffling steps, reduced arm swing, and a flexed trunk and hips, with progressively faster, shorter steps as the patient tries to “catch up” to their own center of mass.
Scissoring gait: Hip adductor spasticity (e.g., cerebral palsy, spinal cord injury) pulls the thighs and knees together during swing, narrowing or crossing the base of support.
Gluteus maximus lurch: Weak hip extensors cause the trunk to lurch posteriorly at initial contact on the involved side, using momentum to substitute for hip extension in early stance.
Quadriceps-weakness gait: Weak quadriceps cause the patient to push the knee into hyperextension or lean the trunk forward over the knee during stance to keep the knee from buckling.
Peripheral neuropathy gait: Peripheral neuropathy can cause a steppage gait when distal weakness produces foot drop, or an unsteady gait when loss of proprioception forces the patient to watch their feet to avoid tripping; the sensory loss makes balance worse with eyes closed or in the dark.