Presentation on theme: "Pathomechanics of Gait and Dynamic Postures part 2"— Presentation transcript:
1Pathomechanics of Gait and Dynamic Postures part 2 Dr .Manal Radwan SalimLecturer of Physical TherapyPharos University
2Determinants of Gait Cont. : (2) Pelvic Tilt:5o dip of the swinging side (i.e. hip adduction) maximum tilt is in mid swingAdvantage: Reduces the height of the apex of the curve of COG by 3/8 inchPathologically: Pelvis dip increase downward of swing side by weakness of abductors of stance limb. , or even pelvis raised up in swing in any problem leads to functional lengthening the swing limb.
3Determinants of Gait Cont.: (3) Knee flexion in stance phase:in Loading response, midstanceShortens the leg in the middle of stance phaseAdvantage: Reduces the height of the apex of the curve of COGPathologically: flexion degree may increases (shorter stance than usual so gives apparent longer swingOr there is limitation in flexion (longer stanced limb i.e affected give problems in other leg stance?!)
4Determinants of Gait Cont.: (4) Ankle Mechanism:lengthens the leg at heel contactAdvantages: a)Smoothens the curve of COGb)Reduces the lowering of COG
5Determinants of Gait Cont. : (5) Foot mechanism:While knee is flexed the leg is lengthened at toe-off as ankle moves from dorsi flexion to plantar flexionAdvantages: a) Smoothens the curve of COGb) Reduces the lowering of COG
6Determinants of Gait Cont. : (6) Lateral displacement of body:The COG is displaced laterally over the weight bearing extremity twice during gait cycle( the motion produced by horizontal shift of pelvis and relative adduction of hip (max at mid stance).
7Weakness in G. Max.: Appears in Gluteus MaximusGluteus maximus shows peak activity inIC, LR (i.e. weight acceptance), andTS, some activity in PS( weight release).Weakness in G. Max.: Appears inEarly stance: IC, IC-LR).G. Max. contract to prevent jack-knifing i.e. excessive hip flexion) and anterior pelvic tilt.N. Path. GRFVICA to hipLR
8Gluteus Maximus Cont.Possible Compensation Patient leans trunk backward (so moves GRFV backward).This is called gluteus maximus gait or Lurch gaitFrom this we can notice that: If bilateral weakness so The gluteus maximus lurch appears in both early and late stance phases of rt limb and lt limb. If unilateral (rt) so it appears in early stance of rt > in late stance of lt
9Hip FlexorsIn stance its activity starts at terminal stance to preswing and increases to initiate swing .Effect of weakness Toe may not clear the floor during swing “Toe Drag”.Compensation:-circumduction at hip.-Pelvic Hike
10Quadriceps In Early stance: Quad. contracts to prevent Quadriceps shows peak activity in LR (i.e. weight acceptance). Some activity in TS and PS (weight release).In Early stance: Quad. contracts to preventjack-knifing of knee.Possible Compensation: Patient leans trunk forward (GRFVmoves anterior).2-Pt use arm as quadriceps by placing hand anterior to thigh,presses knee backward.N. Path. GRFVLRP. To knee3-Turn limb outward to lock knee passively.
11Quadriceps Cont. In Early stance Cont.: In Late stance: 4- Contact ground with flat planter flexed foot so GRFV moves anterior.5-place a shoe or cushion under heel which causes GRFV to move anteriorly.In Late stance:Quad. contracts to control knee flexionSo in case of weakness the knee collapse into flexion leading to -premature flexion into early swing-‘rubber knee’N. Path. GRFVPSP to knee
12HamstringsIn stance: It show little activity, support back of knee against extension moment of GRFV.In swing: *Assist knee flexion in IS. *Decelerates tibial shank in TSWeakness in Hamstrings:In Swing: 1- Inadequate knee flexion.Late Swing: 2-Lack of control of swinging leg3- Knee slapped into extension.In Stance: 4-Reduction of restraining force of heel strike.5-Progressive Genu Recarvatum.Compensation:1- Increased hip flexion in swing2- Circumduction in swing hip3- Hiking with swing pelvis
13Possible causes When in gait cycle description Gait type Spasticity in Limited ROM, pain , …..Weakness inin early stanceLean trunk backwardG. maximus lurchor spasticity in quadriceps or planter flexorsFlexion of hip, knee or ankleh. Flex, hamstring, dorsiflexorsswingToe dragHip flexors, hamstringcircumductionPelvis hiking
14Possible compensations manifestationWhen in Gait cycleproblemOutward rotate leg to lock it passivelyPlace hand in early stance to push knee backwardLean trunk forward in stanceJack Knifing of kneeICQuad weaknessplace a shoe or cushion under heel so GRFV moves anteriorly.IC with flat planter flexed foot so GRFV moves anterior.Pelvis hikingCircumductionIncresed hip flexion in swingProgressive Genu RecarvatumMid stanceHamstring weaknessReduction of restraining forceof heel strikeKnee slapped into extensiondecelerationIncreased hip flexionmidswing
15Pre-Tibial groupAnkle dorsi flexors shows peak activity in IC, LR (i.e. weight acceptance).Weakness in DF appears ina) Early stance: IC, IC-LR).DF Contract to control forefoot lowering. After forefoot contacts floor- pull tibia forward over foot.N. Path. GRFVICP to ankleLR
16Pre-Tibial group Cont. Compensation: ‘high steppage gait’ b) Swing phase:DF contract concentrically in swing sub phases 1- to lift toe up so prevent toes from dragging on ground.2- functionally shorten swinging limb.Compensation:In stance: no compensation what happen is forefoot slaps to the floor ‘drop-foot’ gaitIn Swing: 1-Increased hip flexion‘high steppage gait’2- Circumduction at hip.
17Plantar Flexors (Calf muscle) Calf activity in TS and PS, some activity in MSWeakness in calfs appears in late stancemuscles show peak : as it controls dorsi flexion degree in MS and TS ecentrically.N. Path. GRFVA. To AnkleMSTSPSThen contract concentrically to planterflex ankle joint in PS.Effect of Weakness:Loss of forward thrust - poor transition to early swing
18Plantar Flexors (calf muscle) Cont. Possible Compensation: 1- Outward rotate hips and pronate foot so inner border contact the ground (flat foot gait or calcaneal gait) 2-Ankle maintained in planter flexion in mid stance to avoid excessive dorsi-flexion ?! (passively by genu recarvatum). 3-Maintain foot flat in TS to eliminate dorsi-flexion moment.
19Hip Abductors Gluteus Medius G. Medius contract in mid stance to prevent contra-lateral (swinging) hip from dipping greater than 5 – 80Effect of weakness/absenceContra-lateral hip drops > 5-80Compensation is to lean (‘lurch’) over stance-side LEN. Path. of GRFVLRMSTsMedial to to hip
21COMMON GAIT ABNORMALITIES Cont.: A. Antalgic Gait -Gait pattern in which stance phase on affected side is shortened-Corresponding increase in stance on unaffected side-Common causes: OA, tendinitis
22Usually unilateral, if Bilateral = waddling gait Common causes: COMMON GAIT ABNORMALITIES cont.: B. Lateral Trunk bending’Trendelenberg gaitUsually unilateral, if Bilateral = waddling gaitCommon causes:A. Painful hip B. Hip abductor weaknessC. Leg-length discrepancy D. Abnormal hip joint
23COMMON GAIT ABNORMALITIES Cont.: C. Functional Leg-Length Discrepancy Swing leg: longer than stance leg:Causes dicussed in details in muscle weakness4 common compensations:A. CircumductionB. Hip hikingC. SteppageD. Vaulting
24COMMON GAIT ABNORMALITIES Cont.: D. Increased Walking Base Normal walking base: 5-10 cmCommon causes:DeformitiesAbducted hipValgus kneeInstabilityCerebellar ataxiaProprioception deficits
25COMMON GAIT ABNORMALITIES Cont.: E. Inadequate Dorsiflexion Control In stance phase (Heel contact – Foot flat):Foot slapIn swing phase (mid-swing):Toe dragCauses:Weak Tibialis Ant.Spastic plantarflexors
26COMMON GAIT ABNORMALITIES: F. Excessive knee extension Loss of normal knee flexion during stance phaseKnee may go into hyperextensionGenu recurvatum: hyperextension deformity of kneeCommon causes:Quadriceps weakness (mid-stance)Quadriceps spasticity (mid-stance)Knee flexor weakness (end-stance)* * *
27Gait in the Elderly Men - Murray, Kory & Clarkson Gait was guarded and restrained - attempt to maximal stability and security
28Gait in the Elderly Men - Murray, Kory & Clarkson Gait resembled someone walking on a slippery surfacedecreased step & stride legnthwider dynamic BOSincreased lateral head movementdecreased rotation of pelvis
29Gait in the Elderly Men - Murray, Kory & Clarkson toe/floor clearance distance slightly decreasedlower stance-to-swing ratiodecreased reciprocal arm swing more from elbow than shoulder
30Spasticity and its Impact on Gait Spasticity - resistance to passive stretch
31Spasticity & Gait Effects: Restrict joint excursion Delay transition from one gait phase to the next
32Spasticity & Gait Examples QuadcricepsMay prevent knee from unlocking during interim between HS and FFKnee maintained in extension leading to a ‘vaulting’ over stance limb or circumduction of hipDisrupts (timing) transition to mid- and late stanceMay prevent LE bending during swing phase
33Spasticity & Gait Examples Plantar flexorsIncrease in spastic tone may limit forward rotation of tibia between MS and POMay locate ground reaction force well behind knee causing significant flexion moment during late MS and knee buckling tendencyAnkle may be locked up during PO decreasing propulsive thrust forward - inefficient transition from TO to early swing
34Spasticity & Gait Examples HamstringsMay limit forward swing of LE - decreasing step lengthMay prevent knee from reaching a terminally extended position just prior to HS
35Pathway of GRFV during gait in sagital and frontal plane StancePhasesSagitalHIP JointKnee JointAnkle JointFrontalHeel StrikeALPNFoot FlatMMid StanceHeel OffToe Off