Searc

O&P Library > Atlas of Limb Prosthetics > Chapter 13

Reproduced with
permission from Bowker
HK, Michael JW (eds):
Atlas of Limb
Prosthetics: Surgical,
Prosthetic, and
Rehabilitation
Principles. Rosemont,
IL, American Academy
of Orthopedic Surgeons,
edition 2, 1992, reprinted
2002.
Much of the
material in
this text has
been updated and
published in Atlas of
Amputations and Limb
Deficiencies: Surgical,
Prosthetic, and
Rehabilitation Principles
(retitled third edition of
Atlas of Limb
Deficiencies),
American Academy or
Orthopedic Surgeons.
Click for more
information about this
text.

Chapter 13 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilit

Principles

Normal Gait
Jacquelin Perry, M.D.

Walking depends on the repeated performance by the lower limbs of a sequ

motions that simultaneously advances the body along the desired line of pro
while also maintaining a stable weight-bearing posture. Effectiveness depen
joint mobility and muscle action that is selective in both timing and intensit
function is also optimally conservative of physiologic energy. Pathologic co
alter the mode and efficiency of walking. The loss of some actions necessit
substitution of others if forward progression and stance stability are to be p
Through a detailed knowledge of normal function and the types of gait erro
various pathologic conditions can introduce, the clinician becomes able to d
significant deficits and plan appropriate corrective measures.

NORMAL GAIT
Gait Cycle

Each sequence of limb action (called a gait cycle) involves a period of weig
(stance) and an interval of self-advancement (swing) (Fig 13-1.
gait cycle approximately 60% of the time is spent in stance and 40% in swi
exact duration of these intervals varies with the walking speed. There also a
differences among individuals.

Funding for
digitization of the Atlas of
Limb Prosthetics was
provided by the Northern
Plains Chapter of the
American Academy of
Orthotists & Prosthetists
Fig 13-1. Actions of the limb in stance
and swing during each gait cycle. The
vertical path of the body's center of
gravity is compared with the horizontal
(dotted line). (From Perry J.: Clin
Orthop 1974; 102:18. Used by
permission.)

You can help expand the

O&P Virtual Library
with a
tax-deductible
contribution.

The reciprocal action of the two limbs is timed to trade their weight-bearing
responsibility during a period of double stance (i.e., when both feet are in c
with the ground) and usually involves the initial and terminal 10% intervals
The middle 40% is a period of single stance (single-limb support). During t
the opposite limb is in swing.
Functional Elements

The three components of walking-progression, standing stability, and energ

conservation-involve distinct functional patterns. These need to be understo
appropriate interpretation of some of the limitations displayed by patients. A
for this description they will be separated, during walking all three action p
intertwined throughout each stride.
Progression
There are two main progressional forces:

1. 1.The primary one is forward fall of the body weight (

in single stance as the ankle dorsiflexes beyond neutral and accelera
heel rise.

2. The second, which is generated by the contralateral swinging limb (

starts with the onset of single-limb support. This action is particular
important before the body is aligned for an effective forward fall.

The momentum generated by these two actions is optimally preserved at th

the next stance phase by floor contact with the heel. As the foot drops towa
floor, the pretibial muscles draw the tibia forward (Fig 13-4.
quadriceps ties the femur to the leg so that the thigh also advances (althoug
slightly slower rate). Thus, throughout the stance period the heel, ankle, and
serially serve as a rocker that allows the body to advance over the supportin
(Fig 13-5.). For this to occur the foot must be appropriately positioned by t
swing and controlled as weight is applied. Then, during the support phases
be adequate passive mobility at the ankle. This necessitates both a free join
ability of the calf muscles to yield as they provide tibial stability.

Fig 13-4. Heel contact and loading

response. The body weight applied
through the tibia creates a rocker about
the point of heel contact that drives the
foot to the floor. As the pretibial muscles
decelerate the foot drop, they also draw
the tibia forward and preserve forward
progression. (From Perry J: Normal and
pathologic gait, in Atlas of Orthotics,
2. St Louis, Mosby-Year Book, 1985, p
77. Used by permission.)

Fig 13-5. Stance mobility. The heel,

ankle, and forefoot rockers allow smooth
progression of the trunk mass across the
stationary foot. (From Perry J: Normal
and pathologic gait, in Atlas of
Orthotics, ed 2. St Louis, Mosby-Year
Book, 1985, p 78. Used by permission.)

Standing Stability

Balance is challenged by two factors. The body is top-heavy, and walking c

alters segment alignment. During walking the body divides itself into two f
units-passenger and locomotor.

The head, arms, and trunk are the passenger unit because they are carried r
directly contributing to the act of walking. Muscle action within the neck an
serves only to maintain neutral vertebral alignment. There is minimal postu
occurring during normal gait. Arm swing is primarily a passive reaction to
momentum generated. The small amount of active control has not proved e
evidenced by the ease with which one carries packages. Also, experimental
of arm swing registers no change in the energy cost of walking.
mass center of these segments is just anterior to the tenth thoracic vertebra
lies well above the hip joints. This long lever (33 cm in an average adult
balance of the passenger unit very sensitive to alignment changes of the sup
limbs.

The locomotor unit consists of two limbs joined by the intervening pelvis. T
the pelvis an element of both the passenger and the locomotor units, with tw
mobile junction sites, the lumbar spine and hip joints.

Theoretically, weight-bearing stability of the limb is maximal when its thre

components (thigh, leg, and foot) are vertically aligned so that one is direct
center of the other. If these segments were square blocks, there would be a
shoulder to allow considerable tilting before balance was lost. Instead, the f
tibia are tall narrow bones. Additionally, the articular surfaces are segments
circle, so there are no restraining rims available in the sagittal plane and,
consequently, no intrinsic stability. The skeletal architecture is designed for
This means that other stabilizing mechanisms are needed. At the hip anterio
the knee posteriorly a strong ligament stabilizes one side of the joint. By us
hyperextension to align body weight on the opposite side, the person is able
passive stability. No similar mechanism exists at the ankle or subtalar joints
Instead, here a free range of dorsiflexion-plantar flexion and in-version-eve
exists. Thus, only through direct muscular control is the tibia stabilized ove
Passive stability is further challenged by the fact that the foot does not prov
areas of support anterior and posterior to the ankle axis. Posteriorly the wei
bearing segment of the heel is little more than 1 cm, for the significant facto
rounded contour of the tuberosities and not the full length of the os calcis. B
contrast, the anterior (forefoot) lever that extends to the weight-bearing sur
metatarsal heads averages 10 cm in an adult. Thus, for optimum foot suppo
anterior and posterior leverages), the body weight line (vector) must be ante
ankle joint. This increases the demand for active control of the ankle and su
joints.

During walking the trunk and limb segments are continually moving from b
ahead of the supporting foot. Thus passive stability is a fleeting experience.
onset of stance, flexion torques are created at the hip and knee that must be
by active muscular effort. As body weight moves forward, this demand is g
replaced by passive support from tense fasciae. Conversely, the demand for
ankle restraint (a plantar flexion force) does not begin until body weight mo
forward of that joint axis. Once the forefoot becomes the major area of supp
muscular response must increase rapidly. Thus the ever-changing alignmen
weight is stabilized by selective muscular control.

The timing and intensity of each muscle's activity are dictated by the relatio
body weight to the center of the joint that muscle controls. This is the torqu
a product of force times leverage. The length of the lever (moment arm) is t
perpendicular distance between the body weight line and each joint center.
weight is the basic force, but its effect is modified by the direction in which
moving. The composite effect is determined by measuring the instantaneou
reaction forces. At the beginning and end of stance, body weight drops rapi
the floor. The resulting accelerations increase the ground reaction force to a
greater than the body weight. During the midstance period the body rises sl
the limb becomes more vertical. This somewhat reduces the weight directed
the ground. Consequently, the force demands presented to the muscles vary
the loading experience and the alignment of body weight over the joints. Se
neural control and proprioception as well as adequate strength are needed f
appropriate muscle response.

O&P Library > Atlas of Limb Prosthetics > Chapter 13

The O&P Virtual Library is a project of the Digital Resource Foundation for the Orthotics & Pro
Community. Contact Us | Contribute