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Dr . Manal Radwan Salim Lecturer of Physical Therapy Pharos University

Pathomechanics of Gait and Dynamic Postures part 2. Dr . Manal Radwan Salim Lecturer of Physical Therapy Pharos University. Determinants of Gait Cont. :. (2) Pelvic Tilt : 5 o dip of the swinging side (i.e. hip adduction) maximum tilt is in mid swing

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Dr . Manal Radwan Salim Lecturer of Physical Therapy Pharos University

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  1. Pathomechanics of Gait and Dynamic Postures part 2 Dr .Manal Radwan Salim Lecturer of Physical Therapy Pharos University

  2. Determinants of Gait Cont. : (2) Pelvic Tilt: 5o dip of the swinging side (i.e. hip adduction) maximum tilt is in mid swing Advantage: Reduces the height of the apex of the curve of COG by 3/8 inch Pathologically: 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.

  3. Determinants of Gait Cont.: (3) Knee flexion in stance phase: in Loading response, midstance Shortens the leg in the middle of stance phase Advantage: Reduces the height of the apex of the curve of COG Pathologically: flexion degree may increases (shorter stance than usual so gives apparent longer swing Or there is limitation in flexion (longer stanced limb i.e affected give problems in other leg stance?!)

  4. Determinants of Gait Cont.: • (4) Ankle Mechanism: • lengthens the leg at heel contact • Advantages: a)Smoothens the curve of COG b)Reduces the lowering of COG

  5. Determinants 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 flexion Advantages: a) Smoothens the curve of COG b) Reduces the lowering of COG

  6. Determinants 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).

  7. Gluteus maximus shows peak activity in IC, LR (i.e. weight acceptance), and TS, some activity in PS( weight release). Weakness in G. Max.: Appears in Early stance: (@ IC, IC-LR). G. Max. contract to prevent jack-knifing i.e. excessive hip flexion) and anterior pelvic tilt. Gluteus Maximus

  8. Gluteus Maximus Cont. Possible Compensation Patient leans trunk backward (so moves GRFV backward). This is called gluteus maximus gait or Lurch gait From 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

  9. In 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 Hip Flexors

  10. Quadriceps shows peak activity in LR (i.e. weight acceptance). Some activity in TS and PS (weight release). Quadriceps In Early stance: Quad. contracts to prevent jack-knifing of knee. Possible Compensation: 1-Patient leans trunk forward (GRFV moves anterior). 2-Pt use arm as quadriceps by placing hand anterior to thigh, presses knee backward. 3-Turn limb outward to lock knee passively.

  11. In Late stance: Quad. contracts to control knee flexion So in case of weakness the knee collapse into flexion leading to -premature flexion into early swing-‘rubber knee’ Quadriceps Cont. In Early stance Cont.: 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.

  12. Hamstrings In 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 TS Weakness in Hamstrings: • In Swing: 1- Inadequate knee flexion. • Late Swing:2-Lack of control of swinging leg • 3- Knee slapped into extension. • In Stance: 4-Reduction of restraining force of heel strike. • 5-Progressive GenuRecarvatum. • Compensation: • 1- Increased hip flexion in swing • 2- Circumduction in swing hip • 3- Hiking with swing pelvis

  13. Ankle dorsi flexors shows peak activity in IC, LR (i.e. weight acceptance). Weakness in DF appears in a) Early stance: (@ IC, IC-LR). DF Contract to control forefoot lowering. After forefoot contacts floor- pull tibia forward over foot. Pre-Tibial group

  14. Pre-Tibial group Cont. 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’ gait • In Swing: 1-Increased hip flexion • ‘high steppage gait’ • 2- Circumduction at hip.

  15. Calf activity in TS and PS, some activity in MS Weakness in calfs appears in late stancemuscles show peak : as it controls dorsi flexion degree in MS and TS ecentrically. Plantar Flexors (Calf muscle) Then contract concentrically to planter flex ankle joint in PS. Effect of Weakness: Loss of forward thrust - poor transition to early swing

  16. Plantar 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 genurecarvatum). 3-Maintain foot flat in TS to eliminate dorsi-flexion moment.

  17. Hip Abductors Gluteus Medius G. Medius contract in mid stance to prevent contra-lateral (swinging) hip from dipping greater than 5 – 80 Effect of weakness/absence Contra-lateral hip drops > 5-80 Compensation is to lean (‘lurch’) over stance-side LE

  18. COMMON GAIT ABNORMALITIES A. Antalgic Gait. B. Lateral Trunk bending. C. Functional Leg-Length Discrepancy. D. Increased Walking Base. E. Inadequate Dorsi flexion Control. F. Excessive Knee Extension.

  19. COMMON 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

  20. COMMON GAIT ABNORMALITIES cont.:B.Lateral Trunk bending’Trendelenberg gait Usually unilateral, if Bilateral = waddling gait Common causes: A. Painful hip B. Hip abductor weakness C. Leg-length discrepancy D. Abnormal hip joint

  21. COMMON GAIT ABNORMALITIES Cont.:C.Functional Leg-Length Discrepancy Swing leg: longer than stance leg: Causes dicussed in details in muscle weakness 4 common compensations: A. Circumduction B. Hip hiking C. Steppage D. Vaulting

  22. COMMON GAIT ABNORMALITIES Cont.:D. Increased Walking Base • Normal walking base: 5-10 cm • Common causes: • Deformities • Abducted hip • Valgus knee • Instability • Cerebellar ataxia • Proprioception deficits

  23. COMMON GAIT ABNORMALITIES Cont.: E. Inadequate Dorsiflexion Control • In stance phase (Heel contact – Foot flat): Foot slap • In swing phase (mid-swing): Toe drag • Causes: • Weak Tibialis Ant. • Spastic plantarflexors

  24. COMMON GAIT ABNORMALITIES:F. Excessive knee extension Loss of normal knee flexion during stance phase Knee may go into hyperextension Genu recurvatum: hyperextension deformity of knee Common causes: Quadriceps weakness (mid-stance) Quadriceps spasticity (mid-stance) Knee flexor weakness (end-stance) * * *

  25. Gait in the Elderly Men - Murray, Kory & Clarkson • Gait was guarded and restrained - attempt to maximal stability and security

  26. Gait in the Elderly Men - Murray, Kory & Clarkson • Gait resembled someone walking on a slippery surface • decreased step & stride legnth • wider dynamic BOS • increased lateral head movement • decreased rotation of pelvis

  27. Gait in the Elderly Men - Murray, Kory & Clarkson • toe/floor clearance distance slightly decreased • lower stance-to-swing ratio • decreased reciprocal arm swing more from elbow than shoulder

  28. Spasticity and its Impact on Gait • Spasticity - resistance to passive stretch

  29. Spasticity & Gait Effects: • Restrict joint excursion • Delay transition from one gait phase to the next

  30. Spasticity & Gait Examples • Quadcriceps • May prevent knee from unlocking during interim between HS and FF • Knee maintained in extension leading to a ‘vaulting’ over stance limb or circumduction of hip • Disrupts (timing) transition to mid- and late stance • May prevent LE bending during swing phase

  31. Spasticity & Gait Examples • Plantar flexors • Increase in spastic tone may limit forward rotation of tibia between MS and PO • May locate ground reaction force well behind knee causing significant flexion moment during late MS and knee buckling tendency • Ankle may be locked up during PO decreasing propulsive thrust forward - inefficient transition from TO to early swing

  32. Spasticity & Gait Examples • Hamstrings • May limit forward swing of LE - decreasing step length • May prevent knee from reaching a terminally extended position just prior to HS

  33. Pathway of GRFV during gait in sagital and frontal plane

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