Normal and abnormal gait

Normal Gait cycle

• Series of rhythmical , alternating movements of the trunk & limbs which
result in the forward progression of the body
Phases of gait
• Stance phase
• Swing phase
Stance Phase
• It begins at the instant that one
extremity contacts the ground &
continuous only as long as some
portion of the foot is in contact
with the ground.
• It is approximately 60% of
normal gait duration.
Swing Phase
• It begins as soon as the toe of
one extremity leaves the ground
& ceases just before heel strike
or contact of the same
extremity.
• It makes up 40% of normal gait
cycle.
Stance phase

• Entire period during which the foot is on the ground

• Begins with initial contact : heel strike and ends with toe off
stage
Heel strike : heel strikes ground
Foot flat : foot flat on ground
Mid stance : foot flat, hip & knee are in extension
Heel off : heel off the ground, active extension of hip & knee
Toe off : last event, toes off the floor
 Gait Cycle - Subdivisions:

A. Stance phase:
1. Heel contact: ‘Initial contact’
2. Foot-flat: ‘Loading response’, initial contact of forefoot w. ground
3. Midstance: greater trochanter in alignment w. vertical bisector of foot
4. Heel-off: ‘Terminal stance’
5. Toe-off: ‘Pre-swing’
Variables Affected During Gait Cycle
Pelvic rotation
• pelvis rotates 4 degrees medially (anteriorly) on swing side
• lengthens the limb as it prepares to accept weight

Pelvic tilt
• pelvis drops 4 degrees on swing side
• lowers COG at midstance

Knee flexion in stance

• early knee flexion (15 degrees) at heel strike
• lowers COG, decreasing energy expenditure
• also absorbs shock of heel strike

Foot mechanisms
• ankle plantar flexion at heel strike and first part of stance
Knee mechanisms
• at midstance, the knee extends as the ankle plantar flexes and foot supinates
• restores leg to original length
• reduces fall of pelvis at opposite heel strike

Lateral displacement of pelvis

• pelvis shifts over stance limb
• COG must lie over base of support (stance limb)

Center of gravity (COG)

• in standing position is 5cm anterior to S2 vertebral body
• vertical displacement
• during gait cycle COG displaces vertically in a rhythmic pattern
• the highest point is during midstance phase
• lowest point occurs at the time of double limb support
• horizontal displacement
• COG displaces 5cm horizontally during adult male step
Swing Phase

• When foot is NOT contacting the ground, it is swinging!

• Begins with toe off and ends with heel strike
• Limb advancement phase
• 3 parts of swing phase:
Accelaration : leg swings forward aided by hip flexors
Mid swing
Deceleration : leg slows down- preparing for heel
strike
Gait Cycle - Subdivisions:

B. Swing phase:
1. Acceleration: ‘Initial swing’
2. Midswing: swinging limb overtakes the limb in stance
3. Deceleration: ‘Terminal swing’
Prerequisites(basic) for normal gait
• Normal joints
• Stable, oriented congruently & have normal ROM
• Normal muscle tone and muscle power
• Coordinated cortical control of voluntary muscle action
Clinical analysis of gait

• Should be analysed without knowledge of patient

• Legs adequately exposed
• Bare feet walking
• Patient to walk away from and then towards him
Abnormal gait
Abnormal gait

Antalgic gait
• Due to pain
• Patient avoids weight bearing on affected side
• Stance phase is reduced : e.g. Osteoarthritis

Scissors gait
• One leg crosses over the other
• Adductor spasm e.g.Cerebral palsy
 Abnormal gait
Trendelenberg gait
• Dynamic equivalent of Trendelenberg test
• Causes
- Weakness of hip abductors
- # Neck of femur
- Dislocation or destruction of the hip
Negative

Positive
Abnormal gait
High stepping gait
• Slapping gait
• Foot lifted unusually high to clear ground
e.g. common peroneal nerve palsy, lumbar
nerve root lesion

Waddling gait
• Duck like gait
• Increased lumbar lordosis
• Body sways from side to side
• Normal : pregnancy
• Abnormal : b/l Developmental Dysplasia of
Hip, myopathy
Abnormal gait

In toe gait
• Toes are pointing inwards
• Causes
• Anteversion of femoral neck
• Metatarsus adductus

Gluteus maximus gait

• Evident during the mid-stance phase
• Patient leans back at the hip to passively extend it
e.g.Gluteus maximus weakness as seen in poliomyelitis
 Abnormal gait
Short limb gait
• Marked pelvic tilt
• Trunk dips down each time patient is
in the stance phase of the shortened
limb

Quadriceps gait
• Syn: hand on thigh / hand to knee gait
• Cause : quadriceps weakness (e.g. polio)
• Patient locks his knee into extension by pushing
his hand over the front of lower end of thigh
Synovial Fluid Analysis
INTRODUCTION
Synovial fluid analysis is also known as joint fluid analysis. It helps
diagnose the cause of joint inflammation.

Composition : Synovial fluid is made of hyaluronic acid and lubricin,

proteinases, and collagenases.
INDICATIONS
• Acute joint swelling after injury
• Acute atraumatic synovitis in adults
• Suspected infection
• Chronic synovitis
Acute joint swelling after injury
The distinction between synovitis and bleeding may not be obvious

Acute atraumatic synovitis in adults

Synovial fluid analysis may be the only way to distinguish between infection, gout
and pseudogout. Characteristic crystals can be identified on polarized light
microscopy.

Suspected infection
Joint aspiration is essential for early diagnosis. Examination and lab investigations
takes longer time

Chronic synovitis
Joint aspiration is less urgent, and is only one of many diagnostic procedures in the
investigation of suspected tuberculosis or atypical rheumatic disorders.
PROCEDURE
1. Under strict aseptic conditions
2. Infiltrate skin with local anaesthetia
3. 20-gauge needle is introduced
4. Sample of joint fluid is aspirated
• Even a small quantity of fluid (less of 0.5ml)
is enough for diagnostic analysis
TECHNIQUE
1. Observe immediately volume and appearance of fluid
Normal : Clear and slightly yellow
Cloudy/ Turbid : Presence of cells (signs of inflammation)
Blood-stained : Due to injury/ acute inflammatory disorders/
pigmented villonodular synovitis
2. Single drop of fresh synovial fluid is placed on a glass slide
3. Examine under microscope
Possible : Blood cells, abundant leucocytes, crystals (light microscope)
4. Dry smears are prepared with heparinized fluid, more concentrated
specimens can be obtained if the fluid is centrifuged.

5. After suitable straining (Wright’s and Gram’s), the smear is examined

for pus cells and organisms.
*negative findings do not exclude infection
LABORATORY TESTS
1. Enough fluid, send to investigate for Cells, biochemistry and bacteriology
culture

2. Simultaneous blood specimen allows comparison of synovial glucose

concentration.
- Glucose : infection

3. White cell count < 10000/mm3 : infection, gout or inflammatory arthritis

4. Bacteriological culture and tests for antibiotic sensitivity are essential in

any case of suspected infection
 EXAMINATION OF SYNOVIAL FLUID
SUSPECTED APPEARANCE VISCOSITY WHITE CELLS CRYSTALS BIOCHEMISTRY BACTERIOLOGY
CONDITION
Normal Clear yellow High Few - As for plasma -
Septic arthritis Purulent Low + - Glucose low +
Tuberculous Turbid Low + - Glucose low +
arthritis
Rheumatoid Cloudy Low ++ - - -
arthritis
Gout Cloudy Normal ++ Urate - -
Pseudogout Cloudy Normal + Pyrophyosphate - -
Osteoarthritis Clear yellow High Few Often+ - -