Gait Analysis
Gait observation is often the first and most revealing part of a lower limb examination. Examiners expect you to systematically describe the gait cycle, identify common abnormal patterns (antalgic, Trendelenburg, foot drop), and correlate findings with underlying pathology. Always observe gait BEFORE proceeding to focused examination.
Quick Reference One-Pager
Observation
- Walking aids
- Overall pattern and rhythm
- Stride length and cadence
- Arm swing
- Posture and trunk position
Gait Cycle Phases
- Stance phase (60%): Heel strike → Loading → Midstance → Terminal stance → Pre-swing
- Swing phase (40%): Initial swing → Mid-swing → Terminal swing
Common Pathological Gaits
- Antalgic (painful)
- Trendelenburg (abductor weakness)
- Short leg gait
- Foot drop (steppage)
- Spastic gait (scissoring)
Examination Sequence
- Observe from front, side, behind
- Test heel and toe walking
- Tandem walking (balance)
- Single leg stance (30 seconds)
Introduction and Setup
Before You Start
Environment Requirements:
- Adequate space for walking (at least 10 meters if possible)
- Good lighting
- Flat, firm surface
- Patient appropriately undressed (shorts and bare feet ideal)
Consent Script: "I'd like to watch you walk. Please walk at your normal pace to the end of the room and back. Then I'll ask you to do some additional walking tests."
Equipment:
- Note any walking aids (stick, frame, crutches)
- Footwear should be observed initially, then removed
- Orthotics noted
Normal Gait Cycle
Phases of Gait
One gait cycle = Heel strike to next heel strike of same foot
STANCE PHASE (60% of cycle):
- Initial Contact (Heel Strike): Heel contacts ground
- Loading Response: Weight transfer to limb
- Midstance: Single limb support, body passes over foot
- Terminal Stance (Heel Off): Heel rises, push-off begins
- Pre-swing (Toe Off): Toes leave ground
SWING PHASE (40% of cycle):
- Initial Swing: Foot clears ground
- Mid-swing: Limb passes under body
- Terminal Swing: Limb extends for next heel strike
Key Parameters:
- Cadence: Steps per minute (normal: 100-120)
- Stride length: Distance between successive heel strikes of same foot (normal: 1.4m)
- Step length: Distance between heel strike of one foot and next foot
- Step width: Distance between feet (normal: 5-10cm)
- Walking speed: Normal approximately 1.4 m/s
Determinants of Gait (Saunders): Six mechanisms that minimize vertical and lateral displacement of the center of mass, making gait energy-efficient:
- Pelvic rotation
- Pelvic tilt
- Knee flexion in stance
- Foot mechanism (ankle motion)
- Knee mechanism
- Lateral pelvic displacement
Systematic Observation
Observe:
- Arm swing (asymmetry, absence)
- Trunk position and sway
- Pelvic drop (Trendelenburg)
- Knee alignment (varus thrust, valgus thrust)
- Foot progression angle (in-toeing, out-toeing)
- Foot position at heel strike
Pathological Gait Patterns
Pain-Related Gaits
- description
- Short stance phase on affected side
- mechanism
- Reduces time weight-bearing on painful limb
- causes
- OA, fracture, infection, any painful lower limb condition
- description
- Leg held in extension, circumduction
- mechanism
- Avoids painful/impossible knee/hip flexion
- causes
- Knee arthritis, hip arthritis, fusion
- description
- Abnormal foot placement
- mechanism
- Avoids pressure on painful area
- causes
- Plantar fasciitis, metatarsalgia, ulcer
Weakness-Related Gaits
- description
- Pelvis drops on swing side
- mechanism
- Hip abductor weakness (gluteus medius)
- causes
- Hip OA, post-THR, L5 palsy, DDH, polio
- description
- Trunk shifts OVER affected hip
- mechanism
- Moves center of mass over affected hip
- causes
- Same as Trendelenburg
- description
- High stepping, foot slaps
- mechanism
- Weak ankle dorsiflexion, compensatory hip/knee flexion
- causes
- L5 palsy, common peroneal palsy, HSMN
- description
- Trunk thrown backward at heel strike
- mechanism
- Weak hip extension
- causes
- Muscular dystrophy, polio
- description
- Hand on thigh, knee hyperextension
- mechanism
- Prevents knee collapse
- causes
- Femoral nerve injury, muscular dystrophy
Neurological Gaits
- description
- Circumduction, arm held flexed
- mechanism
- Spasticity, weakness, loss of selectivity
- causes
- Stroke, TBI
- description
- Crouched, internally rotated, adducted hips
- mechanism
- Bilateral spasticity (adductors, hamstrings)
- causes
- Cerebral palsy
- description
- Wide-based, lurching, irregular
- mechanism
- Impaired coordination
- causes
- Cerebellar lesion, alcohol, MS
- description
- Stamping, wide-based, worse with eyes closed
- mechanism
- Proprioceptive loss
- causes
- Peripheral neuropathy, posterior column lesion
- description
- Shuffling, festinating, reduced arm swing
- mechanism
- Rigidity, bradykinesia
- causes
- Parkinson's disease
- description
- Side-to-side trunk sway
- mechanism
- Bilateral hip abductor weakness
- causes
- Muscular dystrophy, bilateral hip disease
Structural Gaits
- description
- Pelvic dip, vaulting on long side
- mechanism
- Compensate for leg length discrepancy
- causes
- LLD from any cause
- description
- Lateral thrust of knee into varus
- mechanism
- Lateral compartment collapse or ligament insufficiency
- causes
- Medial compartment OA, lateral ligament laxity
- description
- Medial thrust of knee into valgus
- mechanism
- Medial compartment collapse or ligament insufficiency
- causes
- Lateral compartment OA, medial ligament laxity
- description
- Knee hyperextension in stance
- mechanism
- Quadriceps weakness or compensation
- causes
- Polio, stroke, quadriceps weakness
Special Walking Tests
Special test
Heel Walking
Test ankle dorsiflexors (L4,5 - tibialis anterior)
Technique
- 1Ask patient to walk on heels only
- 2Observe for ability to maintain position
Positive Sign
Unable to walk on heels, foot drops
Indicates
L5 weakness, common peroneal nerve palsy, foot drop
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Toe Walking
Test ankle plantarflexors (S1,2 - gastrocnemius/soleus)
Technique
- 1Ask patient to walk on toes only
- 2Observe for ability to maintain position
Positive Sign
Unable to rise or maintain position on toes
Indicates
S1 weakness, Achilles rupture, gastrocnemius weakness
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Tandem Walking (Heel-to-Toe)
Test balance and cerebellar function
Technique
- 1Ask patient to walk in straight line placing heel directly in front of toes
- 2Observe for stability
Positive Sign
Unable to maintain balance, veering to one side
Indicates
Cerebellar dysfunction, vestibular dysfunction, sensory ataxia
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Single Leg Stance (Flamingo Test)
Test hip abductor function (Trendelenburg)
Technique
- 1Patient stands on affected leg for 30 seconds
- 2Observe pelvis from behind
Positive Sign
Pelvis drops on unsupported (swing) side
Indicates
Hip abductor weakness (gluteus medius dysfunction)
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Special test
Romberg Test
Differentiate sensory from cerebellar ataxia
Technique
- 1Patient stands with feet together, arms by sides
- 2Observe with eyes open, then closed for 30 seconds
Positive Sign
Able to balance with eyes open but falls/sways with eyes closed
Indicates
Sensory (proprioceptive) ataxia - relies on vision for balance
Diagnostic Accuracy
Ability to detect true positives
Ability to exclude false positives
Cerebral Palsy Gait Patterns
CP Gait Classification (Common Patterns)
Hemiplegic CP (Winters Classification):
- Type I: Drop foot only (ankle)
- Type II: Drop foot + equinus (ankle + knee)
- Type III: Equinus + knee recurvatum (ankle + knee + hip)
- Type IV: Stiff knee + hip involvement (global)
Diplegic CP (Common Patterns):
- True equinus: Ankle plantarflexion, knee extension
- Jump gait: Equinus + knee flexion + hip flexion
- Apparent equinus: Hip and knee flexion cause relative equinus
- Crouch gait: Excessive knee flexion (most severe)
Complete the Examination
Always state to the examiner:
"To complete my gait assessment, I would like to:
- Perform focused examination of the relevant joint(s) identified
- Conduct neurological examination of the lower limbs
- Assess leg length formally
- Examine footwear for wear pattern
- Consider video gait analysis if complex (CP, multiplanar deformity)"
Summary Presentation
“65-year-old woman walks into clinic with obvious limp.”
Common Conditions by Gait Pattern
- gait
- Antalgic + Trendelenburg
- observation
- Short stance, trunk shift, reduced ROM
- confirmWith
- Hip examination, X-ray
- gait
- Antalgic + varus/valgus thrust
- observation
- Stiff, thrust on loading
- confirmWith
- Knee examination, X-ray
- gait
- High-stepping (foot drop)
- observation
- Foot slaps at heel strike, circumduction
- confirmWith
- Neurological exam, nerve conduction
- gait
- Subtle foot drop + Trendelenburg
- observation
- Weak dorsiflexion and hip abduction
- confirmWith
- Lumbar spine exam, MRI
- gait
- Pelvic obliquity, vaulting
- observation
- Asymmetric stance, short side dips
- confirmWith
- Leg length measurement, block test
Gait in Children
Developmental Milestones
- Milestone
- Independent walking begins
- Milestone
- Running, heel-toe pattern emerging
- Milestone
- Heel strike present, arm swing developing
- Milestone
- Adult gait pattern mature
Normal Variants (Physiological):
- Flat feet (arch develops by 6 years)
- In-toeing/out-toeing (often resolves by 8 years)
- Genu varum (bowed legs, normal under 2 years)
- Genu valgum (knock knees, normal 3-6 years)
Pathological (Require Investigation):
- Asymmetric gait
- Pain
- Progressive deformity
- Delay beyond expected correction age
- Associated symptoms (weakness, stiffness)
Examiner Tips
Do
- Observe systematically from all angles
- Use correct terminology
- Correlate gait with pathology
- Test heel and toe walking
- Note walking aids and their use
Don't
- Jump straight to joint examination without observing gait
- Forget to observe arm swing
- Miss subtle Trendelenburg
- Confuse terminology (Trendelenburg vs compensation)
- Forget neurological causes of gait abnormality