Observational Gait Analysis and Correlation With Static Examination
Robert M. Kay
Susan A. Rethlefsen
Tom F. Novacheck
• Introduction
Locomotion is how one moves from place to place. For most people, walking is the primary mode used for the majority of the day, and “gait” describes the pattern with which one walks. The assessment of gait is something we all do in our daily lives, both in our jobs as healthcare professionals and in the community.
Human gait is a complex movement with many components, but there are many characteristic walking patterns encountered in children and young adults. In this chapter, we will explore some of the basics of gait, how to look at gait, and how to identify some of the most common walking abnormalities seen in children.
• Basics of Gait
Despite individual variations in walking pattern, there are certain underlying features of normal gait. Gage1 described the five prerequisites of normal gait: (1) stability in stance, (2) foot clearance in swing, (3) prepositioning of the foot for initial contact, (4) adequate step length, and (5) energy conservation.
In typical gait, 80% of the gait cycle is spent in single-limb stance (one foot on the ground) and the other 20% in double-limb stance (both feet on the ground) (Figure 4.1). Problems which compromise
one’s stability when walking typically decrease the amount of single-limb stance on the affected side, resulting in a corresponding increase in double-limb stance.
one’s stability when walking typically decrease the amount of single-limb stance on the affected side, resulting in a corresponding increase in double-limb stance.
 FIGURE 4.1 Phases of the gait cycle. The first 10% of the gait cycle is double-limb stance (DLS), followed by 40% single-limb stance (SLS), another 10% DLS, and the final 40% being SLS. The first 60% of the gait cycle is stance phase and the final 40%, swing phase. (From Louis ED, Mayer SA, Rowland LP. Merritts Neurology. Philadelphia, PA: Wolters Kluwer; 2016:Figure 14.1.) |
For typical gait, the gait cycle breaks down as follows: the first 10% of the gait cycle is double-limb stance (both feet on the ground), then 40% of single-limb stance, an additional 10% of double-limb (DL) stance, and the last 40% are again single-limb (SL) stance.1,2 Because of symmetry of the two legs in typical gait, one can think of this simply as 10-40-10-40 timing of the gait cycle (10% DL, 40% SL, 10% DL, and 40% SL). This results in each limb contacting the ground for 60% of the gait cycle (the so-called stance phase) and being in the air for the remaining 40% (so-called swing phase) (Figure 4.1).
Looking more closely at stance phase, based on the 10-40-10-40 timing cited above, the first 10% of the gait cycle is double-limb stance. This starts with the foot contacting the ground after being in swing. It therefore starts with initial contact. At initial contact, the hip is maximally flexed, the knee is fully extended, and the ankle is in neutral dorsiflexion. The first 10% of the gait cycle (initial contact and loading response) mainly entails the transfer of all the body weight onto this limb as the other limb is getting ready for swing phase.
The next 40% of the gait cycle is single-limb stance (called midstance and terminal stance) and basically entails progressing one’s weight forward while the stance phase foot remains in contact with the ground. During midstance and terminal stance, the body is advancing over a fixed foot, resulting in progressive ankle dorsiflexion (usually to a maximum of approximately 10°) in terminal stance. By the end of terminal stance, the hip and knee are fully extended, facilitating a long step length.
The next 10% of the gait cycle (the final 10% of stance phase for this limb) is double-limb stance. This 10% is called preswing and involves the processes of readying this stance-phase limb for swing phase, which requires transferring of all the weight off this limb to the other limb. Preswing is marked by rapid hip and knee flexion so that facilitating foot clearance.
The final 40% of the gait cycle is swing phase and involves the progression of the swing phase limb. In mid- and terminal swing, there is progressive hip flexion and knee extension, also allowing limb advancement and a long step length. Swing phase ends with initial contact and the process repeats.
• Principles of Observational Gait Analysis
The most reliable observation of a child’s gait is when the child does not think he/she is being watched. As healthcare providers, this puts us at a significant disadvantage.
In general, it is best to observe the child walking in a long hallway (at least 15 m long, if possible), while barefoot and wearing shorts and sometimes even taping up long shorts (to expose as much of the legs as possible). This is very important since pathology at one level in the extremity(ies) often affects other levels.
Optimally, the child is observed when walking from the front, back, and sides. Assessing stability in stance and foot clearance in swing is important. In stance, observe for hip and knee extension in terminal stance, progressive ankle dorsiflexion from mid- to terminal stance, and balance. In swing phase, observe for hip and knee flexion and ankle dorsiflexion (to at least neutral) to facilitate foot clearance and limb advancement.
For children with subtle gait deviations, it is often necessary to have them run to more accurately assess gait pathology. For very mildly involved children with hemiplegia, running may be the only way to elicit significant gait pathology (
Video 4.1).
Video 4.1).Make sure to look at the child in his/her entirety. Asymmetry of the trunk and upper extremities may be the most evident sign of a neurologic disorder.
For children with braces, they should also be observed walking in their braces. Children who sometimes use walking aids (eg, crutches, walkers, gait trainers, etc) should be observed with and without the devices, whenever possible.
In many cases, the best data regarding someone’s gait are obtained by watching the child walk toward the examining room before seeing the healthcare provider or when leaving the clinic after seeing
the healthcare provider. In such circumstances, the child will walk with a more typical gait pattern for that child (since he/she is not consciously trying to perform a “clinic walk” for the medical personnel).
the healthcare provider. In such circumstances, the child will walk with a more typical gait pattern for that child (since he/she is not consciously trying to perform a “clinic walk” for the medical personnel).
If there is even a remote concern for neuromuscular involvement, a few quick tests can provide useful additional information. Having the child get up from the middle of the floor and looking for a Gowers sign is often useful in young children with toe walking (
Video 4.2). Also, having a child toe walk and heel walk can be useful in assessing strength and muscle control.
Video 4.2). Also, having a child toe walk and heel walk can be useful in assessing strength and muscle control.For young and/or anxious children, getting them to walk may be challenging in the office environment. Having them walk toward their parents, mobile phones, tablets and/or having a ready supply of toys and/or treats may provide sufficient enticement to get even the most hesitant child to walk for you.
When assessing intoeing, it can be useful to put a sticker over the anterior patella and watch the child walk. This will help in the assessment of potential internal hip rotation during gait.
Until one has gained significant experience with observing gait, it is often best to first systematically evaluate one joint/body part at a time. For instance, one may initially focus attention at the ankle and evaluate that joint throughout the gait cycle, before turning attention to the knee, then the hip. This sequential pattern of analysis done in both the frontal and side view.
With the advances in mobile phone technology, we all typically carry a video recording device with us throughout the day. Using one’s mobile phone can facilitate the evaluation of a child’s gait. Numerous apps are available for mobile devices which allow for stop frame, slow motion, marking joint angles, etc (such as Coach’s Eye, Dartfish, Hudl and Kinovea, among others). Health Insurance Portability and Accountability Act (HIPAA) concerns exist, however, in the use of images on unencrypted devices.
• Observing Gait From the Side
When observing from the side, focus on the sagittal (flexion/extension) plane of movement. There are just a few main points in the gait cycle to focus on to get a good handle on the child’s gait pattern.
Looking at the pelvis can be difficult. A very helpful tip-off for anterior pelvic tilt is if there is evident lumbar lordosis (swayback) seen from the side during gait.
At the hip, there should be maximal flexion in terminal swing and initial contact. There is then progressive hip extension throughout stance until maximum hip extension occurs at terminal stance. There is then rapid hip flexion in preswing as the leg readies for swing phase.
At the knee, the main times to focus on are terminal stance and terminal swing (which are both characterized by maximal knee extension) and preswing until initial swing (rapid knee flexion) to facilitate foot clearance in swing.
The ankle has mild plantar flexion in loading response, progressive dorsiflexion in mid- to terminal stance, and then plantar flexion in preswing as the limb gets ready for swing phase. In swing phase, the ankle is basically in neutral dorsiflexion.
• Observing From the Front and Back
When observing from the front and back, the main planes assessed are the coronal plane (looking for abduction and adduction) and the transverse plane (rotational problems such as intoeing and outtoeing). It is important to assess the foot position as well.
Typical gait does not have much excursion in the coronal plane. The pelvis, hips, and knees only vary about 10° total throughout the gait cycle. The legs should be essentially vertical throughout the vast majority of the gait cycle.
In the transverse plane, one can assess rotation, intoeing, and outtoeing. There is mild rotation of the pelvis (slight internal rotation of the pelvis in terminal swing through loading response and mild external rotation in terminal stance). The hips rotate in the opposite direction from the pelvis—mild external rotation in terminal swing and mild internal rotation in terminal stance.
When looking at the transverse plane, one should assess the foot progression angle (FPA), ie, is the foot pointed inward or outward during gait? The average FPA is 10° to 15° external. Similarly, when
evaluating gait, one should look at the knee progression angle (KPA). The KPA should be approximately neutral throughout the gait cycle. If there is a significant difference between the KPA and FPA, then there is deformity below the knee, usually tibial torsion and/or a foot deformity.
evaluating gait, one should look at the knee progression angle (KPA). The KPA should be approximately neutral throughout the gait cycle. If there is a significant difference between the KPA and FPA, then there is deformity below the knee, usually tibial torsion and/or a foot deformity.
When looking at the foot from the front and back, look for abnormal positioning and weight-bearing. The foot should be in a relatively neutral position throughout the gait cycle. In valgus feet, there is excessive medial weight-bearing. For varus feet, the weight-bearing is lateral, and it is useful to assess whether this varus is continuous or in only stance or swing phase.
• Specific Gait Deviations
Some common gait deviations are seen in Table 4.1.
Table 4.1 Common Gait Deviations and Causes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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