Systematic Gait Assessment
Whether a physical therapist is performing a cervical evaluation or ankle evaluation, analyzing a patient's gait pattern should be a standard aspect of every examination. The information gathered during this functional assessment will allow the clinician to quickly make educated decisions regarding the patient's overall presentation. For example, if the patient has a compensated Trendelenburg during the stance phase of gait, one can assume the strength or motor control of the Gluteus Medius is insufficient. One's ability to recognize these patterns will ultimately differentiate a novice clinician from an expert.
GAIT ANALYSIS CONSIDERATIONS
(Each statement below can be due to a number of reasons. I have chosen to include some of the more common clinical short cuts I use. Feel free to add others in the comment box.)
1) Weight bearing equally through both legs
2) Equal and adequate hip extension bilaterally
If the patient does not demonstrate adequate hip extension while ambulating, it is important to assess the strength of the gluteals and/or length of the hip flexors. Clinically, strong/dominant hip flexors will limit a patient's full hip extension.
3) Trunk control during single limb loading
While watching a patient walk, does the torso remain relatively neutral? A common fault often seen in patient's with low back pain is excessive pelvic motion or rotation through the spine. This impairment may indicate poor motor control of the core muscles or poor lumbopelvic rhythm. If this is noted, further motor control testing should be performed.
4) Lacking ankle and knee motion
If a patient lacks ankle dorsiflexion, they may compensate by out-toeing their foot or going into an early heel rise. In either situation, the gastroc muscle is not being utilized throughout the full range of motion. The compensation at the ankle can create achilles issues, knee pain due to the added stress on the quadriceps muscle, or low back pain.
5) Trendelenburg or compensated Trendelenburg
The ability to remain upright through the hips will demonstrate the strength or motor control of the outer hip muscles. When either a Trendelenburg or compensated Trendelenburg is observed, it is important to assess gluteus medius strength. Additionally, this sign can be an indication to assess lumbar mobility, specifically lumbar side bending. The poor gluteal performance will often cause the low back to load asymmetrically with each step.
6) Knee valgus during single limb stance
Observing knee valgus during the gait assessment is another indication for assessing gluteal strength. Knee valgus is typically accompanied by femoral internal rotation and adduction, both signs of inadequate gluteal muscle or hip external rotation activation. Additionally, knee valgus is common in people who over pronate.
7) Excessive pronation or supination
Since I mentioned pronation above, it is important to monitor for excessive supination as well. When supination is noted throughout the gait pattern, it may indicate joint mobility restrictions in great toe extension, subtalar eversion and/or restrictions in hip internal and external range of motion.
Final Movement Advice:
When analyzing one's gait pattern, be sure to be systematic. Either perform the assessment from top-down or vice versa. Look for common substitutions first, then verify these impairments during your joint-by-joint examination! Identifying these common movement substitutions will make you a more efficient clinician. Repeated clinical efficiency will create excellence!
Jim Heafner PT, DPT, OCS