LECOM-SH OPP 1001, Fall 2022, Exam 4

UNIT 4 --> LECTURE 24: GAIT !!!!!!!!!!!!!!!!!!!

plum line (KNOW what passes through) GOD FORBID you DONT know, how can you call yourself a student doc?!

Line, drawn or string. dividing the body in half in Sagittal transverse or Frontal view

Which postural muscles are active during "resting" position?

- Calves

- Neck Muscles

- Jaw muscles

What are the 2 phases of a normal gait?

Stance and swing phase

What are the 4 occurrences in the stance phase?

1) Heel strike

2) Foot flat

3) Midstance

4) Push off

What are the 3 occurrences in the swing phase?

1) Acceleration

2) Midswing

3) Deceleration

Starting from initial contact? What are the 8 steps using New Gait Terms

1) Initial contact

2) loading response

3) mid-stance

4) Terminal stance

5) preswing

6) initial swing

7) mid swing

8) terminal swing

Starting from heel strike? What are the 7 steps using CLASSIC Gait Terms

1) heel strike

2) foot flat

3) midstance

4) heel off

5) toe off

6) midswing

7) heel strike

What is the normal base length of a normal gait? (size doesn't matter, stop judging)

2-4 inch

What is the normal distance of a step length in normal gait?

15-18 inch

What is a normal stride length in a normal gait?

36 inch

what is the normal cadence for a normal gait?

100-120 steps/minute

What is the definition of Base length of the gait?

the distance b/w mid-heel on one foot to mid heel on contralateral foot (width)

What is the definition of step length of a normal gait?

distance b/w the point of initial contact of one foot & the point of initial contact of the opposite foot (length per step)

How do you calculate velocity by using cadence and step length?

Cadence x step length (in units of distance per time) (ie. mph)

What is the definition of length of STEP in a normal gait?

what is the average length?

heel strike on 1 foot to heel strike of opposite foot. (average = 15 inches)

What is the definition of the length of GAIT cycle (stride)

heel strike of 1 foot to heel strike of the same foot = average 30 inch

What is foot progression angle?

-20 - 25°

What could a widened base indicate?

•ABDucted hip, Valgus knee

•Decreased sensation on soles of feet

•Decreased Proprioception

•Cerebellar problems

•Torn Knee cartilage

•Pregnancy

What could narrowed base indicate?

•ADDucted hip, Varus Knee

Scissoring gait (cerebral palsy)

During swing phase, is the ilium anterior or posterior?

Anterior

During stance phase, is the ilium posterior or anterior?

Posterior

during gait, how far does the pelvis and trunk shift laterally?

Which direction?

why?

- 1 inch

- toward weight bearing side

- to center wight over hip

What are the 4 principles of Gait?

(there's also determinants... and more components.... so don't think for a sec you're off the hook with only 4)

1) Stability of the limb in stance phase

2) Clearance of the limb in swing phase

3) Effective shifts of the limb from stance to swing & from swing to stance

4) Occurrence of these components in a fashion that promotes maximum efficiency of energy expenditures

What composes quantitative gait analysis? (3)

• Kinematics (analysis of motion &resulting temporal & stride measurements)

• Dynamic EMG (analysis of muscle activity)

• Kinetics (analysis of forces that produce motion)

What does the stance phase compose of? (4)

• Heel Strike to Toe Off

• 60% of Gait Cycle

• foot in contact with ground at ALL times

• Double support (at start & end)

What does the swing phase compose of? (3)

• Toe Off to Heel Strike

• 40% of Gait Cycle

• foot in contact with the ground at any time

What are the 4 phases of Gait?

1) heel strike

2) foot flat

3) midstance

4) push off

What is the heel strike phase?

The instant the foot contacts the ground

What is the foot flat phase?

From flatfoot position until the opposite foot is ready for swing (loading response)

What is the midstance phase?

From the time the opposite foot is lifted until the ipsilateral tibia is vertical

What is the push off phase?

From heel rise until the opposite foot contact the ground (contralateral heel strike)

What are the 3 steps in the swing phase?

1) acceleration

2) Midswing

3) Deceleration

What is the acceleration phase?

• Toe off until midswing

• Begins with lift-off of the foot from the floor & ends when the foot is aligned with the opposite foot.

What is the Midswing Phase?

• extremity directly below torso

• Begins when the foot is aligned with the opposite foot & ends when the contralateral tibia is vertical

What is the deceleration phase?

•midswing to heel strike

•Begins when the tibia is vertical & ends when the foot contacts the ground (heel strike)

What is the difference between walking and running (IF YOU DON'T KNOW THIS....KILL ME PLEASE, NOT YOURSELF)

Walking :) --> Heel strike of one foot briefly overlaps the toe off the opposite foot & a brief period of both feet in contact with the ground)

Running :) --> No double stance phase, there is a period when both feet are off the ground, & running is therefore literally jumping or bounding or "flying"

What 3 things are ALWAYs active in gait?

Pelvis, knee, and ankle

What are the determinants of gait? (ie what is the movement of the hip? the knee? the foot?)

Pelvic rotation and pelvic tilt, knee flexes and extends, ankle dorsi and plantar flexes

As you take a step forward with the right foot (right is swinging forward), how does the weight shift? how does the innominate move? how does the sacrum move?

The weight shifts to the left, the innominate rotates left and posteriorly (backwards), and the sacrum rotates left on a left axis (L on L torsion OOoooOoOo)

During Heal strike (initial contact) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammy -

Quad boi -

Pretibial m.m. -

calf m.m. -

Iliopsoas - inactive

Gluteus max - eccentric

Gluteus med -eccentric

Hammy -eccentric

Quad boi -eccentric

Pretibial m.m. -eccentric

calf m.m. - inactive

During Foot flat (loading response) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammy -

Quad boi -

Pretibial m.m. -

calf m.m. -

Iliopsoas - inactive

Gluteus max - inactive

Gluteus med - eccentric

Hammy - eccentric

Quad boi - eccentric

Pretibial m.m. - eccentric

calf m.m. - inactive

During midstance (midstance) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammy -

Quad boi -

Pretibial m.m. -

calf m.m. -

Iliopsoas - inactive

Gluteus max - inactive

Gluteus med -eccentric

Hammy - inactive

Quad boi - inactive

Pretibial m.m. - inactive

calf m.m. - eccentric

During Heel off (terminal stance) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammy -

Quad boi -

Pretibial m.m. -

calf m.m. -

Iliopsoas - concentric

Gluteus max - inactive

Gluteus med - eccentric

Hammy - inactive

Quad boi - inactive

Pretibial m.m. - inactive

calf m.m. - concentric

During Toe off (pre-swing) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammy -

Quad boi -

Pretibial m.m. -

calf m.m. -

Iliopsoas - concentric

Gluteus max - inactive

Gluteus med - inactive

Hammy - inactive

Quad boi - eccentric

Pretibial m.m. - inactive

calf m.m. - concentric

During Acceleration (initial swing) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammys -

Quad bois -

Pretibiaterm-73l m.m. -

calf m.m. -

Iliopsoas - concentric

Gluteus max - inactive

Gluteus med - inactive

Hammy - inactive

Quad boi - eccentric

Pretibial m.m. - concentric

calf m.m. - inactive

During midsing (midwing) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammys -

Quad bois -

Pretibial m.m. -

calf m.m. -

Iliopsoas - concentric

Gluteus max - inactive

Gluteus med - inactive

Hammy - eccentric

Quad boi - inactive

Pretibial m.m. - concentric

calf m.m. - inactive

During Deceleration (terminal swing) list if the muscles are inactive, eccentric, or concentric:

Iliopsoas -

Gluteus max -

Gluteus med -

Hammys -

Quad bois -

Pretibial m.m. -

calf m.m. -

Iliopsoas - inactive

Gluteus max - inactive

Gluteus med - inactive

Hammy - eccentric

Quad boi - inactive

Pretibial m.m. - concentric

calf m.m. - inactive

What muscle group is maximal just after heel strike?

Quad group!! --> pulls your ASIS towards the knee

What muscle group is maximal during heel strike?

Pre-tibial group!! --> pulls the PSIS to the popliteal fossa

the 9 phases of Gait stance at heel strike

• Right ilium thrusts forward & rotates anteriorly & externally

• Initial contact before the weight transfers to foot

• Right iliopsoas tight (shortest)

• Gluteal & piriformis longest & most relaxed

• Contraction of quads locks knee in extension

• Hamstrings longest, breaking swing phase

• Tibialis anterior shortens

• Gastrocnemius longest

• Fibular head maximally anterior

What are the 9 phases of Gait stance at flat foot?

• Weight transfers to right leg, force drives femur upward into right acetabulum, raising right acetabulum. Right ilium rotates posteriorly & superiorly

• Weight born laterally to counteract right leaning from transfer weight & balance lateral sway at base. Weight transfers anteriorly

• Iliopsoas relaxes & lengthens

• Gluteals & piriformis contract

• Quads relax after heel strike force transmitted to ileum via locked knee

• Hamstrings contract, flexing knee

• Dorsiflexors relax

• Gastrocnemius & plantar flexors contract as weight transfers

• Fibula slides posteriorly

What are the 7 Phases of Gait stance at midstance?

• Ilium rises & left ilium begins to be carried anterior to the right ilium by swing phase in left lower extremity

• Foot pronates as weight transfer from lateral foot to ball of foot

• Psoas begins to stretch as it relaxes, breaking thigh extension

• Gluteals & piriformis shorten

• Quads tense to stabilize knee from internally rotating as foot enters pronation phase

• Hamstring shortens

Fibular head slides posteriorly

What are the 8 phases of Gait stance at push off?

• Right ilium rotated maximally posterior

• Iliopsoas braking action switching to contractile shortening phase

• Gluteals & piriformis shortest in walking

• Dorsiflexors relax

• Great toe pushes off & weight transfers

• Gastroc & plantar flexors shortest as toes push down

• Quads tightening to brake thigh extension & start swing contraction phase

• Hamstrings shorten

What are the 7 phases of gait swing at acceleration?

• Right ilium is @ maximal height, starts to descend & rotate anteriorly

• Gastroc starts to lengthen

• Fibular head starts to glide anteriorly

• Quads shorten

• Hamstrings begin to relax

• Iliopsoas start to shorten

• Gluteals & piriformis start to relax

What are the 5 phases of gait swing at midswing?

• Lower extremity carries the ilium anteriorly rotating the pelvis on the horizontal plane

• Dorsiflexors shorten so foot clears ground

• Gastrocs relax

• Quads start to extend leg & pulls fibula forward

• Hamstrings, Gluteals & piriformis relax & lengthen

What are the 7 phases of gait swing deceleration?

• Ilium rotating forward maximally with the leg straightening so knee can lock to receive ground reaction force of heel strike.

• Dorsiflexors tight & ready for heel strike

• Fibula maximally anterior

• Hamstrings braking

• Gluteals & piriformis lengthen but are braking swing

• Quads tighten

• Iliopsoas shortening slowed

What is the Sacral position at toe-off/heel strike?

neutral position

What is the sacral position at midstance/midswing?

forward torsion

What is the rotation of the sacrum on the stance leg?

rotated to the "face" (IDK WHAT THIS MEANS.....)

What rotation is the sacrum on right leg midstance? what about left?

R on R axis/ L on L axis

What is the position of the illium/innominate at midstance/midwing?

neutral position

What is the position of the ilium/innominate at heel strike?

positioned at full anterior rotation (greatest in length)

What is the position of the ilium/innominate at toe off?

Positioned at full posterior rotation (shortest leg length)

What type of mechanic does the sacrum follow with L5 if the sacrum is right rotation on right axis?

Type 1 - L5 N SL RR

At right heel strike, what is the rotation of the right ilium? What is the rotation of the hip (and does it move in E or F)? How does the right ilium begin rotate?

• The right ilium is fully anteriorly rotated (hip flexors have pulled the ASIS toward the knee)

• The R hip begins extension (clockwise rotation)

• The R ilium begins a "counter-clockwise" rotation (rotates posteriorly)

What are 6 more determinants of gait...? cause there're more... even tho they've listed others... wtf

•Foot slap (heheh) or foot drag (muscle weakness)

•Inspect shoes for uneven wear

•Width of base

•Ankle eversion or inversion

•Foot ABduction or ADDuction

•Assess stability

What is the hemiplegic gait?

"Extensor synergies"

- hip extension & internal rotation

- knee extension

- circumduction w/ plantar flexion & foot inversion

- arm on the same side is in ADduction, elbow flexion, and wrist curled inward and slightly up

- basically the leg is too long and the person has to swing it around

What is the Ataxic gait?

- poor sensation or coordination

- basically the person is super shaky and has to keep catching themselves

What is the Spastic diplegia (a.k.a. Compass Gait)?

- Scissoring circumductive B/L

- flexion at hips and knees, ankle is drooping and internally rotated,

- shoulders neutral, elbows are flexed, wrists are neutral (not anatomical)

What is the antalgic gait?

"counteracting or avoiding pain"

- basically a limp

What is the parkinsonian gait?

- Small steps, shuffling (Festinating Gait)

- Stooped forward posture with a slight forward lean

What is the steppage gait?

- Swing leg lifted abnormally high

- Excessive hip flexion

- foot is dragging so patient needs to "clear" the leg by hiking hip up

- seen in motor neuron disease such as polio and in peripheral neuropathy

What is the vaulting gait?

- forceful plantar flexion and knee extension of the stance lege

- foot is dragging on one side, so the other side needs more clearance to allow swing through

What is Waddling Gait (penguin)

Rolling from side to side, pelvic rotation and tilt increased on Swing side

What is the circumductive gait?

problem: one foot drags during mid swing

Solution: abduction and circumduction of hip during swing phase

What is the Trendelenburg sign?

- drooping of contralateral hemipelvis below its normal horizontal level during monopedal stance

- caused by weakness or paralysis of the gluteus medius and minimus muscles

- innervated by the superior gluteal muscle

Difference between uncompensated and compensated trendelenburg gait?

uncompensated: contralateral (non-injuried) hip drops

Compensated: lean upper body away from dropped side (towards injured gluts) to level hips

Functional versus anatomical short leg?

- functional can be corrected with OMT (wwoooahhh it's a miracle)

- Anatomical probably requires a lift --> in standing, the psis may be noticeably unlevel; in supine, compare the ASIS and medial mally? and compare the tibial tuberosity and medial mally? i guess

- A POSTURAL X-RAY is the GOLD standard

Components of a typical short leg pattern (on the left)

• Anatomic short leg (right)

• Pelvic side shift and rotation (left)

• L/L Sacral Torsion

• Lumbar curve convex (right)

• Symptoms

--> back pain from short leg is located at the L/L Sacral Torsion. AKA: deep, tender, painful sulcus

--> pain increased from walking or running

In a structural exam of short leg syndrome, what might you observe??

• Sacral base tilts towards the side of short leg

• Iliac crest is low on short leg side

• Lumbar spine - convexity toward

• Chronic: compensatory curve in thoracic

--> Shoulder and scapula lower on same side

When measuring limb length, what are 2 fixed bony points you can use?

ASIS to medial Malleolus

Before a Gait evaluation, you ask for your patient to remove their shoes. What can you observe from their shoes to help determine part of a gait dysfunction?

• Is heel wear equal & posterior-lateral?

• Soles show evidence of inversion, eversion or normal wear?

• Do Soles shows evidence of internal rotation, external rotation or normal?

A list of things to notice during gait :) It's a long one --> flip me over ;)

• Cadence: Is the rate 90-120/min? If not, have them adjust the speed.

• Arm swing: Equality, hyper or hypo, relaxed/tense

• Shoulder/upper body motion: Symmetrical?

• Is it opposite rotation of the lower body?

• Do shoulders maintain equal height?

• Buttocks movement: Symmetry?

• Pelvis: Proper amount of rotation (40 deg); any hip drop?

YOU THOUGHT THAT LIST WAS DONE?!?!? --> when observing my gait, what should you check out with my legs ;)

• Knee: Flexion and extension?

• Foot and ankle motion: Proper dorsiflexion in swing phase and heel strike?

--> Proper plantar flexion at toe off?

--> Inversion, Eversion or normal?

• Foot: Slap, drag or normal?

--> Internal or external rotation or normal?

--> Plantar surface contacting the ground in all portions of the stance phase?

• Base: Width Normal or Greater than 4" or less than 2" Width base _______inches?

• % of time spent in swing phase and stance phase? Swing _____% Stance _____%

I guess there's also a mnemonic??

For stand phase, what does "I Like My Tea Pre-sweetened" mean? (Each capital letter in this phrase)

I --> Initial contact

L --> Loading response (flat foot)

M --> Midstance

T --> Terminal stance

P --> Pre-swing

UGH LAST CARD!!!............................................................................................................................................................................................................................................................................................................................................................................................................................................................(for this unit --> GOTCHA)

*NeVeR gOnNa GiVe YoU Up, NeVer gOnnA let yUo Down*

ANYWAYS --> What's another mnemonic:

For swing phase, what does "In My Teapot" mean? (Each capital letter in this phrase)

I --> initial swing

M --> Midswing

T --> Terminal swing

LECTURE 25: Direct Techniques 4!!!!!!!!!!!!!!!!!!

Things to Review AGAINNNN

Rib dysfunctions:

- exhalation dysfunctions (1, 2, 3-5, 6-8, 9-10)

Lumbar:

- Type 1

- Type 2 (F & E)

Innominate:

- Shears (sup & inf)

Normal rib motions:

Primary ribs 1-5?

Primary ribs 6-10?

Primary ribs 11, 12?

1-5: pump handle

6-10: Bucket handle

11, 12: Caliper

If there is a rib 1 somatic dysfunction, what muscle is being used?

Anterior & Middle scalenes

If there is a rib 2 somatic dysfunction, what muscle is being used?

Posterior scalenes

If there is a rib 3-5 somatic dysfunction, what muscle is being used?

Pectoralis minor

If there is a rib 6-8 somatic dysfunction, what muscle is being used?

Serratus anterior

If there is a rib 9-10 somatic dysfunction, what muscle is being used?

Latissimus dorsi

While performing ME on the ribs, is the DOC on the same side or opposite side as the dysfunction

SAME side

Steps for ME Rib 1 Exhalation Dysfunction: (Ant. &Mid Scalenes)

• Patient is supine

• physician at affected side

• Patient places his hand palm up on his forehead & looks "forward"

• Physician grasps the posterior aspect of the affected rib with the close hand and pulls caudal

• Physician places his away hand on top of the hand on the patient's forehead

• Patient is asked to raise his head off of the table for an isometric contraction

• Physician stabilizes the both the hand on the forehead and the posterior aspect of the rib during the contraction

• The contraction is held for 3-5 seconds

• A two-second pause is observed

• The slack is taken up and the process is repeated 3-5 times

• Reassess

Steps for ME Rib 2 Exhalation Dysfunction: (Post. Scalenes)

• Patient is supine with physician at affected side

• Patient places his hand palm up on his forehead & turns head away

• Physician grasps the posterior aspect of the affected rib with the close hand and pulls caudal

• Physician places his away hand on top of the hand on the patient's forehead

• Patient is asked to raise his head off of the table for an isometric contraction

• Physician stabilizes the both the hand on the forehead and the posterior aspect of the rib during the contraction

• The contraction is held for 3-5 seconds

• A two-second pause is observed

• The slack is taken up and the process is repeated 3-5 times

• Reassess

Why does ME work for exhalation dysfunction?

• The scalene muscles are being recruited to pull the anterior portion of the rib cephalad.

• The physician is pulling down on the posterior aspect of the rib to affect rotation about the axis

• Together, these maneuvers rotate the rib about the transverse axis towards inhalation

Steps for ME Rib 3-5 Exhalation Dysfunction: (Pec Minor)

•Pt Supine

•DOc standing at affected side

•Pt's shoulder abducted to 140-160 degrees

•DOc's stabilizing (contralateral) hand on Pt's elbow

•DOc's near hand (ipsilateral) is on the superior posterior aspect of the affected rib

•Pt lifts elbow anteriorly and laterally at 45 deg.(Toward opposite ASIS)

•Pt takes a deep breath while lifting arm

•DOc provides isometric resistance holding for 3-5 seconds.

•Repeat 3-5 times and reassess.