Gait Lecture 2010 w Narration

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Gait: 

Gait Martin Chisholm BScPT, MScPT, FCAMT Fowler Kennedy Sport Medicine Clinic

The Challenges ... : 

The Challenges ... Movements are small Total calcaneal inv/ev < 10  Movements are fast Stance phase is 62% of gait cycle Normal cadence110-120 steps/min (60 gait cycles) ... 1 cycle/sec Stance phase ≈ 0.60 seconds

Objectives: 

Objectives Understand the purpose of each phase of the gait cycle. Understand what is required to accomplish these. Discuss how to assess these requirements. Observe Gait Biomechanical Scan

Gait: 

Gait What are the primary movements of the hip, knee, ankle, 1 st MTPJ during gait?

Gait: 

Gait What are the primary movements of the hip, knee, ankle, 1 st MTPJ during gait? Flexion and extension (in the sagittal plane)

Stand Up: 

Stand Up Please stand up and walk. You may only flex or extend each joint.

Think outside the sagittal plane: 

Think outside the sagittal plane We do not move exclusively in one plane of motion.

Naming Movements: 

Naming Movements Kitaoka et al, 1995 (Mayo Clinic)

Gait Cycle: 

Gait Cycle Stance Phase Swing Phase Perry, 1992 Kirtley, 2006

Gait Cycle: 

Gait Cycle Perry, 1992 Whittle, 2007

Gait Cycle: 

Gait Cycle Winter, 1985 Kirtley, 2006

Gait Cycle: 

Gait Cycle Loading Phase Midstance Terminal Stance Preswing Initial Swing Midswing Terminal Swing

Loading Phase: 

Loading Phase Initial contact  opposite leg toe off. First period of double limb support Lasts 0% - 12% of gait cycle Adams & Perry, 2006; Kirtley, 2006; Whittle, 2007

Loading Phase: 

Loading Phase Movement occurs around a pivot point centred at the heel Heel = 1 st Rocker

Loading Response: 

Loading Response Michaud, 1993 Whittle, 2007

Transverse Plane Motion: 

Transverse Plane Motion ER IR Pelvis Femur Tibia

Frontal Plane Motion: 

Frontal Plane Motion ADD ABD Femur Tibia

Loading Response - Initial Contact: 

Loading Response - Initial Contact Forces that must be absorbed: Impact (GRF) Internal rotation Adduction

Loading Response - Initial Contact : 

Loading Response - Initial Contact GRF Lateral aspect of calcaneus – lateral to axis of rotation of the STJ

Loading Phase: 

Loading Phase GRF everts the heel IR momentum turns leg in

Loading Phase: 

Loading Phase Absorbs adduction (calcaneus everts, talus adducts). Absorbs internal rotation (talus adducts). Absorbs impact (talus plantar flexes and limb “shortens”)

Loading Phase - Hip: 

Loading Phase - Hip Flexes, then Extends Control internal rotation Control adduction Ext ABD ADD IR ER Flex

Hip: 

Hip Hip extensors control initial GRF, and then stabilize as hip extends

Hip: 

Hip Hip extensors control initial GRF, and then stabilize as hip extends Control internal rotation

Hip: 

Hip Hip extensors control initial GRF, and then stabilize as hip extends Control internal rotation Control adduction

Loading Phase - Knee: 

Loading Phase - Knee At initial contact, the knee is almost fully extended. Initially there is a hyperextension force vector. This quickly changes to a flexion vector.

Knee: 

Knee Flexes Internally Rotates Adducts Flex Ext ER IR ADD ABD

Loading Phase - Knee: 

Loading Phase - Knee Quadriceps Hamstrings TFL Conrols ADD of hip and knee TFL

Loading Phase - Knee: 

Loading Phase - Knee Quadriceps Hamstrings TFL Popliteus Works, then shuts down

Loading Phase - Lateral Stability: 

Loading Phase - Lateral Stability Hip abductors work to control the adduction (not totally eliminate it)

Loading Phase - Ankle/Foot: 

Loading Phase - Ankle/Foot Tibialis Anterior controls the PF Tibialis Posterior controls the pronation with ATFL, Deltoid and Spring ligaments.

Loading Phase – Ankle/Foot: 

Loading Phase – Ankle/Foot Extensors Foot drop Tib. Posterior Control pronation

Loading Phase – Lateral Stability: 

Loading Phase – Lateral Stability Lateral GRF locks up the calcaneocuboid joint into DF, ABD, eversion. Important now and throughout the gait cycle.

Loading Phase - Lateral Stability: 

Loading Phase - Lateral Stability Peroneals quiet. Eversion is passive. Hip abductors and contralateral adductors are working (see later)

Midstance: 

Midstance From foot flat (opposite toe off) to heel rise 2 nd Rocker – pivot around ankle axis 13% - 30% of the gait cycle

Midstance: 

Midstance Period of single limb support Stability challenged by having one limb to use Transition period Ending of absorption phase (pronation) Beginning of propulsion phase (supination)

Midstance - Confusion: 

Midstance - Confusion Some authors simplify matters and say that midstance is the period of single limb support (opposite leg’s swing phase), which includes terminal stance (next phase). From opposite leg toe off Until opposite leg initial contact

Midstance: 

Midstance From foot flat (opposite toe off) to heel rise

Midstance: 

Midstance Period of single limb support Stability challenged by having one limb to use

Midstance – Hip Stability: 

Midstance – Hip Stability Hip abductors work hard to stabilize

Midstance-Knee: 

Midstance-Knee Extending Externally Rotating Flex Ext ER ABD

Midstance - Knee stability: 

Midstance - Knee stability Quads relatively quiet despite knee extending Popliteus active – controlling the ER

Midstance – Knee Stability: 

Midstance – Knee Stability Plantar Flexor – Knee Extensor Couple PFs control the forward momentum Large PF force, keeps GRF anterior to knee. Kirtley, 2006

Midstance – Ankle/Foot Stability: 

Midstance – Ankle/Foot Stability Plantar Flexors Tibialis Posterior Peroneals start

Midstance - Prepare for propulsion: 

Midstance - Prepare for propulsion ER IR Flexion and IR of swinging leg creates ER of stance leg.

Midstance: 

Midstance Internal rotation of swing leg creates ER of stance leg  initiates ABD & DF talus Begins supination of RF RF in neutral by end of Midstance

Terminal Stance : 

Terminal Stance Heel Rise Opposite Leg Initial Contact Still period of single limb support Period of propulsion driven by Plantar flexors Contralateral swing 3 rd rocker – pivot around 1 st MTPJ

Terminal Stance - Hip: 

Terminal Stance - Hip Extended Externally Rotating Abducting Ext ABD ADD IR ER Flex

Terminal Stance Stability: 

Terminal Stance Stability TFL stabilizes laterally

Terminal Stance Stability: 

Terminal Stance Stability TFL stabilizes laterally Hip flexors controlling

Terminal Stance Stability: 

Terminal Stance Stability TFL stabilizes laterally Hip flexors controlling Adductors are beginning to assist in stabilizing (more later)

Terminal Stance Knee: 

Terminal Stance Knee Flexes Quadriceps and Hamstrings quiet, but Popliteus works Flex Ext IR ADD ABD

Terminal Stance – Knee Stability: 

Terminal Stance – Knee Stability Plantar Flexor – Knee Extensor Couple PFs control the forward momentum Large PF force, keeps GRF anterior to knee. In this phase this aids to control the flexion that is occurring. Kirtley, 2006

Terminal Stance - Muscle: 

Terminal Stance - Muscle Plantar flexors active

Terminal Stance Ground Reaction Force: 

Terminal Stance Ground Reaction Force 2 nd Peak in GRF Created by focusing of forces onto FF Occurs prior to toe off

GRF in Knee OA: 

GRF in Knee OA Chen et al, 2003

GRF in PFS: 

GRF in PFS Similar pattern seen in PFS reduced second peak vertical GRF Levinger & Gilleard, 2007 What remains unclear is the relationship between the finding and the condition. Cause or effect?

Terminal Stance Stability: 

Terminal Stance Stability Foot Intrinsics very active

Terminal Stance-Ankle: 

Terminal Stance-Ankle ST joint supinated Ankle plantar flexes

Terminal Stance - Propulsion: 

Terminal Stance - Propulsion Internal rotation of swing leg ER stance leg  ABD & DF talus Continued supination May see “heel whip” or Abductory Twist

Terminal Stance - Propulsion: 

Terminal Stance - Propulsion Once heel begins to lift MTP joints extend Windlass Mechanism Heel inverts RF supinates

Terminal Stance – Propulsion Stability of the FF: 

Terminal Stance – Propulsion Stability of the FF RF supinates Midtarsal axes converge Reduces the sagittal plane PF/DF of the metatarsals (i.e. stabilizes the FF) Blackwood et al, 2005

Terminal Stance – Propulsion 1st Ray Stability: 

Terminal Stance – Propulsion 1 st Ray Stability Eversion of the 1 st Ray is the closed-packed position. Reduced sagittal plane PF/DF ROM if everted. Perez et al, 2008

Terminal Stance - Propulsion: 

Terminal Stance - Propulsion Once heel begins to lift Weight transferred to FF FF must be stable Rearfoot supination 1 st Ray pronation (eversion)

Frontal Plane Motion: 

Frontal Plane Motion Heel Off FF everts while RF inverts EV INV

Terminal Stance - Propulsion: 

Terminal Stance - Propulsion Once heel begins to lift Heel now free to move  ER of leg May see heel whip aka ‘abductory twist’

Terminal Stance Lateral Stability in Propulsion: 

Terminal Stance Lateral Stability in Propulsion Peroneals most active now keeping FF down and everted

Terminal Stance Stability of the 1st Ray: 

Terminal Stance Stability of the 1 st Ray Vital to maintain contact against the GRF Particularly on medial side of foot Peroneus Longus is crucial in this role. Works best if foot supinated Less effective if pronated

Terminal Stance MTP Joints: 

Terminal Stance MTP Joints Convex MT head Concave base of phalanx Sesamoids on 1 st MTP head

Terminal Stance Windlass Mechanism: 

Terminal Stance Windlass Mechanism

Terminal Stance Windlass Mechanism: 

Terminal Stance Windlass Mechanism As the plantar fascia tightens: MT plantar flexes, along with a superior glide at the Cuneiform-MT joint plus a proximal approximation. This induces an anterior subtalar joint glide It also inverts the calcaneus (supination)

Terminal Stance Stability of foot in propulsion: 

Terminal Stance Stability of foot in propulsion RF supination Locks FF Aids efficiency of peroneals FF pronation Locking of 1st Ray Windlass Mechanism Holds arched position Induces further RF supination

Pre-swing: 

Pre-swing Opposite Leg Initial Contact Toe off Technically still a period of stance phase, but quite different Characterized by reduction in WB (loading phase of other leg) Function is to prepare for swing

Pre-swing Ground Reaction Force: 

Pre-swing Ground Reaction Force Just after the 2 nd peak in GRF Release of WB forces Momentum from this PF will PF ankle and flex knee.

Pre-swing - Muscle: 

Pre-swing - Muscle Extensors active Plantar flexors mostly inactive

Pre-swing - Hip: 

Pre-swing - Hip Starts Flexing Externally Rotating Abducting Ext ABD ADD IR ER Flex

Pre-swing Muscle: 

Pre-swing Muscle Hip flexors active

Pre-swing Muscle: 

Pre-swing Muscle Hip flexors active Glute Max and Glute Med active

Pre-swing Muscle: 

Pre-swing Muscle Hip flexors active Glute Max and Glute Med active Adductors active

Pre-swing Muscle: 

Pre-swing Muscle Hamstrings active

Pre-swing Muscle: 

Pre-swing Muscle Hamstrings active Quadriceps

Pre-swing Muscle: 

Pre-swing Muscle Hamstrings active Quadriceps Popliteus

Terminal Stance-Ankle: 

Terminal Stance-Ankle ST joint supinated Ankle plantar flexes

Pre-swing Muscle: 

Pre-swing Muscle Foot Intrinsics still very active

Swing Phase: 

Swing Phase Initial Swing Mid-Swing Terminal Swing

Swing Phase - Highlights: 

Swing Phase - Highlights Foot clearance Creation of Momentum

Initial Swing: 

Initial Swing From toe off to feet adjacent

Initial Swing: 

Initial Swing Hip flexes to 20° Knee flexes to 60° Ankle DFs

Initial Swing-Muscle: 

Initial Swing-Muscle Earlier momentum from hip flexors and plantar flexors crucial. Sartorius most active

Initial Swing-Muscle: 

Initial Swing-Muscle Earlier momentum from hip flexors and plantar flexors crucial. Sartorius most active. Dorsiflexors active

Mid-Swing: 

Mid-Swing From feel adacent to tibia vertical Continued hip flexion Ankle dorsiflexes

Mid-Swing: 

Mid-Swing

Mid-Swing: 

Mid-Swing Hip flexes to 25°-30° Knee begins to extend Ankle DFs to neutral

Mid-Swing-Muscle: 

Mid-Swing-Muscle Generally a quiet period. Hamstrings will work to control the knee extension

Mid-Swing - Muscle: 

Mid-Swing - Muscle Everything is mostly inactive

Terminal Swing: 

Terminal Swing Tibia vertical to initial contact Prepare for landing

Terminal Swing: 

Terminal Swing Hip stays flexed at 25°-30° Knee extends Ankle is dorsiflexed

Terminal Swing-Muscle: 

Terminal Swing-Muscle Glutes fire early in preparation to stabilize.

Terminal Swing-Muscle: 

Terminal Swing-Muscle Adductors Hamstrings Quads

Terminal Swing - Muscle: 

Terminal Swing - Muscle Ankle extensors active again