Gait

Key Points:

  • Evaluation of gait begins with a careful physical exam
  • Observational gait analysis should be performed using a methodological approach
  • Analysis in a gait laboratory provides comprehensive information including muscle kinematics, muscle kinetics, and energy usage during the gait cycle
  • Careful gait evaluation is critical when planning surgical treatment for children with gait deviations and when evaluating the child’s response to treatment 

Description:

Evaluation of gait is a key part of the orthopaedic exam. In-toeing, out-toeing, toe-walking, and limping are just a few of the gait-related reasons for which children may be referred to orthopaedics.  Gait evaluation can be done through observation in the clinic or in a formalized gait laboratory with the addition of high-quality video, EMG, and pedobarography. Regardless of which method for gait evaluation is used, a careful physical exam and a systematic approach to analyzing the child’s gait are required. 

Epidemiology:

Gait analysis is frequently used for children with underlying neuromuscular conditions. It may be used to plan surgeries, and to evaluate treatment responses in patients with cerebral palsy. The current prevalence of cerebral palsy ranges from 1.5 to 4 per 1,000 live births, making this the most common motor disability in childhood(Data and Statistics for CP 2018).  Gait analysis has also been used to help plan and evaluate surgical treatments of ambulatory patients with myelodysplasia (spina bifida). Currently in the United States, the incidence of myelodysplasia ranges from 2.73 to 3.8 per 10,000 live births(Data and Statistics for Spina Bifida 2018). Gait analysis may also be used for children with leg length discrepancies, lower extremity deformities, skeletal dysplasias, clubfoot and a number of other conditions.

Clinical Findings:

The gait cycle is divided into two major phases: stance phase and swing phase. Regardless of walking or running speed, it has been shown that the percentage of time an individual spends in stance versus swing phase is constant, with about 60% of the gait cycle dedicated to stance phase and 40% dedicated to swing phase(Burnette 2016). The gait cycle can be further subdivided as shown below.
 
Stance Phase Swing Phase
Weight Acceptance Single-Limb Stance Limb Advancement
Initial Contact Loading Response Midstance Terminal Stance Pre-swing Initial Swing Mid-swing Terminal Swing

Muscle coordination is critical through the gait cycle to produce an energy efficient gait. Gait deviations can affect each component of the gait cycle and result in either coronal, sagittal, and/or axial plane deviations from normal gait. As the severity of the deviation increases, the energy that the individual requires to ambulate any given distance increases(Karol 2014). 

Gait analysis begins with the physical exam(Chambers 2002).  This should be a comprehensive exam during which the clinician documents hip abduction, flexion, extension, and rotation, as well as knee range of motion, thigh-foot angles, and ankle range of motion. Careful visual inspection can reveal congenital, neurologic or post-traumatic alterations in the resting position of the trunk and extremities that might affect balance and gait. The Thomas test is used to evaluate hip flexion contractures. With the patient supine, one hip is flexed in order to eliminate the lumbar lordosis and the contralateral hip flexion contracture can then be measured. Testing for hip adduction contractures is performed by maximally abducting the hips while the patient is supine and the hips and legs are fully extended. The amount of abduction can be measured for each hip or combined. Knee flexion contractures are measured with the patient supine, and the hips and knees fully extended. Popliteal angles are used to document hamstring tightness. They are measured with the patient supine, and the hips flexed to 90°. The knees are then maximally extended, and the angle is measured with 0° defined as a straight leg. Flexing the hips naturally tightens the proximal hamstrings, so popliteal angles are generally higher than the angles measured for normal knee flexion contractures. Popliteal angles may have use to predict dynamic knee flexion. The Duncan-Ely test measures quadriceps contractures. The patient is placed prone and the knees are maximally flexed. In patients with quadriceps contractures, the pelvis will lift off the table before the heel touches the gluteal region. Spasticity may be encountered during testing, where the patient’s muscles will contract when stretched, but will then relax and allow passive stretching to a greater angle. The angle at which the spasticity occurs, and the maximum amount of passive stretch should be noted. Muscle strength, sensation, reflexes, and the presence of pathologic reflexes or upper motor neuron signs should be documented as well. 

Careful observation of the child walking in the clinic is essential. To appreciate coronal plane deviations, such as lateral deviations of the trunk or pelvis, the child should be observed walking both towards and away from the examiner. Documentation of the foot progression angle during gait reveals how factors such as femoral anteversion, tibial torsion and dynamic control of hip, knee, ankle and foot position combine to affect gait. Observing the child in the sagittal plane will demonstrate the flexion and extension arc of the child’s hips, knees and ankles during the gait cycle. Obtaining video of the child walking allows the clinician to spend more time evaluating the gait outside of clinic so that more careful documentation of coronal and sagittal plane movement can be performed. 
 

Imaging Studies:

X-rays can be used to document structural abnormalities of the spine, pelvis, and lower extremities that might affect gait. If the clinical exam is not clear, CT or MRI can be used to document the structural rotational profile of the patient by measuring femoral anteversion and tibial torsion(Chambers 2002). 

Evaluation in a formal gait laboratory is the gold standard for gait analysis(Gage 2004). Markers are used to document the position of the trunk, upper and lower extremities during the gait cycle and this information is used to generate kinematic data on the movement of the trunk, pelvis, hips, knees and ankles during the gait cycle. Video is obtained of the child walking both towards and away from the cameras as well as from each side. This can be combined with EMG, to demonstrate how each major muscle group behaves during the gait cycle.4 Abnormally sustained muscle activity documented on EMG can be a sign of pathologic spasticity interfering with gait. Foot plates can be used for pedobarographs, which can document weight distribution through the foot both in stance and over the course of the gait cycle(Karol 2014).

Etiology:

While scientists and physicians had attempted to understand and characterize bipedal locomotion for years, gait analysis did not truly begin to be formalized as a method of patient evaluation until the 1940s(Baker 2007). During this time, traumatic casualties from World War II and the polio epidemic created a large population of patients with acquired gait deviations.  Drs. Verne Inman and Howard Eberhart created a laboratory at the University of California at Berkley to study normal locomotion. Establishing normal values for gait created the foundation upon which analyzing gait deviations, due to either traumatic or neuromuscular conditions, was established. Inman and Eberhard worked with Saunders to write the landmark article “The major determinants in normal and pathological gait” in 1953, in which they described the six determinants of gait(Saunders 1953).  Drs. Jacquelin Perry and David Sutherland are credited with building upon Inman’s work to truly formalize clinical gait analysis by developing standardized approaches to observation gait analysis, using cinematography to capture gait in the coronal and sagittal planes, and EMG to incorporate understanding of muscle activity during the gait cycle(Perry 1974;Sutherland 1972).

Today, gait analysis is most commonly used to characterize gait among pediatric patients with neuromuscular conditions such as cerebral palsy and myelomeningocele(Gage 2004; Davids 2014). Often, surgeons who specialize in the treatment of these conditions will use gait analysis do document gait deviation as a form of preoperative planning, then use subsequent gait analysis to help determine whether surgical or medical intervention has resulted in a functional improvement(Nicholson 2018; Boyer 2018). However, many clinician scientists have also used gait analysis to understand the effects of amputation, prosthetic use, and limb reconstruction on gait(Jeans 2014; Ackman 2013). 

Treatment:

Treatment should be determined based on clinical exam findings as well as careful evaluation of the child’s gait, regardless of whether the gait evaluation is observational in the clinic or performed in a gait laboratory. The treatment plan should reflect the clinician’s evaluation of muscle strength, muscle tone, structural causes of gait deviation (ie—femoral anteversion, tibial torsion), and the presence of joint contractures. Also, many children have associated conditions that can affect surgical risk or the ability to appropriately recover from surgery.  Confirming that the patient is medically optimized for surgery, that the patient and family are motivated to perform any necessary postoperative rehabilitation and that the family has appropriate access to postoperative rehabilitation are essential components of the treatment plan.

Complications:

Gait analysis alone carries no significant risk to the patient. However, it should be noted that each clinician and each gait analysis laboratory may have different ranges that they believe are “normal” and “abnormal”(Chambers 2002).  This lack of true standardization can mean that a provider in the clinic or a physician reading a formal gait study can offer different treatment suggestions based on their interpretation of the same data. This may lead to significantly different surgical plans, with each surgical intervention carrying its own specific risks for the patient.

Video Resources:

POSNAcademy
Jon David MD - 5 minute clinical gait analysis

References:

 
  1. Data & Statistics for Cerebral Palsy. Available at: https://www.cdc.gov/ncbddd/cp/data.html. Accessed September 1, 2018.
  2. Data and Statistics on Spina Bifida. Available at: https://www.cdc.gov/ncbddd/spinabifida/data.html. Accessed September 1, 2018.
  3. Karol LA: Gait Analysis, in Herring JA (ed) Tachdjian's pediatric orthopaedics : from the Texas Scottish Rite Hospital for Children, ed Fifth edition. Philadelphia, PA: Elsevier Saunders,, 2014, vol 1, pp 2 volumes (xli, 1516, 1146 pages.
  4. Gage JR: The treatment of gait problems in cerebral palsy. London: Mac Keith : Distributed by Cambridge University Press, 2004, pp xiv, 448 p.
  5. Chambers HG, Sutherland DH: A practical guide to gait analysis. J Am Acad Orthop Surg 2002;10:222-231.
  6. Baker R: The history of gait analysis before the advent of modern computers. Gait Posture 2007;26:331-342.
  7. Saunders JB, Inman VT, Eberhart HD: The major determinants in normal and pathological gait. J Bone Joint Surg Am 1953;35-A:543-558.
  8. Perry J: Clinical gait analyzer. Bull Prosthet Res 1974:188-192.
  9. Sutherland DH, Hagy JL: Measurement of gait movements from motion picture film. J Bone Joint Surg Am 1972;54:787-797.
  10. Davids JR, Bagley AM: Identification of common gait disruption patterns in children with cerebral palsy. J Am Acad Orthop Surg 2014;22:782-790.
  11. Nicholson K, Lennon N, Church C, Miller F: Gait Analysis Parameters and Walking Activity Pre- and Postoperatively in Children With Cerebral Palsy. Pediatr Phys Ther 2018;30:203-207.
  12. Boyer ER, Stout JL, Laine JC, et al.: Long-Term Outcomes of Distal Femoral Extension Osteotomy and Patellar Tendon Advancement in Individuals with Cerebral Palsy. J Bone Joint Surg Am 2018;100:31-41.
  13. Jeans KA, Karol LA, Cummings D, Singhal K: Comparison of gait after Syme and transtibial amputation in children: factors that may play a role in function. J Bone Joint Surg Am 2014;96:1641-1647.
  14. Ackman J, Altiok H, Flanagan A, et al.: Long-term follow-up of Van Nes rotationplasty in patients with congenital proximal focal femoral deficiency. Bone Joint J 2013;95-B:192-198.

Top Contributors:

Elizabeth W. Hubbard MD