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C H A P T E R 5 

Gait Analysis Lori A. Karol

the plantigrade foot. Finally, the heel rises at terminal

Chapter Outline stance.
Stance phase can be divided into single-limb support and
Phases of Gait      71 double-limb support phases. There are two periods of
Temporal Parameters      71 double-limb support, when both legs are in contact with the
Neurologic Control of Gait      72 ground at the same time. The first period occurs at initial
Function of Gait      72 contact. The second period of double-limb support occurs
Gait Energy      72 at the end of stance phase just before swing phase as the
Kinematics      73 body weight is shifted onto the other limb and the heel rises
Muscle Activity      74 from the floor in preparation for push-off.

Swing Phase
Observing a child’s gait, whether in a sophisticated comput- Swing phase encompasses three separate periods—initial
erized laboratory or simply in the hallway of a clinic, is an swing, midswing, and terminal swing. Initial swing begins
integral part of the orthopaedic examination. A systematic with toe-off and continues as the foot is raised from the
approach to gait analysis—that is, looking at the trunk and ground and the limb moves forward. Midswing starts as
each joint moving in all three planes (sagittal, coronal, and the swing limb advances past the contralateral stance limb,
transverse)—can yield valuable information about the the knee extends, and the foot travels in a forward-swinging
patient’s condition and help in establishing a treatment arc. Deceleration, or terminal swing, occurs at the end of
plan. For a child’s gait to be examined properly, the patient swing phase as the musculature of the forward-moving
needs to be as unclothed as deemed appropriate. swing limb smoothly stops the limb, preparing for initial
The examination should begin with an assessment of contact with the ground, and the gait cycle is completed.
lower extremity passive range of motion and muscle
strength. The physician should then observe the child
Time Spent in Each Phase
walking from the level of the child—for example, sitting
while examining the gait of small children. Whenever pos- The percentage of time spent in each phase of gait is con-
sible, the child should also be asked to run. There should sistent among normal individuals. As the speed at which a
be adequate space for the child to walk comfortably and person walks increases, the amount of time that is spent in
naturally. A thorough evaluation of the head, trunk, upper double-limb support decreases. During running, double-
extremities, hips, knees, and ankles, with the child viewed limb support disappears and is replaced by double-limb
from the front and side, should be completed. Joint motion float, a period during which neither leg is in contact with
during gait can then be compared with passive range of the ground.40
motion and strength.

Temporal Parameters
Phases of Gait
Distance and time measurements calculated during gait
The gait cycle is divided into two phases, stance and swing analysis are referred to as cadence parameters (Box 5-1).
(Fig. 5-1). Stance phase is defined as the time during which Step length is defined as the distance between the two feet
the limb is in contact with the ground and supporting the during double-limb support and is measured from the heel
weight of the body. Conversely, swing phase is the time of one foot to the heel of the contralateral foot. Step length
when the limb is advancing forward off the ground. During can differ between the right and left sides. Stride length is
swing phase, the advancing limb is not in contact with the the distance one limb travels during the stance and swing
ground and body weight is supported by the contralateral phases. It is measured from the point of foot contact at
limb. Stance phase occupies 60% of the gait cycle and the beginning of stance phase to the point of contact by
swing phase occupies 40%. Both phases can be subdivided the same foot at the end of swing phase. Step time is the
further. amount of time used to complete one step length. Cadence
is the number of steps taken per minute. Walking velocity
is the distance traveled per time (usually measured in
Stance Phase
meters per second). Normal values matched for age are
Stance phase begins when the foot contacts the ground, available for these cadence parameters.54
termed heel strike or initial contact. Next, loading response Small children walk with greater cadence but smaller
occurs as the foot plantar-flexes to the ground and weight step and stride lengths, resulting in many quick, small steps.
is accepted. In midstance, the tibia moves forward over As children grow, their step and stride lengths increase and

72 SECTION I  Disciplines

Weight acceptance Single-limb support Limb advancement
Initial contact Loading response Midstance Terminal stance Preswing Initial swing Midswing Terminal swing

60% 40%

FIGURE 5-1  The gait cycle for the right leg. In stance phase, the foot is in contact with the ground and the limb supports the weight of
the body; in swing phase, the limb advances forward off the ground.

Box 5-1  Cadence Parameters Function of Gait

Step length:  Distance between two feet during double-limb The simplest function of gait is to travel from one point to
support another. Normal ambulation is likened to a controlled
Stride length:  Distance one limb travels during stance and forward fall. The swing limb comes forward to stop the fall
swing phases and accept the weight of the body. The joint motions inher-
Step time:  Time needed to complete one step length ent in normal gait serve this purpose. Body weight is trans-
Cadence:  Number of steps per minute
ferred from one limb to the other in a smooth fashion, and
Walking velocity:  Distance traveled per time (m/sec)
the forward momentum of the body is sustained.

Gait Energy
cadence decreases.3,48,54 Step length increases linearly with
increasing leg length.54 Nomograms have been constructed Although gait is designed to be energy-efficient, bipedal gait
to determine normal cadence parameters for children based is inherently unstable and inefficient. Quadrupeds (e.g.,
on their height.56 dogs) run faster than humans, regardless of size. Their
center of gravity is suspended between the four limbs on
the ground, and the vertebral and trunk muscles act to
Neurologic Control of Gait augment stride. In human gait, the center of gravity is not
balanced between the limbs, nor do the trunk and spinal
The entire neurologic system plays a role in gait. Most of muscles play a significant role in walking.
the muscular actions that occur during gait are programmed To conserve energy, coordinated movements of the joints
as involuntary reflex arcs involving all areas of the brain and of the lower extremities minimize the rise and fall of the
spinal cord. The extrapyramidal tracts are responsible for center of gravity, located just anterior to the second sacral
most complex, unconscious pathways. Miller and Scott pro- vertebra.24 Muscular activity during gait is precisely timed,
posed the concept of the “spinal locomotor generator,” des- and very few concentric contractions of the muscles are
ignated neurons within the spinal cord that are responsible required during normal ambulation. Inertia is used to its
for reflex stepping movements.36 Golgi tendon units, muscle fullest advantage to lessen the work of walking.
spindles, and joint receptors produce neurologic feedback Abnormal deviations in gait can have significant physio-
and serve as dampening devices for the coordination of gait. logic costs and substantially increase the energy required
Voluntary modulation of gait (e.g., altering speed, stepping to walk. Deviations such as a weak muscle, contracted
over an obstacle, changing direction) is made possible joint, or impediment of a cast may change gait enough
through interaction of the motor cortex.25 The cerebellum to increase the metabolic requirements, thereby causing
is important in controlling balance. the individual to tire easily. The amount of energy required
A child’s gait changes as the neurologic system matures.31 to walk can be measured by quantifying oxygen consump-
Infants normally walk with greater hip and knee flexion, tion and oxygen cost.9 Oxygen uptake and oxygen cost
flexed arms, and a wider base of gait than older children. during walking are greater in children younger than 12
As the neurologic system continues to develop in a cepha- years than in teenagers.59 An indirect measure of energy
locaudal direction, the efficiency and smoothness of gait expenditure is the heart rate, which rises as oxygen con-
increase.48 However, when the neurologic system is abnor- sumption increases.44 The physiologic cost index (PCI) is
mal (e.g., in cerebral palsy), the delicate control of gait is calculated using the child’s heart rate and walking speed.6
disturbed, leading to pathologic reflexes and abnormal Repeatability in PCI data ranges in the literature from high
movements. to low.5,6,9
CHAPTER 5  Gait Analysis 73

Table 5-1  Six Determinants of Gait Sagittal Plane

Determinant Strategy In the sagittal plane, the pelvis is tilted anteriorly approxi-
mately 15 degrees (see Fig. 5-2, A). There is minimal
Pelvic rotation Decreases angle between limbs and
motion of the anterior tilt as each leg is advanced forward.
ground, flattens arc of pathway of
center of gravity, allowing stride to
Alterations in pelvic tilt can occur when there are contrac-
lengthen without increasing drop tures of muscles around the hip. For example, if the ham-
of center of gravity at point of strings are tight, the pelvis typically assumes a more posterior
initial contact tilt.
The hip is flexed at initial contact and then extends fully
Pelvic tilt Decreases vertical displacement of
center of gravity by approximately
during stance phase as the body advances over the planted
50% and shortens pendulum of foot (see Fig. 5-2, B). At heel rise and push-off, the hip
limb by knee flexion in swing phase flexes rapidly to pull the stance phase limb off the ground.
The hip continues to flex during swing phase.
Knee flexion Reduces vertical displacement of center
The knee exhibits a more complex pattern (see Fig. 5-2,
after initial of gravity as weight of body is
contact in carried forward over stance limb
C). At initial contact, the knee flexes approximately 15
stance phase degrees, buffering the acceptance of body weight through
knee flexion. The knee then extends during stance phase to
Foot and ankle Smooths out path of center of gravity neutral position or minimal flexion. At heel rise, the knee
motion when coupled with knee motion
begins to flex again, reaching maximal flexion in early swing
Knee motion Smooths out path of center of gravity phase to allow the foot to clear the ground as the limb
when coupled with foot and ankle advances. During the remainder of swing phase, the knee
motion extends passively, using forward momentum. The normal
Lateral Reduces lateral movement of center of kinematics of the knee is disturbed in gait secondary to
displacement gravity toward stance foot during spasticity from cerebral palsy. Deviations range from hyper-
of pelvis gait cycle extension of the knee in stance phase if the heel cord is
tight, to crouch gait, resulting in flexion in stance phase
caused by tight hamstrings, to inability to flex the knee in
In 1953, Saunders and colleagues described the six swing phase caused by inappropriate rectus femoris action.18
determinants of gait whereby the body reduces the amount Ankle sagittal plane kinematics starts with a neutral
of energy required to ambulate (Table 5-1).45 These six ankle at initial contact, when the heel normally strikes the
strategies work in harmony to minimize the rise and fall of ground (see Fig. 5-2, D). The ankle then plantar-flexes 5 to
the center of gravity (vertical displacement) and the side to 10 degrees as the forefoot comes to rest on the ground. This
side motion of the pelvis (horizontal displacement). The plantar flexion is known as first rocker. The ankle dorsiflexes
end result is the establishment of a smooth pathway for the throughout midstance as the tibia moves forward over the
forward progression of the body’s center of gravity during plantigrade foot (second rocker). During third rocker, the
gait. The center of gravity displaces an average of ⅛-inch ankle plantar-flexes and the heel rises to prepare for push-
during gait, with the lowest point at 50% of the gait cycle off (Fig. 5-3). Dorsiflexion of the ankle back to a neutral
during double-limb support.45 position is seen during swing phase to allow for clearing of
An example of these determinants in action is flexion of the foot. In patients with peroneal nerve palsy and foot
the knee coupled to ankle joint motion in stance phase. If drop, dorsiflexion during swing phase is impaired. The indi-
one imagines how much rise and fall is felt when walking vidual compensates by hyperflexing the knee and hip in
with a cylinder cast with knee extension, the contribution swing phase to avoid dragging the toes, a pattern termed
of knee flexion in stance phase (the third determinant) steppage gait.
to minimizing energy required for walking is easily
Coronal Plane
Pelvic obliquity is observed in the coronal plane (see Fig.
Kinematics 5-2, E). Each hemipelvis rises slightly during swing phase to
augment the ability to advance the swing limb. Pelvic rise
Kinematics is defined as the study of the angular rotations must be accompanied by a contralateral fall, so in the stance
of each joint during movement. In simpler terms, kinemat- phase the hemipelvis drops slightly. Accentuated pelvic
ics denotes the motions observed and measured at the obliquity may be seen in patients with limb length discrep-
pelvis, hip, knee, and ankle during the stance and swing ancy, and accentuated pelvic drop in swing phase is seen in
phases of gait (Fig. 5-2). Kinematics can be observed in patients with abductor lurches or Trendelenburg gait (e.g.,
three planes—the sagittal plane (flexion and extension), patients with myelomeningocele).
coronal plane (hip abduction and adduction), and transverse Minimal hip motion in the coronal plane occurs during
plane (rotation of the hips, tibiae, or feet). The data are normal gait (see Fig. 5-2, F). Each hip slightly adducts
collected by the three-dimensional tracking of markers during stance phase and abducts during swing phase. If a
placed over bony landmarks by infrared cameras positioned patient has a scissoring gait, as is often seen in cerebral palsy,
in the gait laboratory. Normal kinematics14 for each plane the adduction is more extreme and may occur throughout
are briefly described in the following sections. the gait cycle, leading to difficulty advancing the swing limb.
74 SECTION I  Disciplines


45 60

Anterior Flexion



Degrees Degrees 20


–10 –20
0 25 50 75 100 0 25 50 75 100
A % Gait cycle B % Gait cycle


75 45
Flexion Dorsiflexion


Degrees 30
Degrees 0


Extension Plantar flexion
–15 –45
0 25 50 75 100 0 25 50 75 100
C % Gait cycle
D % Gait cycle


20 30

Degrees 0 Degrees 0


Down –20
0 25 50 75 100 –30
0 25 50 75 100
E % Gait cycle F % Gait cycle
FIGURE 5-2  Kinematics (joint rotation angle) of the pelvis, hip, knee, and ankle during stance and swing phases of gait in the sagittal and
coronal planes. Stance phase begins at 0% of the gait cycle. Swing phase begins at the dotted vertical line. A, Anterior tilt of the pelvis.
B, Hip flexion and extension. C, Knee flexion and extension. D, Ankle plantar flexion and dorsiflexion. E, Pelvic obliquity rise and fall.
F, Hip adduction and abduction.

at the beach. The normal foot progression angle is approxi-

Transverse Plane
mately 10 to 15 degrees externally (Fig. 5-4).
In the transverse plane, kinematic data measure rotation.
The pelvis and hips rotate minimally during gait. The tibiae
should not exhibit a range of motion but, instead, have Muscle Activity
a mild fixed external rotation. The foot progression angle
is the angle that the foot makes with the path the subject Gait is initiated through muscle activity (Box 5-2). Once
is walking, which can be likened to footprints in the sand started, the transition of the body to a steady gait pattern
CHAPTER 5  Gait Analysis 75

Box 5-2  Muscle Activity During Gait

• Types of muscle contraction:
■ Concentric—generates power and accelerates body

■ Eccentric—slows down and stabilizes joint motions

during gait
• Stance phase—muscles of leg and foot work to stabilize
plantigrade foot
• Swing phase—momentum generated by gastrocsoleus and
hip flexors at terminal stance carries leg forward
Rocker 1 Rocker 2 Rocker 3
FIGURE 5-3  Kinematics of the ankle in the sagittal plane. First
rocker, Ankle plantar-flexes 5 to 10 degrees as the forefoot comes Raw cycle vs. % gait cycle
to rest on the ground; second rocker, ankle then dorsiflexes
71 R. rectus femoris
throughout midstance as the tibia moves forward over the
plantigrade foot; third rocker, ankle then plantar-flexes and the
heel rises to prepare for push-off.
65 R. vastus medialis

56 R. med. hamstrings

227 R. tibialis anterior


231 R. gastrocnemius

221 R. soleus

0 10 20 30 40 50 60 70 80 90 100
Left cycle: 3 Right cycle: 3
FIGURE 5-5  Normal electromyographic patterns of muscle activity
during gait. Initial contact occurs at the left edge of the box, and
the division between the stance and swing phases occurs at 60%
of the gait cycle (vertical line).

patterns are seen in pathologic gait, such as the gait exhib-

Foot progression angle
(approx. 10-15° external)
ited by patients with cerebral palsy.

FIGURE 5-4  Foot progression angle, the angle that the foot makes
Types of Muscle Contraction
with the path on which the subject is walking (often likened to
footprints in the sand). The normal foot progression angle is Two types of muscle contractions occur during gait. A con-
approximately 10 to 15 degrees externally. centric contraction occurs when the muscle shortens,
thereby generating power. An eccentric contraction occurs
when the muscle lengthens, despite electrical contraction.
is accomplished in approximately three steps.35 Gait is Concentric contractions generate power and accelerate the
maintained by a combination of momentum and muscle body forward. Eccentric contractions slow and stabilize
contraction. The presence of electrical activity in the joint motions during gait, thereby minimizing energy
muscles of the lower extremity can be recorded by electro- requirements. Muscles undergoing eccentric contractions
myography during walking. Surface electrodes, which are outnumber those with concentric contractions during gait.
applied to the skin surface for superficial muscles, or needle
electrodes, inserted into the muscle for deeper muscles Concentric Contractions
such as the posterior tibialis, can document the timing of Two large concentric contractions occur at terminal stance.
muscle activity while walking.27,64 There are set patterns to The gastrocsoleus muscle contracts to lift the heel off the
muscle activity observed by electromyography in normal ground and push off. The iliopsoas muscle also contracts
children during gait63 (Fig. 5-5), and these patterns vary concentrically, flexing the hip and pulling the stance phase
with walking velocity.42 Deviations from these normal limb off the ground at terminal stance and early swing. The
76 SECTION I  Disciplines

gastrocsoleus and iliopsoas muscles are believed to be the and foot work to stabilize the plantigrade foot. In swing
two primary accelerators of gait, although controversy exists phase, momentum generated by the gastrocsoleus and hip
as to which muscle contributes more toward forward pro- flexors at terminal stance carries the leg forward. Knee
pulsion of the body.42,52,61 During swing phase, the anterior flexion in early swing, and then extension at terminal swing,
tibialis muscle undergoes a concentric contraction. This dor- occur passively. The main concentric contraction that occurs
siflexes the ankle and provides clearance for the swing foot. during swing phase is that of the anterior tibialis, which
dorsiflexes the foot for easier clearance during swing and
Eccentric Contractions prepositions the foot for initial contact.
Eccentric contractions slow down and smooth joint motions.
The anterior tibialis muscle contracts eccentrically at initial Kinetics
contact, firing despite plantar flexion of the ankle as the foot Kinetics are the forces generated by the muscles and joints
is lowered to the ground. In doing so, the foot is gently during gait. Kinetic data are reported as moments (forces
lowered to the floor and acceptance of body weight can acting about a center of rotation) and powers. These forces
occur gradually. If the anterior tibialis muscle does not fire, can be measured from force plates in a gait analysis labora-
the foot “slaps” to the floor at initial contact. The gastroc- tory. If one knows the motion occurring kinematically at a
soleus contracts eccentrically throughout the second rocker joint and which muscles are active during that period, the
of stance phase, controlling the rate of dorsiflexion of the kinetic forces can be better understood.
ankle as the tibia advances forward over the plantigrade For example, the anterior tibialis fires at initial contact
foot.53 In the absence of normal gastrocsoleus strength, the while the ankle is plantar-flexing to lower the foot to the
ankle dorsiflexes excessively, resulting in poor push-off and ground. The result of this eccentric contraction is power
calcaneus gait.28,46 absorption, the magnitude of which can be measured in the
A powerful eccentric contraction occurring during weight laboratory (Fig. 5-6). The gastrocsoleus fires at terminal
acceptance in stance phase is that of the hip abductors. The stance as the ankle plantar-flexes at push-off. This concen-
abductors of the stance phase limb fire to limit contralateral tric contraction leads to power generation. There are char-
pelvic drop as the swing limb comes off the ground. Mean- acteristic patterns of power generation and absorption at
while, the stance limb hip adducts slightly. If the gluteal each joint (Fig. 5-7).26,41 Kinetics depend on walking veloc-
muscles are weak, they cannot generate a sufficient eccen- ity.13,47,58,61 Kinetics in younger children differ from adult
tric contraction and the hemipelvis of the swing limb drops, kinetics. Differences include diminished ankle plantar
resulting in a Trendelenburg gait. The trunk can compensate flexion moment and power generation and decreased hip
for the pelvic drop by swaying over the stance limb. This abductor movement.10 An adult pattern of kinetics is prob-
brings the center of gravity over the affected hip and lessens ably reached by 5 years of age.40
the pelvic drop. Patients with Trendelenburg gait use more
energy to walk. Pedobarography
Pedobarography is the measurement of plantar pressures
during gait. Using specialized force plates with a high
Muscle Activity During Stance
number of sensors per area, the contact area of the foot and
and Swing Phases
pressure and timing of the pressure can be documented.
More muscle activity occurs during stance phase than during The foot is divided into different segments, termed masks,
swing phase. During stance phase, the muscles of the leg and the pressure in each mask can be studied (Fig. 5-8).


1 3
Pla Gen

Dor Abs
–1 –1
0 25 50 75 100 0 25 50 75 100
A Gait cycle (%) B Gait cycle (%)
FIGURE 5-6  Ankle kinetics graphs showing joint net moments and powers. A, Ankle flexion moment during stance (measured in
newton-meters per kilogram [Nm/kg]). B, Total ankle power (measured in W/kg). Note the burst of power at terminal stance caused
by the concentric contraction of the gastrocsoleus (and the short period of power absorption at initial contact). Abs, Absorption (−);
Gen, generation (+).
CHAPTER 5  Gait Analysis 77

Pressure data for the feet of younger children demonstrate to abnormalities in gait.11,12,43 Pathologic gaits are described
a number of differences compared with those of adults.32 in greater detail in their respective neuromuscular
For example, younger children typically have higher medial chapters.
midfoot pressure, which correlates clinically with lack of
the longitudinal arch of the foot.4
Gait Analysis Laboratories
Pathologic Gait The study of gait in a laboratory dates back to 1957, when
Deviations from normal gait occur in a variety of orthopae- Inman began evaluating joint motion.24 From that start, gait
dic conditions. Disorders that result in muscle weakness analysis was used primarily to document neuromuscular
(e.g., spina bifida, muscular dystrophy), spasticity (e.g., gait, first in patients with poliomyelitis and then in those
cerebral palsy), or contractures (e.g., arthrogryposis) lead with cerebral palsy and myelomeningocele. Over time,
computer software has been developed that allows three-
dimensional analysis. Although most software measures
motion at the pelvis, hip, knee, and ankle, models have been
TOTAL HIP POWER developed to assess motion in smaller joints (i.e., segments
2 of the foot), the upper extremity, and the trunk.34,57
Gait analysis is most often used for preoperative plan-
ning and documentation of postoperative outcome in
patients with cerebral palsy (Fig. 5-9).*
Despite standard methodology, variation is present in data
measured in different laboratories on different days. This

can result in differing surgical or nonsurgical recommenda-

tions in children with cerebral palsy.39 Repeat testing in
children with spasticity on either the same day or on dif-
ferent days shows less reproducibility than in normal
Motion analysis now is also being applied to spinal defor-
mity,29 and it has been used as an outcome measurement
0 25 50 75 100 for evaluating surgical treatment of nonneurologic orthopae-
% Gait cycle
FIGURE 5-7  Kinetics graph of hip power (measured in W/kg).
Note the burst of power generation at terminal stance as the
iliopsoas pulls the leg off the ground. Abs, Absorption (−); *References 7, 8, 11, 15-17, 31, 38, 55, 62.

Gen, generation (+). References 2, 14, 22, 28, 30, 37, 49, 51, 60.

FIGURE 5-8  Pedobarograph of right foot with equinocavovarus deformity. A, Pressure mapping shows excessive weight bearing
underneath the fifth metatarsal base and head. B, Improved pressure distribution after plantar fascia release, posterior tibialis lengthening,
Achilles tendon lengthening, first metatarsal osteotomy, and split anterior tibialis tendon transfer. C, Before surgery, initial contact (green
dot) occurs in the lateral forefoot. D, After surgery, initial contact occurs at the heel (red square) and the center of pressure progresses
normally to the second toe.
78 SECTION I  Disciplines

FIGURE 5-9  Six-year-old boy with spastic diplegia undergoing gait analysis. Markers are used to collect kinematic data; electromyographic
data are being simultaneously gathered.

dic conditions, such as clubfeet, fractures, and degenerative nontechnical means of quantifying gait deviations, such as
joint arthritis.† the functional mobility scale and observational gait scale,
Research in motion analysis continues in the fields of and the use of video gait analysis have been proposed for
arthroplasty, prosthetics,1 and orthotics,23 stimulating the use in the clinical setting.19-21,33
development of newer products and lending a scientific
basis to new and innovative designs.
Although gait analysis can provide data regarding joint
movement and gait dysfunction, it is time-consuming and
not readily available in many orthopaedic centers. Other For References, see expertconsult.com. 
CHAPTER 5  Gait Analysis 78.e1

References 26. Kadaba MP, Ramakrishnan HK, Wootten ME: Measurement of

lower extremity kinematics during level walking, J Orthop Res
1. Ashley RK, Vallier GT, Skinner SR: Gait analysis in pediatric lower 8:383, 1990.
extremity amputees, Orthop Rev 21:745, 1992. 27. Kadaba MP, Wootten ME, Gainey J, et al: Repeatability of phasic
2. Asperheim MS, Moore C, Carroll NC, et al: Evaluation of residual muscle activity: performance of surface and intramuscular wire
clubfoot deformities using gait analysis, J Pediatr Orthop B 4:49, electrodes in gait analysis, J Orthop Res 3:350, 1985.
1995. 28. Karol LA, Concha MC, Johnston CE 2nd: Gait analysis and muscle
3. Beck RJ, Andriacchi TP, Kuo KN, et al: Changes in the gait patterns strength in children with surgically treated clubfeet, J Pediatr
of growing children, J Bone Joint Surg Am 63:1452, 1981. Orthop 17:790, 1997.
4. Bertsch C, Unger H, Winkelmann W, et al: Evaluation of early 29. Khodadadeh S, Eisenstein SM: Gait analysis of patients with low
walking patterns from plantar pressure distribution measurements. back pain before and after surgery, Spine 18:1451, 1993.
First-year results of 42 children, Gait Posture 19:235, 2004. 30. Kitaoka HB, Wikenheiser MA, Shaughnessy WJ, et al: Gait abnor-
5. Boyd R, Fatone S, Rodda J, et al: High- or low-technology measure- malities following resection of talocalcaneal coalition, J Bone Joint
ments of energy expenditure in clinical gait analysis? Dev Med Surg Am 79:369, 1997.
Child Neurol 41:676, 1999. 31. Lee EH, Goh JC, Bose K: Value of gait analysis in the assessment
6. Butler P, Engelbrecht M, Major RE, et al: Physiological cost index of surgery in cerebral palsy, Arch Phys Med Rehabil 73:642, 1992.
of walking for normal children and its use as an indicator of physi- 32. Liu XC, Thometz JG, Tassone C, et al: Dynamic plantar pressure
cal handicap, Dev Med Child Neurol 26:607, 1984. measurement for the normal subject: free-mapping model for the
7. Chang FM, Rhodes JT, Flynn KM, et al: The role of gait analysis analysis of pediatric foot deformities, J Pediatr Orthop 25:103,
in treating gait abnormalities in cerebral palsy, Orthop Clin North 2005.
Am 41:489, 2010. 33. Mackey AH, Lobb GL, Walt SE, et al: Reliability and validity of
8. Chang FM, Seidl AJ, Muthusamy K, et al: Effectiveness of instru- the Observational Gait Scale in children with spastic diplegia, Dev
mented gait analysis in children with cerebral palsy—comparison Med Child Neurol 45:4, 2003.
of outcomes, J Pediatr Orthop 26:612, 2006. 34. MacWilliams BA, Cowley M, Nicholson DE: Foot kinematics and
9. Corry IS, Duffy CM, Cosgrave AP, et al: Measurement of oxygen kinetics during adolescent gait, Gait Posture 17:214, 2003.
consumption in disabled children by the Cosmed K2 portable 35. Mann RA, Hagy JL, White V, et al: The initiation of gait, J Bone
telemetry system, Dev Med Child Neurol 38:585, 1996. Joint Surg Am 61:232, 1979.
10. Cupp T, Oeffinger D, Tylkowski C, et al: Age-related kinetic 36. Miller S, Scott PD: The spinal locomotor generator, Exp Brain Res
changes in normal pediatrics, J Pediatr Orthop 19:475, 1999. 30:387, 1977.
11. De Luca PA: Gait analysis in the treatment of the ambulatory child 37. Mittlmeier T, Morlock MM, Hertlein H, et al: Analysis of mor-
with cerebral palsy, Clin Orthop Relat Res 264:65, 1991. phology and gait function after intraarticular calcaneal fracture,
12. Duffy CM, Hill AE, Cosgrove AP, et al: Three-dimensional gait J Orthop Trauma 7:303, 1993.
analysis in spina bifida, J Pediatr Orthop 16:786, 1996. 38. Narayanan UG: Management of children with ambulatory cerebral
13. Eng JJ, Winter DA: Kinetic analysis of the lower limbs during palsy: an evidence-based review, J Pediatr Orthop 32(Suppl
walking: what information can be gained from a three-dimensional 2):S172, 2012.
model? J Biomech 28:753, 1995. 39. Noonan KJ, Halliday S, Browne R, et al: Interobserver variability
14. Fowler E, Zernicke R, Setoguchi Y, et al: Energy expenditure of gait analysis in patients with cerebral palsy, J Pediatr Orthop
during walking by children who have proximal femoral focal defi- 23:279, 2003.
ciency, J Bone Joint Surg Am 78:1857, 1996. 40. Ounpuu S: The biomechanics of running: a kinematic and kinetic
15. Gage JR: Gait analysis. An essential tool in the treatment of cere- analysis, Instr Course Lect 39:305, 1990.
bral palsy, Clin Orthop Relat Res 288:126, 1993. 41. Ounpuu S, Gage JR, Davis RB: Three-dimensional lower extrem-
16. Gage JR: The clinical use of kinetics for evaluation of pathologic ity joint kinetics in normal pediatric gait, J Pediatr Orthop 11:341,
gait in cerebral palsy, Instr Course Lect 44:507, 1995. 1991.
17. Gage JR, De Luca PA, Renshaw TS: Gait analysis: principle and 42. Perry J: Kinesiology of lower extremity bracing, Clin Orthop Relat
applications with emphasis on its use in cerebral palsy, Instr Course Res 102:18, 1974.
Lect 45:491, 1996. 43. Rao S, Dietz F, Yack HJ: Kinematics and kinetics during gait in
18. Gage JR, Perry J, Hicks RR, et al: Rectus femoris transfer to symptomatic and asymptomatic limbs of children with myelome-
improve knee function of children with cerebral palsy, Dev Med ningocele, J Pediatr Orthop 32:106, 2012.
Child Neurol 29:159, 1987. 44. Rose J, Gamble JG, Medeiros J, et al: Energy cost of walking in
19. Graham HK, Harvey A, Rodda J, et al: The Functional Mobility normal children and in those with cerebral palsy: comparison of
Scale (FMS), J Pediatr Orthop 24:514, 2004. heart rate and oxygen uptake, J Pediatr Orthop 9:276, 1989.
20. Grunt S, van Kampen PJ, van der Krogt MM, et al: Reproducibility 45. Saunders JB, Inman VT, Eberhart HD: The major determinants of
and validity of video screen measurements of gait in children with normal and pathological gait, J Bone Joint Surg Am 35:543, 1953.
spastic cerebral palsy, Gait Posture 31:489, 2010. 46. Segal LS, Thomas SE, Mazur JM, et al: Calcaneal gait in spastic
21. Harvey A, Gorter JW: Video gait analysis for ambulatory children diplegia after heel cord lengthening: a study with gait analysis,
with cerebral palsy: why, when, where and how! Gait Posture J Pediatr Orthop 9:697, 1989.
33:501, 2011. 47. Stansfield BW, Hillman SJ, Hazlewood ME, et al: Sagittal joint
22. Hilding MB, Lanshammar H, Ryd L: A relationship between kinematics, moments, and powers are predominantly character-
dynamic and static assessments of knee joint load. Gait analysis ized by speed of progression, not age, in normal children, J Pediatr
and radiography before and after knee replacement in 45 patients, Orthop 21:403, 2001.
Acta Orthop Scand 66:317, 1995. 48. Statham L, Murray MP: Early walking patterns of normal children,
23. Hirsch G, McBride ME, Murray DD, et al: Chopart prosthesis and Clin Orthop Relat Res 79:8, 1971.
semirigid foot orthosis in traumatic forefoot amputation. Com- 49. Steenhoff JR, Daanen HA, Taminiau AH: Functional analysis of
parative gait analysis, Am J Phys Med Rehabil 75:283, 1996. patients who have had a modified Van Nes rotationplasty, J Bone
24. Inman VT: Conservation of energy in ambulation, Bull Prosthet Res Joint Surg Am 75:1451, 1993.
26:9, 1968. 50. Steinwender G, Saraph V, Scheiber S, et al: Intrasubject repeat-
25. Joseph J: Neurological control of locomotion, Dev Med Child ability of gait analysis data in normal and spastic children, Clin
Neurol 27:822, 1985. Biomech 15:134, 2000.
78.e2 SECTION I  Disciplines

51. Sucato DJ, Tulchin K, Shrader MW, et al: Gait, hip strength and 58. van der Linden ML, Kerr AM, Hazlewood ME, et al: Kinematic
functional outcomes after a Ganz periacetabular osteotomy for and kinetic gait characteristics of normal children walking at a
adolescent hip dysplasia, J Pediatr Orthop 30:344, 2010. range of clinically relevant speeds, J Pediatr Orthop 22:800, 2002.
52. Sutherland D: An electromyographic study of the plantar flexors 59. Waters RL, Hislop HJ, Thomas L, et al: Energy cost of walking in
of the ankle in normal walking on the level, J Bone Joint Surg Am normal children and teenagers, Dev Med Child Neurol 25:184,
48:66, 1966. 1983.
53. Sutherland DH, Cooper L, Daniel D: The role of the ankle 60. Westhoff B, Martiny F, Reith A, et al: Computerized gait analysis
plantar flexors in normal walking, J Bone Joint Surg Am 62:354, in Legg-Calve-Perthes disease—analysis of the sagittal plane, Gait
1980. Posture 35:541, 2012.
54. Sutherland DH, Olshen R, Cooper L, et al: The development of 61. Winter DA: Energy generation and absorption at the ankle and
mature gait, J Bone Joint Surg Am 62:336, 1980. knee during fast, natural, and slow cadences, Clin Orthop Relat
55. Thomason P, Selber P, Graham HK: Single Event Multilevel Res 175:147, 1983.
Surgery in children with bilateral spastic cerebral palsy: a 5-year 62. Winters TF Jr, Gage JR, Hicks R: Gait patterns in spastic hemiple-
prospective cohort study, Gait Posture 37:23, 2013. gia in children and young adults, J Bone Joint Surg Am 69:437,
56. Todd FN, Lamoreux LW, Skinner SR, et al: Variations in the gait 1987.
of normal children. A graph applicable to the documentation of 63. Wootten ME, Kadaba MP, Cochran GV: Dynamic electromyogra-
abnormalities, J Bone Joint Surg Am 71:196, 1989. phy. II. Normal patterns during gait, J Orthop Res 8:259, 1990.
57. Tulchin K, Orendurff M, Karol L: A comparison of multi-segment 64. Young CC, Rose SE, Biden EN, et al: The effect of surface and
foot kinematics during level overground and treadmill walking, internal electrodes on the gait of children with cerebral palsy,
Gait Posture 31:104, 2010. spastic diplegic type, J Orthop Res 7:732, 1989.