Chapter 02 Gait Cycle

Question 1

The normal gait cycle has two primary components: ________ phase, which represents the duration of foot contact with the ground, and ________ phase, which represents the period in which the foot is in the air.

Answer 1

The normal gait cycle has two primary components: stance phase, which represents the duration of foot contact with the ground, and swing phase, which represents the period in which the foot is in the air.

Question 2

The typical gait pattern consists of approximately ________% stance phase and ________% swing phase.

Answer 2

The typical gait pattern consists of approximately 60% stance phase and 40% swing phase.

Question 3

A Step is defined as the time measured from an event in one foot to the subsequent occurrence of the same event in the ______ foot.

Answer 3

A Step is defined as the time measured from an event in one foot to the subsequent occurrence of the same event in the other foot.

Question 4

A Stride is defined as the time measured from an event in one foot to the subsequent occurrence of the same event in the ______ foot.

Answer 4

A Stride is defined as the time measured from an event in one foot to the subsequent occurrence of the same event in the same foot.

Question 5

Gait is most efficient when vertical and lateral excursions of the body’s COG are minimized. They identified six naturally occurring “determinants” in normal gait that reduced these excursions and suggested that pathologic gait could be identified when these determinants were compromised.

1. _________ rotation in the horizontal plane – The pelvis rotates 4° to each side, which occurs maximally during double support, elevating the nadir of the COG pathway curve by about 3/8″.
2. _________ tilt in the frontal plane – The pelvis drops 5° on the side of the swinging leg controlled by the hip abductors, shaving 3/16″ from the apex of the COG pathway curve.
3. _________ flexion – KF at midstance (10° to 15°) lowers the apex of the COG by 7/16″.
4. Knee and _________ motion – The rotation over the calcaneus in early stance with rotation over the metatarsal heads in late stance combined with KF in late stance produces a smooth sinusoidal pathway for the COG.
5. Lateral ________ displacement – Normal anatomic valgus at the knee and varus at the hip decreases lateral sway, reducing total horizontal excursion from about 6″ to

Answer 5

Gait is most efficient when vertical and lateral excursions of the body’s COG are minimized. They identified six naturally occurring “determinants” in normal gait that reduced these excursions and suggested that pathologic gait could be identified when these determinants were compromised.

1. Pelvic rotation in the horizontal plane – The pelvis rotates 4° to each side, which occurs maximally during double support, elevating the nadir of the COG pathway curve by about 3/8″.
2. Pelvic tilt in the frontal plane – The pelvis drops 5° on the side of the swinging leg controlled by the hip abductors, shaving 3/16″ from the apex of the COG pathway curve.
3. Knee flexion – KF at midstance (10° to 15°) lowers the apex of the COG by 7/16″.
4. Knee and ankle motion – The rotation over the calcaneus in early stance with rotation over the metatarsal heads in late stance combined with KF in late stance produces a smooth sinusoidal pathway for the COG.
5. Lateral pelvic displacement – Normal anatomic valgus at the knee and varus at the hip decreases lateral sway, reducing total horizontal excursion from about 6″ to

Question 6

The COG is located approximately ______ inches anterior to ________.

Answer 6

The COG is located ~2″ anterior to S2.

Question 7

The __________ complex (primarily the __________) is the only muscle normally active during quiet standing. Ligaments and bony articulations maintain the stability of the other joints.

Answer 7

The gastroc–soleus complex (primarily the soleus) is the only muscle normally active during quiet standing. Ligaments and bony articulations maintain the stability of the other joints.

Question 8

Ankle Dorsiflexors – These muscles (primarily the __________, but also the __________ and the __________) eccentrically contract to smoothly lower the foot from heel strike to foot flat. They also concentrically contract during the swing phase to dorsi-flex the ankle and effectively shorten the swinging limb in order to clear the ground.

Answer 8

Ankle Dorsiflexors – These muscles (primarily the tibialis anterior, but also the extensor digitorum longus and the extensor hallucis longus) eccentrically contract to smoothly lower the foot from heel strike to foot flat. They also concentrically contract during the swing phase to dorsi-flex the ankle and effectively shorten the swinging limb in order to clear the ground.

Question 9

Ankle Plantar Flexors – The __________ __________ act eccentrically during midstance to control ankle dorsiflexion caused by the body’s forward momentum. At push-off, they act concentrically to lift the heel and toes off the ground.

Answer 9

Ankle Plantar Flexors – The triceps surae act eccentrically during midstance to control ankle dorsiflexion caused by the body’s forward momentum. At push-off, they act concentrically to lift the heel and toes off the ground.

Question 10

Hip Abductors – The __________ __________ and __________ contract eccentrically during stance phase to limit pelvic tilt of the swing phase leg.

Answer 10

Hip Abductors – The gluteus medius and minimus contract eccentrically during stance phase to limit pelvic tilt of the swing phase leg.

Question 11

Hip Flexors – The hip flexors (primarily the __________) contract eccentrically after midstance phase to slow truncal extension caused by the GRF passing behind the hip. The tensor fasciae latae, pectineus, sartorius, and iliopsoas contract concentrically to flex the hip and shorten the limb for effective ground clearance during swing phase.

Answer 11

Hip Flexors – The hip flexors (primarily the iliopsoas) contract eccentrically after midstance phase to slow truncal extension caused by the GRF passing behind the hip. The tensor fasciae latae, pectineus, sartorius, and iliopsoas contract concentrically to flex the hip and shorten the limb for effective ground clearance during swing phase.

Question 12

Hip Extensors – The __________ __________ and __________ start to eccentrically contract just before heel strike to maintain hip stability and slow down the forward momentum of the trunk, since the GRF is anterior to the hip at this stage. They become essentially inactive after foot flat, once the GRF passes posterior to the hip. The hamstrings may weakly contract during the swing phase to flex the knee for ground clearance.
Hamstrings have a double peak of activity just prior to and after heel strike. The first peak occurs during swing phase when there is an open kinetic chain (foot not in contact with ground). This peak decelerates the forward swing of the leg by eccentrically contracting during hip extension and flexing at the knee. At the moment of heel strike, the open kinetic chain is converted to a closed kinetic chain (foot in contact with ground), while the hamstrings act predominantly as a hip extensor preventing both hip and knee buckling.
There is a less consistent peak of activity during late stance phase when hip extension by the gluteus maximus helps propel the COG forward.

Answer 12

Hip Extensors – The gluteus maximus and hamstrings start to eccentrically contract just before heel strike to maintain hip stability and slow down the forward momentum of the trunk, since the GRF is anterior to the hip at this stage. They become essentially inactive after foot flat, once the GRF passes posterior to the hip. The hamstrings may weakly contract during the swing phase to flex the knee for ground clearance.
Hamstrings have a double peak of activity just prior to and after heel strike. The first peak occurs during swing phase when there is an open kinetic chain (foot not in contact with ground). This peak decelerates the forward swing of the leg by eccentrically contracting during hip extension and flexing at the knee. At the moment of heel strike, the open kinetic chain is converted to a closed kinetic chain (foot in contact with ground), while the hamstrings act predominantly as a hip extensor preventing both hip and knee buckling.
There is a less consistent peak of activity during late stance phase when hip extension by the gluteus maximus helps propel the COG forward.

Question 13

Knee Extensors – The __________ act primarily to absorb shock during heel strike and keep the knee stable by eccentric contraction. They are also active just before toe-off to help initiate the forward swing of the limb.

Answer 13

Knee Extensors – The quadriceps act primarily to absorb shock during heel strike and keep the knee stable by eccentric contraction. They are also active just before toe-off to help initiate the forward swing of the limb.

Question 14

Antalgic Gait – To reduce pain, there is avoidance of WB on the affected limb. The examiner may note a decrease in the __________ phase, a reduced __________ length on the unaffected side, and a prolonged period of __________ support.

Answer 14

Antalgic Gait – To reduce pain, there is avoidance of WB on the affected limb. The examiner may note a decrease in the stance phase, a reduced step length on the unaffected side, and a prolonged period of double support.

Question 15

Gastrocnemius Gait – Weak __________ flexors during terminal stance and toe-off prevent adequate heel lift. To limit the drop in the COG that occurs without heel lift during terminal stance, the step length of the contralateral leg is shortened. Treatment: a solid or semisolid __________ with a full-length footplate simulates plantar flexion during terminal stance.

Answer 15

Gastrocnemius Gait – Weak plantar flexors during terminal stance and toe-off prevent adequate heel lift. To limit the drop in the COG that occurs without heel lift during terminal stance, the step length of the contralateral leg is shortened. Treatment: a solid or semisolid AFO with a full-length footplate simulates plantar flexion during terminal stance.

Question 16

Gluteus Medius–Minimus (Trendelenburg) Gait – In an uncompensated Trendelenburg gait (Fig. 2-4A), there is contralateral __________ drop secondary to the inability of the hip __________ to stabilize the pelvis during stance. In a compensated Trendelenburg gait (Fig. 2-4B), the patient compensates for weak abductors by having a __________ __________over the affected side as a compensatory maneuver to reduce the stress on the weak muscles. Treatment: a __________used in the __________ hand widens the base of support and decreases the hip abductor strength needed to keep the pelvis level. In b/l abductor weakness, b/l __________ with a four-point gait may be used.

Answer 16

Gluteus Medius–Minimus (Trendelenburg) Gait – In an uncompensated Trendelenburg gait (Fig. 2-4A), there is contralateral pelvic drop secondary to the inability of the hip abductors to stabilize the pelvis during stance. In a compensated Trendelenburg gait (Fig. 2-4B), the patient compensates for weak abductors by having a lateral lurch over the affected side as a compensatory maneuver to reduce the stress on the weak muscles. Treatment: a cane used in the contralateral hand widens the base of support and decreases the hip abductor strength needed to keep the pelvis level. In b/l abductor weakness, b/l canes with a four-point gait may be used.

Question 17

Gluteus Maximus (Extensor Lurch) Gait – This may be seen following injury to the ______ ______ nerve or a ______ hip fracture. Weakened hip ______ are unable to decelerate the forward momentum of the body (hip flexion moment) at heel strike. To compensate, the subject adopts a prominent posterior lean and locks the hip joint in extension against the iliofemoral ligament, which keeps the body’s COG behind the hip. Treatment: two ______ or ______ are used for a ______-point gait (Fig. 2-5).

Answer 17

Gluteus Maximus (Extensor Lurch) Gait – This may be seen following injury to the inferior gluteal nerve or a subtrochanteric hip fracture. Weakened hip extensors are unable to decelerate the forward momentum of the body (hip flexion moment) at heel strike. To compensate, the subject adopts a prominent posterior lean and locks the hip joint in extension against the iliofemoral ligament, which keeps the body’s COG behind the hip. Treatment: two crutches or canes are used for a three-point gait (Fig. 2-5).

Question 18

Quadriceps (Back Knee) Gait – With weakness or inhibition of the quadriceps (e.g., distal ______ fracture), the patient will adopt measures to prevent ______ of the knee. One compensation is the use of the hands to force the knee into ______. Also, patients may lurch their trunks forward at initial contact and strongly contract their ankle plantar flexors to bring the COG in front of the knee and force it into extension. Another compensatory technique might be to ______ rotate the leg at initial contact and early stance to bring the medial collateral ligament anteriorly and prevent knee buckling. Treatment: a ______ ______ may be used to provide knee stability at heel strike (Fig. 2-6).

Answer 18

Quadriceps (Back Knee) Gait – With weakness or inhibition of the quadriceps (e.g., distal femoral fracture), the patient will adopt measures to prevent buckling of the knee. One compensation is the use of the hands to force the knee into extension. Also, patients may lurch their trunks forward at initial contact and strongly contract their ankle plantar flexors to bring the COG in front of the knee and force it into extension. Another compensatory technique might be to externally rotate the leg at initial contact and early stance to bring the medial collateral ligament anteriorly and prevent knee buckling. Treatment: a knee brace may be used to provide knee stability at heel strike (Fig. 2-6).

Question 19

Tibialis Anterior Gait – ______ muscle weakness that is at least antigravity (≥3/5 grade) may cause ______ ______ after heel strike. If the muscles are

Answer 19

Tibialis Anterior Gait – Pretibial muscle weakness that is at least antigravity (≥3/5 grade) may cause foot slap after heel strike. If the muscles are

Question 20

Hemiplegic Gait – Patients with ______ synergies will typically ambulate ______. The typical ______ synergy pattern is toward knee ______, ankle ______, and ______. Therefore, ______ tone effectively makes the plegic limb longer than the nonplegic side. Patients compensate with a ______ gait via excessive hip abduction to allow for toe clearance and ending with toe strike. Despite the ______, there is a decreased step length and swing phase on the plegic side. Gait speed will be reduced in order to maintain an acceptable rate of energy expenditure. Treatment: a solid ______ or a hinged ______ with a posterior stop to decrease effective limb length may be helpful. A small degree of plantarflexion, however, should be maintained to promote knee stability for patients with quadriceps weakness. If patients demonstrate genu recurvatum, a small degree of ______ or addition of a heel lift will be indicated (Fig. 2-8).

Answer 20

Hemiplegic Gait – Patients with extensor synergies will typically ambulate independently. The typical extensor synergy pattern is toward knee extension, ankle plantarflexion, and inversion. Therefore, extensor tone effectively makes the plegic limb longer than the nonplegic side. Patients compensate with a circumduction gait via excessive hip abduction to allow for toe clearance and ending with toe strike. Despite the circumduction, there is a decreased step length and swing phase on the plegic side. Gait speed will be reduced in order to maintain an acceptable rate of energy expenditure. Treatment: a solid AFO or a hinged AFO with a posterior stop to decrease effective limb length may be helpful. A small degree of plantarflexion, however, should be maintained to promote knee stability for patients with quadriceps weakness. If patients demonstrate genu recurvatum, a small degree of dorsiflexion or addition of a heel lift will be indicated (Fig. 2-8).

Question 21

Parkinsonian Gait – The classic triad of Parkinson’s disease is ______, ______, and ______, with at least the last two affecting gait. While standing, the knees, trunk, and neck are typically flexed and the body appears stiff. When there is ambulation, there is a characteristic shuffling gait with short quickening steps, as if the patient were racing after the COG (______). Turns are made “______ ______.” Decreased arm swing further compromises balance. Treatment: heel lifts and assistive devices may help reduce the tendency to fall ______. Walkers with added weight may provide additional stability. Physical therapy to address postural issues can be helpful (Fig. 2-9).

Answer 21

Parkinsonian Gait – The classic triad of Parkinson’s disease is tremor, bradykinesia, and instability, with at least the last two affecting gait. While standing, the knees, trunk, and neck are typically flexed and the body appears stiff. When there is ambulation, there is a characteristic shuffling gait with short quickening steps, as if the patient were racing after the COG (festination). Turns are made “en bloc.” Decreased arm swing further compromises balance. Treatment: heel lifts and assistive devices may help reduce the tendency to fall backward. Walkers with added weight may provide additional stability. Physical therapy to address postural issues can be helpful (Fig. 2-9).

Question 22

Spastic Paraplegia or Diplegia/Crouched Gait – Often seen in ______ patients. While standing, the hip and knees are flexed and internally rotated and the foot is held in ______. When there is ambulation, the increased ______ tone at the thighs causes the knees to scissor in front of each other with each step. Hip adduction causes short step lengths, making the feet to seem like they are sticking to the floor. Balance may be impaired as a result of a narrowing base of support, and to compensate for this, the patient tends to lean forward and toward the supporting side. The upper extremities tend to be semiflexed with elbows held out to the sides. Diagnostic nerve blocks may help establish whether or not a contracture is present. Treatment: AFOs can be used to address equinovarus. ______ may be helpful for adductor scissoring and equinovarus. Use of an assistive device (e.g., walker) may provide additional stability.

Answer 22

Spastic Paraplegia or Diplegia/Crouched Gait – Often seen in CP patients. While standing, the hip and knees are flexed and internally rotated and the foot is held in equinovarus. When there is ambulation, the increased adductor tone at the thighs causes the knees to scissor in front of each other with each step. Hip adduction causes short step lengths, making the feet to seem like they are sticking to the floor. Balance may be impaired as a result of a narrowing base of support, and to compensate for this, the patient tends to lean forward and toward the supporting side. The upper extremities tend to be semiflexed with elbows held out to the sides. Diagnostic nerve blocks may help establish whether or not a contracture is present. Treatment: AFOs can be used to address equinovarus. Botox may be helpful for adductor scissoring and equinovarus. Use of an assistive device (e.g., walker) may provide additional stability.

Question 23

In general, a cane should be held in the hand ______ to the lower limb with neuromuscular weakness or joint pathology and is advanced with the affected limb together in a three-point gait pattern. Stairs are usually ascended with the ______ lower limb first, then the cane and affected limb. The affected lower limb and cane proceed down first during stair descent. (“Up with the ______, down with the ______.”) In practice, however, there are no hard and fast rules.
Cane length should be from the bottom of the shoe’s heel to the upper border of the ______ ______ with the patient standing. The shoulders should be level and the arm holding the cane should be ______ ~20° to 30° at the elbow, to provide proper push-off. A cane can unload up to ______% of body weight off the affected lower limb, depending on cane design and the patient’s level of training.
The basis for holding a cane on the opposite side of hip joint pathology is elegantly described elsewhere.
In essence, the cane provides a rotatory moment (C [see Fig. 2-10]) that counteracts the weight of the body (W) and reduces the force of the gluteus medius (F) necessary to maintain equilibrium at the hip fulcrum (H) when the affected lower limb is in single support stance phase.

Answer 23

In general, a cane should be held in the hand opposite to the lower limb with neuromuscular weakness or joint pathology and is advanced with the affected limb together in a three-point gait pattern. Stairs are usually ascended with the stronger lower limb first, then the cane and affected limb. The affected lower limb and cane proceed down first during stair descent. (“Up with the good, down with the bad.”) In practice, however, there are no hard and fast rules.
Cane length should be from the bottom of the shoe’s heel to the upper border of the greater trochanter with the patient standing. The shoulders should be level and the arm holding the cane should be flexed ~20° to 30° at the elbow, to provide proper push-off. A cane can unload up to 20% of body weight off the affected lower limb, depending on cane design and the patient’s level of training.
The basis for holding a cane on the opposite side of hip joint pathology is elegantly described elsewhere.2
In essence, the cane provides a rotatory moment (C [see Fig. 2-10]) that counteracts the weight of the body (W) and reduces the force of the gluteus medius (F) necessary to maintain equilibrium at the hip fulcrum (H) when the affected lower limb is in single support stance phase.

Question 24

_______ have two points of contact with the body and are thus more stable than _______. Shoulder depressors (_______ _______ and _______ _______) are important muscles in ambulation with crutches. Other important muscles that need to be strengthened in preparation for crutch use include the triceps brachii, biceps brachii, quadriceps, hip extensors, and hip abductors.

Answer 24

Crutches have two points of contact with the body and are thus more stable than canes. Shoulder depressors (latissimus dorsi and pectoralis major) are important muscles in ambulation with crutches. Other important muscles that need to be strengthened in preparation for crutch use include the triceps brachii, biceps brachii, quadriceps, hip extensors, and hip abductors.

Question 25

Axillary crutch: Length is 1″ to 2″ plus the distance from the anterior axillary fold to a point on the ground 6” lateral to the bottom of the heel while standing. The handpiece is placed with the elbow flexed 30°, the wrist in extension, and the fingers forming a fist. The patient should be able to raise the body 1″ to 2″ by complete elbow extension. Use of _______ _______on the axillary area of the crutch, although a popular practice, should be discouraged. This encourages the habit of resting the body on the crutches, which increases the risk of _______ _______ neuropathies. When used properly, b/1 crutches can provide total WB relief to a lower limb (Fig. 2-11A).

Answer 25

Axillary crutch: Length is 1″ to 2″ plus the distance from the anterior axillary fold to a point on the ground 6” lateral to the bottom of the heel while standing. The handpiece is placed with the elbow flexed 30°, the wrist in extension, and the fingers forming a fist. The patient should be able to raise the body 1″ to 2″ by complete elbow extension. Use of heavy padding on the axillary area of the crutch, although a popular practice, should be discouraged. This encourages the habit of resting the body on the crutches, which increases the risk of compressive radial neuropathies. When used properly, b/1 crutches can provide total WB relief to a lower limb (Fig. 2-11A).

Question 26

Forearm crutches (Lofstrand): These are indicated if pressure in the axilla is contra-indicated, e.g., open wound and compression neuropathy. They provide less trunk support than axillary crutches. A single forearm crutch can relieve up to _______% of body weight off a lower limb. B/1 forearm crutches can provide total WB relief to a lower limb (Fig. 2-11B).

Answer 26

Forearm crutches (Lofstrand): These are indicated if pressure in the axilla is contra-indicated, e.g., open wound and compression neuropathy. They provide less trunk support than axillary crutches. A single forearm crutch can relieve up to 40% to 50% of body weight off a lower limb. B/1 forearm crutches can provide total WB relief to a lower limb (Fig. 2-11B).

Question 27

Crutch gaits: The crutches and involved limb serve as point 1, while the uninvolved limb is point 2 in the 2-point (or “hop-to”) gait. In the 3-point gait (i.e., the involved limb is PWB), the crutches (1 point) and each limb (points 2 and 3) are advanced separately, with any two of the three points maintaining contact with the ground at all times. In the 4-point gait, point 3 is the involved leg. Each point is advanced separately. _______ is forsaken for increased stability or balance (Fig. 2-12A). When negotiating stairs w/o a banister, one method might be stronger limb → weaker limb → crutch → crutch for ascent and crutch → crutch → weaker limb → stronger limb for descent. A rail or banister, if present, replaces one of the crutches in the above method (Fig. 2-12B).

Answer 27

Crutch gaits: The crutches and involved limb serve as point 1, while the uninvolved limb is point 2 in the 2-point (or “hop-to”) gait. In the 3-point gait (i.e., the involved limb is PWB), the crutches (1 point) and each limb (points 2 and 3) are advanced separately, with any two of the three points maintaining contact with the ground at all times. In the 4-point gait, point 3 is the involved leg. Each point is advanced separately. Efficiency is forsaken for increased stability or balance (Fig. 2-12A). When negotiating stairs w/o a banister, one method might be stronger limb → weaker limb → crutch → crutch for ascent and crutch → crutch → weaker limb → stronger limb for descent. A rail or banister, if present, replaces one of the crutches in the above method (Fig. 2-12B).

Question 28

Walkers provide a wider base of support and safer gait than canes or crutches (Fig. 2-13A). They allow up to _______% WB relief from an affected lower limb depending on how they are used. A walker is fitted by placing it about 10″ to 12″ in front of the patient. The proper height is set with the patient standing straight, shoulders relaxed, and the elbows flexed about 20°. The main disadvantages are that they cause a slow and awkward gait and in the long term can promote bad posture.

Answer 28

Walkers provide a wider base of support and safer gait than canes or crutches (Fig. 2-13A). They allow up to 100% WB relief from an affected lower limb depending on how they are used. A walker is fitted by placing it about 10″ to 12″ in front of the patient. The proper height is set with the patient standing straight, shoulders relaxed, and the elbows flexed about 20°. The main disadvantages are that they cause a slow and awkward gait and in the long term can promote bad posture.

Question 29

_______ walkers are indicated for patients who lack the coordination or strength in the upper limbs to lift and advance a standard walker and are preferred in the rehab of total joint replacement because of the smoother gait.

Answer 29

Rolling walkers are indicated for patients who lack the coordination or strength in the upper limbs to lift and advance a standard walker and are preferred in the rehab of total joint replacement because of the smoother gait.

Question 30

A _______ is used by a hemiplegic. It is wide based, provides more _______ support than a quad-cane, and is advanced by the nonplegic side.

Answer 30

A hemiwalker is used by a hemiplegic. It is wide based, provides more lateral support than a quad-cane, and is advanced by the nonplegic side.

Question 31

_______ walkers (Fig. 2-13B) are used in a variety of situations including distal upper extremity joint deformities, grip weakness, and flexion contractures of the elbow. They allow WB at the elbow, bypassing the hand, wrist, and part of the forearm, and are useful for patients with multiple fractures that may preclude use of a nonplatform device.

Answer 31

Platform walkers (Fig. 2-13B) are used in a variety of situations including distal upper extremity joint deformities, grip weakness, and flexion contractures of the elbow. They allow WB at the elbow, bypassing the hand, wrist, and part of the forearm, and are useful for patients with multiple fractures that may preclude use of a nonplatform device.