Gait disorders in

Musculoskeletal
dysfunctions
Gait Abnormalities
CLASIFICATION of PATHOLOGIC
GAIT/ GAIT DEVIATIONS

 Pathologic Gait Patterns

 A. Neuromuscular
 B. Musculoskeletal and
 C. Isolated Motor Weakness Gait
problems (a sub-class of A).
Neuromuscular Aetiologies

 Neurologiccauses result form any

dysfunction of the Central and
Peripheral Nervous Systems and
Muscles.

 The consequences are changes in

 +) Motor tone and
 ii) motor control
Musculoskeletal Aetiologies
of Gait Deviations

 a. Hip pathology
 b. Knee pathology
 c. Foot and Ankle Pathology
 d. Leg Length Discrepancy
 e. Skeletal abnormality
i Club foot - Equine Gait
 ii/ Coxa vara ) Waddling Gait
 iii/ Double Congenital Hip
Displacement Waddling Gait
Sub-classfied as isolated
Motor Weakness Gait Problems
 Gluteus Medius Gait or Trendelenburg
Gait (TG) Characterized by leaning of the
trunk to the affected side while walking;
caused by paralysis or paresis of the
gluteus medius muscle- hip abductors.

 Thistype of gait may also be seen in L5

radiculopathy and after poliomyelitis, but
is then usually seen in combination with
foot drop.
 Gluteus Maximums (Lurch)
Gait- (GMG).
 In weakness of Gluteus Maximus (the major hip
extensor) the falling forward of the subject at
heel strike is at stake.

 The individual throws the trunk backward with

a “lurch” using abdominal and paraspinal
muscle activation just after heel strike.

 The is apparent forward protrusion of the

affected hip.
Hip flexor weakness Gait
(HFG)
 Backward trunk lurch toward
unaffected side occur in Hip Flexors
weakness-Hip flexor weakness
Gait (HFG).

 The inertia generated from trunk and

hip activity form push off to
midswing usually carry the affected
limb into flexion (at the hip).
 The stride length is shortened on the
Hip flexor weakness: L2-L3
Nerve root compression
Gait with hip flexor
contracture
Hip extensor weakness
(Posterior lurch gait)
 Backward trunk lean with
hyperextended hip during stance
phase of affected limb.

 Thisaction moves the line of gravity

of the trunk behind the hip
and reduces the need for hip
extension torque
Steppage Gait (SG) or Drop
Foot/ Slap Foot Gait.
 This results from Ankle Dorsiflexors weakness.

 Gait deviation is noticed at heel strike which is

absent in severe cases.

 There is loss of plantar flexion control, eccentric

control of dorsiflexions is decreased.

 In severe weakness foot falls into plantar flexion

during swing phase.

 Toe clearance is ensured by compensatory

exaggerated hip and knee flexion (Steppage gait).
Quadriceps Weakness Gait
(QG) Gait
 deviation is apparent at the heel strike.

 The affected knee is locked in hyper extension at

heel strike.

 Some subjects place their hand on the thigh at

heel strike and stance to assist the knee
hyperextended position.

 The affected leg lags at the swing phase resulting

in excessive heel rise during fast walking
Hip Pathology may result in Antalgic Gait

 Osteoarthritis
 Diminished ROM particularly flexion and
internal rotation

 Initially compensatory motion on the

lumbar spine, reduction in hip flexion in
swing phase and reduction of extension
in the stand phase

 later hip hiking on contralateral side, tip

Antalgic Gait

Avoidance Gait.
 Avoiding weight bearing on affected
side.

 There is decrease in stance phase in

order to quickly unloaded the
mechanical stress on the painful joint.

 There is tendency to avoid heel strike to

avoid jarring and excess loading on the
painful hip
Antalgic gait
 Certain motions to avoid acute pain.

Conditions associated with

antalgic gait
 Trauma
 Osteoarthritis
 Pelvic girdle pain
 Coxalgia
 Tarsal tunnel syndrome
Knee pathology presents
variable gaits
 Intra
articular effusion- slight knee flexion is
maintained throughout gait cycle.

 Avoidance of heel strike results in Antalgic

gait.
Antalgic gait results from -
 Meniscal tear, loose body, fracture, infection
has in septic arthritis and synovitis

 Hyperesteusion/ recurvatum gait results

from ligamentous instability
Knee pathology
 Varus thrust gait also results from
injuries to the posterior cruciate
ligament, lateral collateral ligament,
posterior joint capsule and popliteus
tendon.

 Varus
thrust occur at the stance
phase in the gait cycle.

 Combined injuries of lateral

collateral ligament and posterior
Knee pathology

 Injury to the anterior cruciate ligament result

in Quadriceps Avoidance Gait.

 In order to decrease or avoid the stress

tendency to anterior subluxation of the tibia
(which the anterior cruciate ligament
presents) by decreasing the stride length and
avoiding knee flexion during the midstance
phase.

 Toe- walking or Steppage Gait is common in

persons with flexion contracture of the knee.
Foot and Ankle Pathology

 Trauma, inflammatory disorders, plantar fascitis

,degenerative disorders of the foot and ankle
will result in Antalgic Gait/tiptoeing Gait.

 In an attempt to limit weight bearing stride

length is shortened, normal heel-to-toe motion
is diminished or lost.

 There are variations of antalgic gait in

forefoot and hindfoot pathologies- avoidance of
loading of foot section that aggravate pain.
Leg Length Discrepancy
(LLD)
 LLD can be relative (or apparent) and true (or real) .

 Relative Leg length Discrepancy can result from

scoliosis and contracture of the hip knee and ankle.

 True leg length Discrepancy is the result of

asymmetry in lengths of the pelvis, femur or tibia.

LLD can result in (ipsilateral to the shortened side )

 Pelvic Obliquity (Tilt)
 Decreased hip and knee flexions
 Decreased plantar flexion and/or hyper pronation
 In addition to the compensatory pelvic drop there
is apparent elevation of the shoulder on the
affected side and exaggerated flexion of the hip,
knee and plantar flexion of the ipsilateral side.

 LLD can result in Tip toeing (Gait) (on the

shortened limb) during stance with full knee
extension.

 Not All LLDs requires “shoe raise” or heel

compensation or heel lift. It is important to know
the aetiology and treat the underlying cause.
Skeletal Abnormalities

 Equine Gait (EG) may result from untreated

congenital talipes equinus, or congenital talipes
equinovalrus or paralysis of the peroneals. Equine
gaits a

 characterized by high steps on toes or on clubbed

foot. In severe cases subjects walk on the dorsum
(lateral aspect ) of the affected foot.

 Waddling Gait (WG). This is gait in which the feet

are wide apart resembling that of a duck. It is seen
in '. vara and double congenital displacement of
the hip .
Propulsive gait
A stopped, rigid posture, with the
head and neck bent forward.
Diplegic Gait
 The patient has spasticity in the lower
extremities greater than the upper
extremities.

 The hips and knees are flexed and

abducted with the angles extended
and internally rotated.
Diplegic Gait
 When the patient walks both lower
extremities are circumducted and
the upper extremities are held in a
mid or low guard position.

 usually seen with bilateral

periventricular lesions.
 The legs are more affected than the
arms because the corticospinal tract
axons that are going to the legs are
closet to the ventricles
Diplegic Gait

 AnUNM lesion affecting both lower

extremities.

 Spasticity
and weakness of the legs
and uses a walker for steadiness.

 Thereis bilateral circumduction of

the lower extremities.
Neuropathic Gait

 This type of gait is most often seen

in peripheral nerve disease where
the distal lower extremity is most
affected.

 Because the doesiflexors are weak,

the patient has a high stepping gait
in an attempt to avoid dragging the
toe on the ground.
Myopathic Gait
 Withmuscular diseases, the proximal
pelvic girdle muscles are usually the
most weak.

 Because of this patient will not be

able to stabilize the pelvis as they lift
their leg to step forward, so the
pelvis will tilt toward the non-weight
bearing leg which results in a waddle
type of gait.
Myopathic Gait

 Pelvic girdle weakness, which produces a

wadding type of gait.

 Note the lumbar hyperlordosis with the

shoulders thrust backwards and the
abdomen being protuberant.

 This posture places the center of gravity

behind the hips so the patient doesn’t fall
forward because of weak back and hip
extensors.
Choreiform Gait

 Thisis a hyperkinetic gait seen with

certain types of basal ganglia
disorders.

 Thereis intrusion of irregular, jerky,

involuntary movements in both the
upper and lower extremities.
Choreiform Gait

 Note the involuntary, irregular, jerky

movements of the body and extremities,
especially on the right side.

 There are also choreiform movements of

the face.

 A lot of her movements have a writhing,

snake-like quality to them, which could
be called choreoathetosis.
Ataxic Gait

 The patient’s gait is wide-based with

truncal instability and irregular
lurching steps which results in lateral
veering and if severe, falling.

 This
type of gait is seen in midline
cerebellar disease. It can also be
seen with severe lose of
proprioception (sensory ataxia).
Causes of Abnormal Gaits/
Assessment
 Pain
 Muscle weakness
 Hypertonicity/Spasticity
 Radiculopathy
 Poor Posture
 Loss of balance
 Skeletal Abnormalities/Deformity
Gait Assessment
Gait Outcome Measures

 Dynamic Gait Index (DGI)

 Figure 8 Walk Test.
 Four Square Step Test (4SST)
 5 times sit to stand and sit (arm crossed
to chest)
 Functional Gait Assessment (FGA)
 Gait Abnormality Rating Scale -
modified (GARS-m): Gait Abnormality
Rating Scale (GARS) is a videotape-
based analysis of 16 facets of human
 Gait Speed.
 Timed Up and Go (TUG)
 3-Meter Backwards Walk Test
 Amputee Mobility Predictor
 Groningen Meander Walking Test:
Aerobic fitness test
Management of Gait
disorders
 Physical
management is essentially
conservative.

 This
conservative treatment which is
sometimes complementary to
medication

 involves
measures to counter or
ameliorate the consequences of the
patho-physiological changes taking
 The cardinal aims of physical therapy
in the management of gait disorders
are to relieve pain, prevent
deterioration, improve and restore
functions
Muscle strength vs Gait

 Gait appears most robust to

weakness of hip and knee extensors,
which can tolerate weakness well
and without a substantial increase in
muscle stress.

 In contrast, gait is most sensitive to

weakness of plantarflexors, hip
abductors, and hip flexors.
Pain management

 Thermal energies depending on

indication

 Shortwave diathermy (SWD) has the

deepest heating effect and it is more
effective than superficial heat
modalities.
Physiologic and therapeutic
effects of SWD
 based on increase in blood flow
 enzymatic activities
 metabolism with consequent
reduction in pain, inflammation and
muscle spasm
 increased elasticity of connective
tissues and range of motion
 Increase in the synthesis of
glucosamine
OKC exercise, SWD and the
combination of both
 Both significantly decreased pain
 OKC alone is significantly better
 The beneficial effects of OKC
exercise may includes:

 increasedblood circulation and

oxygen uptake to the muscles
around the joint
 enhancing tissues repair
 promoting cartilage nutrition
Open kinetic chain exercises

3 phases
(1). Air Cycling –
 The legs raised with the hip joints
flexed to about 90 degrees and
knees bent to a moderate extent in
the air
 slow and steady balance
 for a period of two minutes.
 During the air cycling of the legs the
hands were placed by the sides
(2). Active straight leg raise

 This involved raising the entire

affected leg and holding the knee as
tight as possible in the air for 5
seconds.

 then lower the leg and rest for 2

seconds.

 Two (2) sets of 10 times were

repeated with a rest interval of 1
3. Quadriceps set exercises

 isometric contraction and holding of

the quadriceps muscles as tightly as
possible

 dorsiflexion at the ankle; and

pressing the posterior aspect of the
knee down to the mat.

 Two sets of ten times, repeated with

a rest interval of 60 seconds
Total OKC exercise
programmes
 15-20 minutes per session
 followed by 2 minutes cool- down
involving active stretch and range of
motion
Other Pain management
strategies
 Cryoanalgesia
 Electroanalgesia
 Anti-inflammatory/Analgesic
Iontophoresis
 Interferential Therapy
Muscle weakness

Strengthening programmes
 Manual Resisted Exercises
 Progressive Resisted Exercises
 Electrical Muscle stimulation
 Functional electrical stimulation
Primary & Significant contributors for support and
progression in walking.

 Gluteal muscles
 abdominal muscles
 Gluteus maximus
 Gluteus medius
 Vasti
 Hamstrings
 Gastrocnemius
 Soleus are the
Strengthening hip Extensors

GLUTE BRIDGE

 feet should be 12–16

inches from your butt.
 Push pelvis upwards
by squeezing the
glutes.
 Hold for 2 seconds
and lower your hips
back to the ground.
 This is one rep.
 Complete 8–12 reps of
2–3 sets
 Hip thrust

 Brace the core, and push

your pelvis upward by
squeezing your glutes.

 Avoid pushing with your

lower back and keep
your chest in the same
position throughout the
whole movement.

 Then, gently bring the

weight back down.

 Aim for 8–12 reps of 2–3

 Quadruped kickbacks

 Engage the core and ensure the

spine is in a neutral position.

 Shift the weight to left side and lift

right leg off the ground.

 Push right foot up and back,

straightening the knee, as if trying
to drive the heel into the wall
behind.
 Avoid rotating the hips or
shoulders.
 The glutes should be doing most
of the work. Take special caution
not to arch your lower back. Keep
your leg at hip height.
 Return your leg back to the
 Stepups

 Secure a box or bench.

 Stand 6–12 inches behind a
secured box or bench.
 Be sure the surface will not
move.
 Lift your right foot on top of
the box/bench.
 All joints should at 90-degree
angles.
 Next, push foot into the
box/bench and squeeze your
glutes to lift the body up.
 Then, lower the body back
down.
 This is one rep.
 Continue this for 15–20 reps.
Then, switch feet.
 Standing kickbacks

 Standing 1–2 feet from a

wall, counter, or box, place
the palms of hands against
it.
 Lean slightly forward and lift
the left foot off the ground
with your knee slightly bent.
Ensure the core is tight and
back straight.
 Extend your leg backwards
around 60–90 degrees,
making sure to contract the
glutes.
 Return the leg back to the
starting position. This is one
rep.
 Complete 8–12 reps of 2–3
 Upright hip thrusts

 Kneel on pad on the

ground with knees about
hip-width apart. The
shins should be flat on
the ground and your
back upright.

 With your hands on the

hips, push the hips back
until the butt is touching
calves.

 Then, squeeze the glutes

then kneel sit and stand
Glute bridge and hamstring curl on the
stability ball

 Need a stability ball

 Lie on the back with
the calves and feet on
top of a stability ball.
knees will be straight.
 Place hands at the
sides with palms
facing down.
 Using the glutes and
hamstrings, lift the
bottom off the ground
so that the body
forms a straight line.
This is the starting
Glute bridge and hamstring curl on the
stability ball

 From this hip

extension position,
pull the stability ball
toward the butt,
performing a
hamstring curl.
 Slowly straighten the
legs to return to a
straight line. Keep the
body lifted off the
ground and begin
another curl. Or, if
opting out of the leg
curl, lift and lower the
 Prone hip extension on the
stability ball
 Lay the lower stomach or
hips on the ball.
 Put the hands on the
ground in front of the ball
with the arms straight.
 Squeeze the glutes, and
lift the legs off the ground
until they are in line with
the torso. Keep the core
engaged and in contact
with the ball.
 Avoid extending the lower
back, and keep the knees
straight.
 Slowly lower the legs
back down to the starting
Strentghening Hip Extensors
Hypertonicity/Spasticity

 Cryotherapy
 EMS: 3 schools of thought
 Magnesium sulphate iontophoresis
 Passive stretching
 PNF Techniques
 FES
FES Vs EMS
 Gait training with FES is more effective
than EMS in improving mobility, balance,
gait performance and reducing spasticity
in stroke patients.

 FES regains voluntary motor functions by

developing neuroprostheses.

 It helps central nervous system to re-learn

the execution of impaired functions.


Radiculopathy

 Exercise therapy
 Mobilization techniques:
 SLR Technique
 Lumbar rotation techniques
 VOP/TOP
 Myofascial Release
Management of Poor Posture/Skeletal
Abnormalities/Deformity

 Postural corrections
 Muscle strengthening programmes
 Mobilization & Stretching Techniques
 Splinting
 EMG
 Biofeedback
 Management of post surgical
complications
Management of Loss of balance &
Incoordination

 Static balance training

 Dynamic balance training
 Frenkel’s Exercise programme
 Frenkel’s mat for gait training
Specific Exercises for Gait
Training
Hip Flexors stretch
Hip Flexor Trio Stretch