Patient Care Skills GAIT ADA (exam 2)

Gait Phases

-Initial contact

-loading response

-mid stance

-terminal stance

-pre swing

initial swing

-mid swing

-terminal swing

Initial Contact Phase

-Heel first hits ground (heel strike)

-Ankle= neutral

-Knee= extended

-Arms= Ipsilateral side is extended, Contralateral side is flexed

Initial contact phase problems

-If there is decreased DF range of motion, foot hits flat

-If there is decreased knee extension/strength, knee will not get fully extended

-If there is decreased hamstring strength, knee may snap into extension

Loading Response Phase

-shock absorption

-Ankle= Plantarflexed

-Knee= mildly flexed

-Hip= mildly flexed

-Arms= ipsilateral side extended, contralateral side is moving from flexion to neutral

Loading response phase problems

-weak dorsiflexors with eccentric control can cause foot slap

-weak quads can cause decreased knee stability during flexion

Mid Stance Phase

-Ankle= Plantarflexion to dorsiflexion

-Knee=extended

-Hip= neutral

-Arms= ipsilateral side is neutral, contralateral side is moving from flexion to neutral

Mid stance phase problems

-excessive hip/knee flexion due to pain or weakness

-contralateral pelvic tilt

Terminal Stance Phase

-Push off phase

-Ankle= increase in dorsiflexion, then start plantarflexion

-Knee= extended

-Hip= extended

-Arms= ipsilateral side is in flexion, contralateral side is in extension

Terminal Stance Phase problems

-weak plantarflexors can cause poor push off power

Pre Swing Phase

-Ankle= increase in Plantarflexion

-Knee= flexion

-Hip= flexion

-Arms= Ipsilateral side moves further into flexion, contralateral side moves further into extension

Initial Swing Phase

-Ankle= moves into dorsiflexion from plantarflexion

-Knee=increase flexion

-Hip= increase flexion

-Arms= ipsilateral side moves from flexion to neutral, contralateral side moves from extension to neutral

Mid swing Phase

-Ankle= neutral

-Knee= decrease flexion

-Hip= increase flexion

-Arms= ipsilateral side is neutral, contralateral side is moving from neutral to flexion

Terminal swing phase

-Ankle= neutral

-Knee= extended

-hip= flexed

-arms= ipsilateral side in extension, contralateral side in flexion

Parameters of gait

-Base of support

-Center of Gravity

-Knee during stance

-Pelvic/trunk lateral shift

-Stride length

-Stride width

-Cadence

-pelvic rotation

-upper extremities

Base of support

-normal BOS should NOT exceed 2-4 inches from heel to heel

-Clients may widen their BOS without knowing due to dizziness, pain, balance problems, and diminished sensation in the foot.

-occasionally client may need to be instructed to widen their BOS

Center of Gravity

-COG lies anterior to S2 and normally does not oscillate more than 2 inches in a vertical direction

-if this vertical motion is altered, it may indicate pathology of the hip, knee, or foot

Knee during stance

-The knee should remain extended during all components of stance phase EXCEPT during heel strike (between initial contact and loading response)

Pelvic/lateral trunk shift

-Normally weight shifts to the WB side during stance approximately 1 inch

-Weakness or instability indicates deviations

Stride length

-Normal length of a step is 15 inches

-measured from heel to heel

Stride width

-normal stride width is 2-4 inches from mid heel to mid heel

Cadence

-Average cadence is 100-116 steps per minute

-If changes occur in cadence, energy expenditure will increase and number of steps will decrease

-age, fatigue, pain, instability, and uneven surfaces may also decrease cadence

Pelvic rotation

-during swing phase, pelvis rotates 10 degrees forward on swing side and the contralateral side demonstrates fulcrum for movement

-if there is pain or decreased ROM, rotation will not occur

Upper extremities

-move in contralateral patterns

Muscle weakness that can affect gait

-weak ankle (Plantarflexors and Dorsiflexors)

-weak knee (Extensors (quads) and flexors (hamstrings))

-weak hip (Extensors (posterior) and flexors (anterior))

Weak ankle muscles

-Weak Dorsiflexors=

• Makes it hard to get from push off to heel strike. This will cause foot will slap on the floor because DF’s can not control the foot lowering.

• This can also cause steppage gait because the person can not lift toes high enough during swing phase, so toes may drag ground and may have to lift knee and hip higher to clear the ground.

• muscles include tibialis anterior, extensor hallucis longus, and extensor digitorum longus

-Weak Plantarflexors=

• Can make push off difficult (foot flat or calcaneal gait)

• muscles include gastrocnemius and soleus

Knee muscle weakness

-weak extensors (quads)=

• makes it difficult to hold WB in stance phases

• Patient may have to push their knee with their hand to be able to extend their knee

• patient may have to lean their trunk forward to decrease the demand on the quads

-weak flexors (hamstrings)=

• do not have significant impact other than not being able to slow down that straightening knee motion during swing phases, so the leg may swing forward uncontrollably

• harder heel strike or possible knee hyperextension

hip muscle weakness

-Weak extensors=

• trouble controlling trunk moving from heelstrike to midstance (extension of hip)

• may lean backwards to help keep hip stable and reduce demand on gluteus maximus

-weak Flexors=

• difficulty bring leg forward during initial swing phase

• quads

-weak abductors=

• make it difficult to hold during WB phases

• weak hip abductors on one side (gluteus medius), so the opposite side of pelvis drops

• known as trendelenburg gait

Instability

-ankle

-knee

-hip

-cerebellar

-sensory deficits

ankle instability

-results in difficulty to get from heelstrike to pushoff if ankle can not be held in position (initial contact-terminal phase)

knee instability

-knee dislocations, meniscal problems, ligamentous problems result in difficulty with heelstrike to pushoff because knee must support body weight during most stance phases (initial contact-terminal stance)

Hip instability

-results in difficulty with ALL weight bearing activities

-major weight bearing joint

cerebellar instability

-patient increases their base of support

sensory deficit

-produces inability to feel feet or lower extremity placement

-may feel the need to increase base of support, walker faster or slower, and look at feet or ground

Pain

-antalgic gait is the pattern of diminished WB and compensatory patterns secondary to pain in the involved extremity

• ankle pain

• knee pain

• hip pain

Ankle pain

-poorly fitted shoes, heel spurs, bunions, gout, arthritis, fallen arches, and corns can all result in ankle pain with WB to push off

-this causes a tendency to “hop” instead of fully completing initial contact/heelstrike

-minimizing time and pressure on painful side (antalgic gait)

knee pain

-difficulty during stance phase (weight bearing)

hip pain

-difficulty during stance phase (weight bearing)

Immobile/fused ankle

-fused great toe or ankle results in difficulty with push off, heelstrike, and stance

Immobile/fused knee

-fused knees result in difficulty in the beginning at push off through heelstrike

-one needs approximately 60 degrees of knee flexion for normal gait

Immobile/fused hip

-hip fusion results in difficulty moving away from midstance

common gait deviations

-antalgic gait

-arthrogenic gait

-cerebellar ataxia

-equinus gait

-foot drop or foot slap gait

-gastrocnemius/soleus gait

-gluteus maximus gait

-gluteus medius gait (trendelenburg)

-hemiplegic gait

-parkinson gait

Antalgic gait

-where patient avoids weight bearing on the involved extremity (where there is pain) and shorten the time they are bearing on that extremity (usually stance phase).

-shift weight to uninvolved side and unload involved side

arthrogenic gait

-patient will elevate pelvis and utilize circumduction on the involved side during gait

-uninvolved side will show increased plantarflexion at the ankle

-usually with hip or knee injury

cerebellar ataxia gait

-typical for patients with a cerebellar disorder

-gait pattern is unsteady, irregular, wide BOS, and swaying toward involved lower extremity

equinus gait

-demonstrated by patients with ankle deformity, spasticity of posterior tibialis, and contractures

-patient will demonstrate excessive plantarflexion during gait cycle

foot drop and foot slap gait

-patients foot will slap down on the ground due to secondary weak or absent dorsiflexor

-patient will lift involved extremity knee high, resulting in foot drop

-can also be called steppage foot gait because they are lifting foot excessively high to clear the ground

gasrocnemius/soleus gait

-during push off, the patients heel will not come off the ground resulting in involved lower extremity lagging behind the noninvolved side

-weak plantarflexors

gluteus maximus gait

-patient will place thoracic spine posterior to maintain hip extension during stance

-patient may also show elevated pelvis on involved lower extremity to maintain the knee in extension during midstance

-this is a compensatory technique for gluteus maximus muscle weakness

gluteus medius gait

-trendelenburg gait

-patient will lean over hip to place center of gravity over involved hip, and the pelvis of uninvolved side will dip during swing phase

-this is a compensatory technique for gluteus medius weakness, congenital hip deformities, coxa vara, and hip dislocations

hemiplegic gait

-gait is demonstrated in patients with one lower extremity shorter than the other

-patient swings the involved lower extremity in circumduction, no heel strike, and strike occurs with forefoot

parkinson gait

-patient will demonstrate a slow shuffling gait, difficulty initiating first movement, loss of reciprocal upper extremity swing, center of gravity forward, increased walking speeds, and difficulty stopping.