ASSESSMENT OF GAIT

The clinician begins the gait assessment with an overall look at the patient while they walk and noting the
cadence, stride length, step length, and velocity. The arm swing during gait also should be observed. If an
individual has a problem with the foot or ankle on one side, the opposite arm swing often is decreased. The
patient is observed from head to toe and then back again, from the side, from the front, and then from the back.
In addition to observing the patient walking at his or her normal pace, the clinician should observe the patient
walking at varying speeds. This can be achieved by asking the patient to change walking speed.

Gait is assessed by having the patient walk barefoot, and with footwear. Barefoot walking provides
information about foot function without support and can highlight compensations, such as excessive pronation,
and foot deformities, such as claw toes. Having the patient walk with footwear can provide information about
the effectiveness of the footwear to counteract the compensations. The patient should be asked to walk on the
toes, and then on the heels. An inability to perform either of these actions could be the result of pain, weakness,
or a motion restriction. Metatarsalgia is indicated if the metatarsal heads are made more painful with barefoot
walking. Pain at initial contact may indicate a heel spur, bone contusion, calcaneal fat pad injury, or bursitis.

The patient’s footwear is examined for patterns of wear. The greatest amount of wear on the sole of the shoe
should occur beneath the ball of the foot, and in the area corresponding to the first, second, and third
metatarsophalangeal joints, and slight wear to the lateral side of the heel. The upper portion of the shoe should
demonstrate a transverse crease at the level of the metatarsophalangeal joints. A stiff first metatarsophalangeal
joint can produce a crease line that runs obliquely, from forward and medial to backward and lateral. Scuffing
of the shoe might indicate tibialis anterior weakness or adaptively shortened heel cords.

The patient’s foot also is examined for callus formation, blisters, corns, and bunions. Callus formation on
the sole of the foot is an indicator of dysfunction and provides the clinician with an index to the degree of shear
stresses applied to the foot, and a clear outline of abnormal weight-bearing areas. Adequate amounts of calluses
may provide protection, but in excess amounts they may cause pain. Callus formation under the second and
third metatarsal heads could indicate excessive pronation in a flexible foot, or Morton’s neuroma if just under
the former. A callus under the fifth, and sometimes the fourth, metatarsal head may indicate an abnormally rigid
foot. The patient is asked to walk in his or her usual manner and at the usual speed.
Anterior View
When observing the patient from the front, the clinician can note the following:
• Head position. The subject’s head should not move too much during gait in a lateral or vertical direction
and should remain fairly stationary during the gait cycle.
• Amount of lateral tilt of the pelvis.
• Amount of lateral displacement of the trunk and pelvis.
• Whether there is excessive swaying of the trunk or pelvis.
• Amount of vertical displacement. Vertical displacement can be assessed by observing the patient’s
head. A “bouncing” gait is characteristic of adaptively shortened gastrocnemii, or increased tone of the
gastrocnemius and soleus.
• Reciprocal arm swing. Movements of the upper trunk and limbs usually occur in the opposite directions
to the pelvis and the lower limbs.
• Whether the shoulders are depressed, retracted, or elevated.
• Whether the elbows are flexed or extended.
• Amount of hip adduction or abduction that occurs. Causes of excessive adduction include an excessive
angle of the coxa vara, hip abductor weakness, hip adductor contracture or spasticity, and contralateral
hip abduction contracture. Excessive hip abduction may be caused by an abduction contracture, a short
leg, obesity, impaired balance, or hip flexor weakness.
• Amount of valgus or varus at the knee.
• Width of the base of support.
• Degree of “toe-out.” The term toe-out refers to the angle formed by the intersection of the line of
progression of the foot and the line extending from the center of the heel through the second metatarsal.
The normal toe-out angle is approximately 7 degrees, and this angle decreases as the speed of gait
increases.
• Whether any circumduction of the hip occurs. Hip circumduction can indicate a leg-length
discrepancy, decreased ability of the knee to flex, or hip abductor shortening or overuse.
• Whether any hip hiking occurs. Hip hiking can indicate a leg-length discrepancy, hamstring weakness,
or shortening of the quadratus lumborum.
• Evidence of thigh atrophy.
• Degree of rotation of the whole lower extremity. Because positioning the lower extremity in external
rotation decreases the stress on the subtalar joint complex, an individual with a foot or ankle problem
often adopts this position during gait. Excessive internal or external rotation of the femur can indicate
adaptive shortening of the medial or lateral hamstrings, respectively, resulting in anteversion or
retroversion, respectively.
Lateral View

• Amount of thoracic and shoulder rotation. Each shoulder and arm should swing reciprocally, with equal
motion.
• Orientation of trunk. The trunk should remain erect and level during the gait cycle as it moves in the
opposite direction to the pelvis. Compensation can occur in the lumbar spine for a loss of motion at the hip.
A backward lean of the trunk may result from weak hip extensors or inadequate hip flexion. A forward lean
of the trunk may result from pathology of the hip, knee, or ankle; abdominal muscle weakness; decreased
spinal mobility; or hip flexion contracture. Forward leaning during the loading response and early midstance
intervals may indicate hip extensor weakness.
• Orientation of the pelvic tilt. An anterior pelvic tilt of 10 degrees is considered normal. Excessive anterior
tilting can be caused by weak hip extensors, hip flexion contracture, or hip flexor spasticity. Excessive
posterior pelvic tilting during gait usually occurs in the presence of hip flexor weakness.
• Degree of hip extension. Causes of inadequate hip extension and excessive hip flexion include hip flexion
contracture, iliotibial band contracture, hip flexor spasticity, or pain. Causes of inadequate hip flexion may
include hip flexor weakness or hip joint arthrodesis.
• Knee flexion and extension. The knee should be extended during the initial contact interval, followed by
slight flexion during the loading response interval. During the swing period, there must be sufficient knee
flexion. Causes of excessive knee flexion and inadequate knee extension include inappropriate hamstring
activity, knee flexion contracture, soleus weakness, and excessive ankle plantar flexion. Causes of
inadequate flexion and excessive extension at the knee include quadriceps weakness, pain, quadriceps
spasticity, excessive ankle plantar flexion, hip flexor weakness, and knee extension contractures. Individuals
with genu recurvatum may have a functional strength deficit in the quadriceps muscle or gastrocnemius that
allows knee hyperextension.
• Ankle dorsiflexion and plantar flexion. During midstance, the ankle dorsiflexes and the body pivots over
the stationary foot. At the end of the stance period, the ankle should be seen to plantar flex to raise the heel.
At the beginning of the swing period, the ankle is plantar flexed, moving into dorsiflexion as the swing
period progresses and reaching a neutral position at the time of heel contact at the termination of the swing.
Excessive plantar flexion in midswing, initial contact, and loading response may be caused by pretibial
(especially the anterior tibialis) weakness. Excessive plantar flexion also may be caused by plantar flexion
contracture, soleus and gastrocnemius spasticity, or weak quadriceps. Excessive dorsiflexion may be caused
by soleus weakness, ankle fusion, or persistent knee flexion during the midstance period.
• Stride length of each limb.
• Cadence. The cadence should be normal for the patient’s age
• Heel rise. An early heel rise indicates an adaptively shortened Achilles tendon. Delayed heel rise may
indicate a weak gastrocnemius-soleus complex.
• Heel contact. A low heel contact during initial contact may be caused by plantar flexion contracture, tibialis
anterior weakness, or premature action by the calf muscles.
• Preswing. An exaggerated preswing is manifested by the patient walking on the toes. Causes include pes
equines deformity, adaptive shortening or increased tone of the triceps surae, weakness of the dorsiflexors,
and knee flexion occurring at midstance. A decreased preswing is often characterized by a lack of plantar
flexion at terminal stance and preswing. Causes for this can include ankle or foot pain or weakness of the
plantar flexor muscles.

Posterior View
• Amount of subtalar inversion (varus) or eversion (valgus). Excessive inversion and eversion usually relate
to abnormal muscular control. Generally speaking, varus tends to be the dominant dysfunction in spastic
patients, whereas valgus tends to be more common with flaccid paralysis.
• Base of support.
• Pelvic list.
• Degree of hip rotation. As in standing, excessive femoral internal rotation past the midstance of gait will
accentuate genu recurvatum. Causes of excessive external hip rotation may include gluteus maximus
overactivity and excessive ankle plantar flexion. Causes of excessive internal hip rotation include medial
hamstring overactivity, hip adductor overactivity, anterior abductor overactivity, and quadriceps weakness.
• Amount of hip adduction or abduction.
• Amount of knee/ tibial rotation.