Dụng Cụ Chỉnh Hình Và Chân Tay Giả Trong Phục Hồi Chức Năng (Ấn Bản Thứ 3)

92
Section I  Building Baseline Knowledge
Title
Authors
Journal
Partial hand amputation and work
Burger H, Maver T, Marincek C
Disabil Rehabil 2007;29(17):1317-21
Prosthetic rehabilitation of persons with lower limb amputations
due to tumour
Kauzlaric N, Kauzlaric KS, Kolundzic R
Eur J Cancer Care 2007;16(3):238-43
Posttraumatic finger reconstruction with microsurgical transplantation
of toes
Wallace CG, Wei FC
Hand Clin 2007;23(1):117-28
Skin problems in lower limb amputees: an overview by case reports
Meulenbelt HE, Geertzen JH, Dijkstra PU, Jonkman MF
J Eur Acad Dermatol Venereol
2007;21(2):147-55
Complex limb salvage or early amputation for severe lower-limb
injury: a meta-analysis of observational studies
Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ,
Bhandari M
J Orthop Trauma 2007;21(1):70-6
Peripheral arterial disease
Aronow WS
Geriatrics 2007;62(1):19-25
Best practice in the assessment and management of diabetic
foot ulcers
Delmas L
Rehabil Nurs 2006;31(6):228-34
Intermittent claudication
Cassar K
BMJ 2006;333(7576):1002-5
Physical capacity and walking ability after lower limb amputation:
a systematic review
van Velzen JM, van Bennekom CA, Polomski W,
Slootman JR, van der Woude LH, Houdijk H
Clin Rehabil 2006;20(11):999-1016
Lower extremity reconstruction
Heller L, Kronowitz SJ
J Surg Oncol 2006;94(6):479-89
Prosthetic rehabilitation for older dysvascular people following
a unilateral transfemoral amputation
Cumming JC, Barr S, Howe TE
Cochrane Database Syst Rev
2006;(4):CD005260
Reviews Published from 2006 to July 2011, Identified by Searching PubMed Electronic Research Database Using Search Terms “Limb Amputation AND Rehabilitation”
and with the limits: a) review and b) English—cont'd

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
93
APPENDIX 4-2
Examples of Clinical Practice Guidelines Available from the National Guideline Clearinghouse ()
Title
NGC#
Sponsoring Professional Organization(s)
SEARCH TERMS: ORTHOSIS OR ORTHOTIC AND REHABILITATION
Best evidence statement (BESt). Lower extremity orthoses for children with hemiplegic
cerebral palsy.
NGC:007670
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Diagnosis and management of Duchenne muscular dystrophy, part 2: implementation
of multidisciplinary care.
NGC:007681
DMD Care Considerations Working Group - Independent Expert Panel
Heel pain - plantar fasciitis: clinical practice guidelines linked to the International
Classification of Functioning, Disability, and Health from the Orthopaedic Section
of the American Physical Therapy Association.
NGC:007274
The Orthopaedic Section of the American Physical Therapy Association,
Inc. - Medical Specialty Society
Clinical practice guidelines for gait training.
NGC:005309
Ottawa Panel - Independent Expert Panel
Best evidence statement (BESt). Intensive partial body weight supported treadmill
training.
NGC:008168
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Evidence-based care guideline for therapy management of congenital muscular
torticollis in children age 0 to 36 months.
NGC:007301
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Improving outcomes for people with sarcoma.
NGC:004878
National Collaborating Centre for Cancer - National Government Agency
[Non-U.S.]
Diagnosis and treatment of forefoot disorders. Section 2. Central metatarsalgia.
NGC:007478
American College of Foot and Ankle Surgeons - Medical Specialty Society
Guideline for the evidence-informed primary care management of low back pain.
NGC:007704
Institute of Health Economics - Nonprofit Research Organization; Toward
Optimized Practice - State/Local Government Agency [Non-U.S.]
VA/DoD clinical practice guideline for the management of stroke rehabilitation.
NGC:008250
American Heart Association - Professional Association; American Stroke
Association - Disease Specific Society; Department of Defense - Federal
Government Agency [U.S.]; Department of Veterans Affairs - Federal
Government Agency [U.S.]; Veterans Health Administration - Federal
Government Agency [U.S.]
European Federation of Neurological Societies/Peripheral Nerve Society guideline
on management of chronic inflammatory demyelinating polyradiculoneuropathy:
report of a joint task force of the European Federation of Neurological Societies
and the Peripheral Nerve Society – first revision.
NGC:007904
European Federation of Neurological Societies - Medical Specialty Society;
Peripheral Nerve Society - Disease Specific Society
Osteoporosis and fracture prevention in the long-term care setting.
NGC:007637
American Medical Directors Association - Professional Association
VA/DoD clinical practice guideline for rehabilitation of lower limb amputation.
NGC:006060
Department of Defense - Federal Government Agency [U.S.]; Department
of Veterans Affairs - Federal Government Agency [U.S.]; Veterans Health
Administration - Federal Government Agency [U.S.]
Ankle & foot (acute & chronic).
NGC:008511
Work Loss Data Institute - For Profit Organization.
(Continued)

94
Section I  Building Baseline Knowledge
Title
NGC#
Sponsoring Professional Organization(s)
Rehabilitation. In: Clinical guidelines for stroke management 2010.
NGC:008108
National Stroke Foundation (Australia) - Nonprofit Organization
Occupational therapy practice guidelines for adults with traumatic brain injury.
NGC:007509
American Occupational Therapy Association, Inc. - Professional
Association
Diagnosis and treatment of forefoot disorders. Section 4. Tailor's bunion.
NGC:007480
American College of Foot and Ankle Surgeons - Medical Specialty Society
Evidence-based care guideline for serial casting of the lower extremity.
NGC:007161
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Management of patients with stroke: rehabilitation, prevention and management of
complications, and discharge planning. A national clinical guideline.
NGC:007955
Scottish Intercollegiate Guidelines Network - National Government
Agency [Non-U.S.]
Evidence-based care guideline for pediatric constraint induced movement therapy (CIMT).
NGC:007162
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
EFNS guideline on diagnosis and management of limb girdle muscular dystrophies.
NGC:006935
European Federation of Neurological Societies - Medical Specialty Society
Occupational therapy practice guidelines for adults with neurodegenerative diseases.
NGC:007508
American Occupational Therapy Association, Inc. - Professional
Association
Diabetic foot disorders: a clinical practice guideline.
NGC:005270
American College of Foot and Ankle Surgeons - Medical Specialty Society
Pressure ulcer prevention and treatment. Health care protocol.
NGC:007847
Institute for Clinical Systems Improvement - Nonprofit Organization
Management of diabetes. A national clinical guideline.
NGC:007892
Scottish Intercollegiate Guidelines Network - National Government
Agency [Non-U.S.]
Metastatic spinal cord compression. Diagnosis and management of adults at risk
of and with metastatic spinal cord compression.
NGC:007194
National Collaborating Centre for Cancer - National Government
Agency [Non-U.S.]
Clinical practice guideline for the management of rheumatoid arthritis in Spain.
NGC:006691
Advanced Research Techniques in the Health Services - For Profit
Research Organization; Spanish Society of Rheumatology - Medical
Specialty Society
Traumatic brain injury: diagnosis, acute management and rehabilitation.
NGC:005397
New Zealand Guidelines Group - Nonprofit Organization
SEARCH TERMS: PROSTHESIS OR AMPUTATION AND REHABILITATION
VA/DoD clinical practice guideline for rehabilitation of lower limb amputation.
NGC:006060
Department of Defense - Federal Government Agency [U.S.]; Department
of Veterans Affairs - Federal Government Agency [U.S.]; Veterans Health
Administration - Federal Government Agency [U.S.]
ACR Appropriateness Criteria® imaging after total knee arthroplasty.
NGC:005538
American College of Radiology - Medical Specialty Society
The diagnosis of periprosthetic joint infections of the hip and knee.
NGC:007976
American Academy of Orthopaedic Surgeons (AAOS) - Medical
Specialty Society
Chronic wounds of the lower extremity.
NGC:005966
American Society of Plastic Surgeons - Medical Specialty Society
Long-term follow-up guidelines for survivors of childhood, adolescent, and young
adult cancers. Sections 107-132: surgery.
NGC:007572
Children's Oncology Group - Medical Specialty Society
Ankle & foot (acute & chronic).
NGC:008511
Work Loss Data Institute - For Profit Organization
Examples of Clinical Practice Guidelines Available from the National Guideline Clearinghouse ()—cont'd

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
95
Shoulder (acute & chronic).
NGC:008320
Work Loss Data Institute - For Profit Organization
Surgical site infection: prevention and treatment of surgical site infection.
NGC:006827
National Collaborating Centre for Women's and Children's Health -
National Government Agency [Non-U.S.]
American Academy of Orthopaedic Surgeons clinical guideline on prevention
of symptomatic pulmonary embolism in patients undergoing total hip or knee
arthroplasty.
NGC:005665
American Academy of Orthopaedic Surgeons (AAOS) - Medical Specialty
Society
Improving outcomes for people with sarcoma.
NGC:004878
National Collaborating Centre for Cancer - National Government
Agency [Non-U.S.]
Clinical practice guideline for the management of rheumatoid arthritis in Spain.
NGC:006691
Advanced Research Techniques in the Health Services - For Profit
Research Organization; Spanish Society of Rheumatology - Medical
Specialty Society
Diabetic foot disorders: a clinical practice guideline.
NGC:005270
American College of Foot and Ankle Surgeons - Medical Specialty Society
ACR Appropriateness Criteria claudication — suspected vascular etiology.
NGC:007810
American College of Radiology - Medical Specialty Society
(1) Reducing foot complications for people with diabetes. (2) Reducing foot
complications for people with diabetes 2007 supplement.
NGC:006572
Registered Nurses' Association of Ontario - Professional Association
Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome.
NGC:008311
Work Loss Data Institute - For Profit Organization
Warfarin therapy - management during invasive procedures and surgery.
NGC:008152
Medical Services Commission, British Columbia - National Government
Agency [Non-U.S.]
ACR Appropriateness Criteria® acute shoulder pain.
NGC:007928
American College of Radiology - Medical Specialty Society
Prevention of venous thrombosis.
NGC:006599
Finnish Medical Society Duodecim - Professional Association
VA/DoD clinical practice guideline for the management of stroke rehabilitation.
NGC:008250
American Heart Association - Professional Association; American Stroke
Association - Disease Specific Society; Department of Defense - Federal
Government Agency [U.S.]; Department of Veterans Affairs - Federal
Government Agency [U.S.]; Veterans Health Administration - Federal
Government Agency [U.S.]
Palliative treatment of cancer.
NGC:005820
Finnish Medical Society Duodecim - Professional Association. View all
guidelines by the developer(s) Compare Selected
EFNS guidelines on neurostimulation therapy for neuropathic pain.
NGC:005909
European Federation of Neurological Societies - Medical Specialty Society
NKF-KDOQI clinical practice guidelines for vascular access: update 2006.
NGC:005331
National Kidney Foundation - Disease Specific Society
Guideline for management of wounds in patients with lower-extremity arterial disease.
NGC:006521
Wound, Ostomy, and Continence Nurses Society - Professional Association
Assessment and management of stage I to IV pressure ulcers.
NGC:005793
Registered Nurses' Association of Ontario - Professional Association

96
Section I  Building Baseline Knowledge
APPENDIX 4-3
Results of Search Using PEDro Database*
Type of Study
Title
Authors
Source
Clinical Practice
Guideline
Non-drug treatment (excluding surgery) in rheumatoid
arthritis: Clinical practice guidelines
Forestier R, Andre-Vert J, Guillez P,
Coudeyre E, Lefevre-Colau MM,
Combe B, Mayoux-Benhamou MA
Joint Bone Spine 2009;76(6):691-698
Systematic Review
Foot orthoses for patellofemoral pain in adults
Hossain M, Alexander P, Burls A,
Jobanputra P
Cochrane Database Syst Rev
2011;Issue 1
Systematic Review
The efficacy of foot orthoses in the treatment of individuals
with patellofemoral pain syndrome: a systematic review
Barton CJ, Munteanu SE, Menz HB,
Crossley KM
Sports Med 2010;40(5):377-395
Systematic Review
Non-surgical interventions for paediatric pes planus
Rome K, Ashford RL, Evans A
Cochrane Database Syst Rev
2010;Issue 7
Systematic Review
Does the use of orthoses improve self-reported pain and
function measures in patients with plantar fasciitis?
A meta-analysis
Lee SY, McKeon P, Hertel J
Phys Ther Sport 2009;10(1):12-18
Systematic Review
Rehabilitation interventions for foot drop in neuromuscular
disease
Sackley C, Disler PB, Turner-Stokes L,
Wade DT, Brittle N, Hoppitt T
Cochrane Database Syst Rev
2009;Issue 3
Systematic Review
Diagnosis and management of deformational plagiocephaly
Robinson S, Proctor M
J Neurosurg Pediatr 2009;3(4):284-295
Systematic Review
The real risks of steroid injection for plantar fasciitis, with a
review of conservative therapies
Tatli YZ, Kapasi S
Curr Rev Musculoskel Med 2009;19;2(1):3-9
Systematic Review
Evaluation of the scope and quality of systematic reviews
on nonpharmacological conservative treatment for
patellofemoral pain syndrome
Barton CJ, Webster KE, Menz HB
J Orthopaed Sports Phys Ther
2008;38(9):529-541
Systematic Review
Review of selected physical therapy interventions for school
age children with disabilities
Effgen SK, McEwen IR
Phys Ther Rev 2008;13(5):297-312
Systematic Review
Efficacy of ankle-foot orthoses on gait of children with
cerebral palsy: systematic review of literature
Figueiredo EM, Ferreira GB, Moreira RCM,
Kirkwood RN, Fetters L
Pediatr Phys Ther 2008;20(3):207-223
Systematic Review
Custom-made foot orthoses for the treatment of foot pain
Hawke F, Burns J, Radford JA, du Toit V
Cochrane Database Syst Rev
2008;Issue 3
Systematic Review
Effectiveness of foot orthoses for treatment and prevention
of lower limb injuries: a review
Hume P, Hopkins W, Rome K, Maulder P,
Coyle G, Nigg B
Sports Med 2008;38(9):759-779
Systematic Review
Exercise therapy and orthotic devices in rheumatoid
arthritis: evidence-based review
Oldfield V, Felson DT
Curr Opin Rheumatol 2008;20(3):353-359

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
97
Systematic Review
Treatment for Charcot-Marie-Tooth disease
Young P, de Jonghe P, Stogbauer F, Butterfass-
Bahloul T
Cochrane Database Syst Rev
2008;Issue 1
Systematic Review
Head shape measurement standards and cranial orthoses in
the treatment of infants with deformational plagiocephaly
McGarry A, Dixon MT, Greig RJ,
Hamilton DR, Sexton S, Smart H
Dev Med Child Neurol 2008;50(8):568-576
Systematic Review
Interventions for the prevention and treatment of pes cavus
Burns J, Landorf KB, Ryan MM, Crosbie J,
Ouvrier RA
Cochrane Database Syst Rev
2007;Issue 4
Systematic Review
An evaluation of research evidence for selected physical
therapy interventions for plantar fasciitis
de vera Barredo R, Menna D, Farris JW
J Phys Ther Sci 2007;19(1):41-56
Systematic Review
A systematic review of the efficacy of gait rehabilitation
strategies for spinal cord injury
Lam T, Eng JJ, Wolfe DL, Hsieh JTC,
Whittaker M
Topics Spinal Cord Inj Rehabil
2007;13(1):32-57
Systematic Review
Evaluating interventions to improve gait in cerebral palsy:
a meta-analysis of spatiotemporal measures
Paul SM, Siegel KL, Malley J, Jaeger RJ
Dev Med Child Neurol 2007;49(7):542-549
Systematic Review
Effectiveness of upper and lower limb casting and orthoses in
children with cerebral palsy: an overview of review articles
Autti-Ramo I, Suoranta J, Anttila H,
Malmivaara A, Makela M
Am J Phys Med Rehabil 2006;85(1):89-103
Systematic Review
A critical review of foot orthoses in the rheumatoid
arthritic foot
Clark H, Rome K, Plant M, O'Hare K, Gray J
Rheumatology 2006;45(2):139-145
Systematic Review
A review of the literature pertaining to KAFOs and HKAFOs
for ambulation
Fatone S
J Prosthet Orthot 2006;18(3 S):137-168
Systematic Review
Conservative therapy for plantar fasciitis: a narrative review
of randomized controlled trials
Stuber K, Kristmanson K
J Can Chiropract Assoc 2006;50(2):118-133
Clinical Trial
Effective orthotic therapy for the painful cavus foot
Burns J, Crosbie J, Ouvrier R
Australas J Podiatr Med 2006;40(3):61-66
Clinical Trial
Effective orthotic therapy for the painful cavus foot:
a randomized controlled trial
Burns J, Crosbie J, Ouvrier R, Hunt A
J Am Podiatr Med Assoc 2006;96(3):205-211
Clinical Trial
Effectiveness of foot orthoses to treat plantar fasciitis:
a randomized trial
Landorf KB, Keenan A, Herbert RD
Arch Intern Med 2006 26;166(12):1305-1310
Clinical Trial
Effectiveness of prefabricated and customized foot orthoses
made from low-cost foam for non-complicated plantar
fasciitis: a randomized controlled trial
Baldassin V, Gomes CR, Beraldo PS
Arch Phys Med Rehabil 2009;90(4):701-706
Clinical Trial
Foot orthoses and physiotherapy in the treatment of
patellofemoral pain syndrome: randomised clinical trial
Collins N, Crossley K, Beller E, Darnell R,
McPoil T, Vicenzino B
Br Sports Med 2009;43(3):169-176
Clinical Trial
Neutral functional realignment orthosis prevents hand pain
in patients with subacute stroke: a randomized trial
Burge E, Kupper D, Finckh A, Ryerson S,
Schnider A, Leemann B
Arch Phys Med Rehabil 2008;89(10):1857-1862
(Continued)

98
Section I  Building Baseline Knowledge
Type of Study
Title
Authors
Source
Clinical Trial
Foot orthoses and physiotherapy in the treatment of
patellofemoral pain syndrome: randomised clinical trial
Collins N, Crossley K, Beller E, Darnell R,
McPoil T, Vicenzino B
BMJ 2008;337(7677):a1735
Clinical Trial
Influence of foot orthoses on plantar pressures, foot pain
and walking ability of rheumatoid arthritis patients — a
randomised controlled study
Novak P, Burger H, Tomsic M, Marincek C,
Vidmar G
Disabil Rehabil 2009;31(8):638-645
Clinical Trial
A randomized controlled trial of two types of in-shoe
orthoses in children with flexible excess pronation of the feet
Whitford D, Esterman A
Foot Ankle Int 2007;28(6):715-723
Clinical Trial
Foot orthoses for the treatment of plantar fasciitis
Roos E, Engstrom M, Soderberg B
Foot Ankle Int 2006;27(8):606-611
Clinical Trial
Static progressive stretch brace as a treatment of pain and
functional limitations associated with plantar fasciitis:
a pilot study
Sharma NK, Loudon JK
Foot Ankle Spec 2010;3(3):117-124
Clinical Trial
Use of low-frequency electrical stimulation for the treatment
of plantar fasciitis
Stratton M, McPoil TG, Cornwall MW,
Patrick K
J Am Podiatr Med Assoc 2009;99(6):481-488
Clinical Trial
The effect of rigid versus flexible spinal orthosis on the clinical
efficacy and acceptance of the patients with adolescent
idiopathic scoliosis
Wong MS, Cheng JC, Lam TP, Ng BK, Sin SW,
Lee-Shum SL, Chow DH, Tam SY
Spine 2008;33(12):1360-1365
Clinical Trial
Comparison of 3 preventive methods to reduce the
recurrence of ankle inversion sprains in male soccer players
Mohammadi F
Am J Sports Med 2007;35(6):922-926
Clinical Trial
Effect of treadmill training and supramalleolar orthosis use
on motor skill development in infants with down
syndrome: a randomized clinical trial
Looper J, Ulrich DA
Phys Ther 2010;90(3):382-390
Clinical Trial
The immediate effect of orthotic management on grip
strength of patients with lateral epicondylosis
Jafarian FS, Demneh ES, Tyson SF
J Orthopaed Sports Phys Ther
2009;39(6):484-489
Clinical Trial
Nonsurgical management of posterior tibial tendon
dysfunction with orthoses and resistive exercise: a
randomized controlled trial
Kulig K, Reischl SF, Pomrantz AB,
Burnfield JM, Mais-Requejo S,
Thordarson DB, Smith RW
Phys Ther 2009;89(1):26-37
Clinical Trial
The effect of dynamic ankle foot orthoses on function in
children with cerebral palsy
Bjornson KF, Schmale GA, Adamczyk-Foster A,
McLaughlin J
J Pediatr Orthopaed 2006;26(6):773-776
Clinical Trial
Immediate effects of an individually designed functional
ankle-foot orthosis on stance and gait in hemiparetic
patients
Pohl M, Mehrholz J
Clin Rehabil 2006;20(4):324-330
Clinical Trial
Plantar fasciopathy treated with dynamic splinting: a
randomized controlled trial
Sheridan L, Lopez A, Perez A, John MM,
Willis FB, Shanmugam R
J Am Podiatr Med Assoc 2010;100(3):161-165
Results of Search Using PEDro Database*—cont'd

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
99
Clinical Trial
Foot orthoses in the prevention of injury in initial
military training
Franklyn-Miller A, Wilson C, Bilzon J,
McCrory P
Am J Sports Med 2011;39(1):30-37
Clinical Trial
Effect of foot orthoses contour on pain perception in
individuals with patellofemoral pain
McPoil TG, Vicenzino B, Cornwall MW
J Am Podiatr Med Assoc 2011;101(1):7-16
Clinical Trial
Does orthotic use affect upper extremity support during
upright play in infants with down syndrome?
Looper J, Ulrich D
Phys Occup Ther Pediatr 2011;23(1):70-77
Clinical Trial
Kinematic features of rear-foot motion using anterior and
posterior ankle-foot orthoses in stroke patients with
hemiplegic gait
Chen C, Hong W, Wang C, Wu KP,
Kang C, Tang SF
Arch Phys Med Rehabil 2010;91(12):1862-1868
Clinical Trial
Changes in gait economy between full-contact custom-made
foot orthoses and prefabricated inserts in patients with
musculoskeletal pain: a randomized clinical trial
Trotter LC, Pierrynowski MR
J Am Podiatr Med Assoc 2008;98(6):429-435
Clinical Trial

The short-term effectiveness of full contact custom-made
foot orthoses and prefabricated shoe inserts on lower-
extremity musculoskeletal pain: a randomized clinical trial
Trotter LC, Pierrynowski MR

J Am Podiatr Med Assoc 2008;98(5):357-363

*Key word: orthoses (limited to articles/abstracts published January 2006 – July 2011).

100
Section I  Building Baseline Knowledge
APPENDIX 4-4
Results of Search Using Hooked on Evidence, APTA*
Title
Author
Sources
Effects of carbon fibre spring orthoses on gait in ambulatory
children with motor disorders and plantarflexor weakness
Bartonek A, Eriksson M, Gutierrez-Farewik EM
Dev Med Child Neurol 2007; 49(8): 615-620
The effect of dynamic ankle foot orthoses on function in
children with cerebral palsy
Bjornson KF, Schmale GA, Adamczyk-Foster A,
McLaughlin J
J Pediatr Orthop 2006; 26(6): 773-776
Effects of ankle-foot orthoses on ankle and foot kinematics in
patient with ankle osteoarthritis
Huang YC, Harbst K, Kotajarvi B, Hansen D, Koff MF,
Kitaoka HB, Kaufman KR
Arch Phys Med Rehabil 2006; 87(5): 710-716
Changes in gait economy between full-contact custom-made
foot orthoses and prefabricated inserts in patients with
musculoskeletal pain: a randomized clinical trial
Trotter LC, Pierrynowski MR
J Am Podiatr Med Assoc 2008; 98(6): 429-435
Effectiveness of prefabricated and customized foot orthoses
made from low-cost foam for noncomplicated plantar
fasciitis: a randomized controlled trial
Baldassin V, Gomes CR, Beraldo PS
Arch Phys Med Rehabil 2009; 90(4): 701-706
Foot orthoses and physiotherapy in the treatment of
patellofemoral pain syndrome: randomised clinical trial
Collins N, Crossley K, Beller E, Darnell R, McPoil T,
Vicenzino B
BMJ 2008; 337(7677): 1034-1036
Nonsurgical management of posterior tibial tendon
dysfunction with orthoses and resistive exercise: a
randomized controlled trial
Kulig K, Reischl SF, Pomrantz AB, Burnfield JM,
Mais-Requejo S, Thordarson DB, Smith RW
Phys Ther 2009; 89(1): 26-37
Reach performance and postural adjustments during
standing in children with severe spastic diplegia using
dynamic ankle-foot orthoses
Naslund A, Sundelin G, Hirschfeld H
J Rehabil Med 2007; 39(9): 715-723
Use of strutter orthoses for an adolescent with myelodysplasia
Magee JA, Kenney DM
Pediatr Phys Ther 2008; 20(1): 81-88
Impact of ankle-foot orthoses on static foot alignment in
children with cerebral palsy
Westberry DE, Davids JR, Shaver JC, Tanner SL, Blackhurst
DW, Davis RB
J Bone Joint Surg Am 2007; 89(4): 806-813
Foot orthoses for the treatment of plantar fasciitis
Roos E, Engstrom M, Soderberg B
Foot Ankle Int 2006; 27(8): 606-611
Does orthotic use affect upper extremity support during
upright play in infants with down syndrome?
Looper J, Ulrich D
Pediatr Phys Ther 2011; 23(1): 70-77
Use of foot orthoses and calf stretching for individuals with
medial tibial stress syndrome
Loudon JK, Dolphino MR
Foot Ankle Spec 2010; 3(1): 15-20
Do ankle orthoses improve ankle proprioceptive thresholds or
unipedal balance in older persons with peripheral neuropathy?
Son J, Ashton-Miller JA, Richardson JK
Am J Phys Med Rehabil 2010; 89(5): 369-375
Use of low-frequency electrical stimulation for the treatment
of plantar fasciitis
Stratton M, McPoil TG, Cornwall MW, Patrick K
J Am Podiatric Med Assoc 2009; 99(6): 481-488

Chapter 4  An Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
101
Effective orthotic therapy for the painful cavus foot:
a randomized controlled trial
Burns J, Crosbie J, Ouvrier R, Hunt A
J Am Podiatr Med Assoc 2006; 96(3): 205-211
Ankle bracing, plantar-flexion angle, and ankle muscle
latencies during inversion stress in healthy participants
Kernozek T, Durall CJ, Friske A, Mussallem M
J Athl Train 2008; 43(1): 37-43
Comparison of 3 preventive methods to reduce the recurrence
of ankle inversion sprains in male soccer players
Mohammadi F
Am J Sports Med 2007; 35(6): 922-926
Use of a postoperative lumbar corset after lumbar spinal
arthrodesis for degenerative conditions of the spine. a
prospective randomized trial
Yee AJ, Yoo JU, Marsolais EB, Carlson G, Poe-Kochert C,
Bohlman HH, Emery SE
J Bone Joint Surg Am 2008; 90(10): 2062-2068
Short- and long-term influences of a custom foot orthotic
intervention on lower extremity dynamics
MacLean CL, Davis IS, Hamill J
Clin J Sport Med 2008; 18(4): 338-343
The influence of foot orthoses on the function of a child with
developmental delay
George DA, Elchert L
Pediatr Phys Ther 2007; 19(4): 332-336
Changes in joint kinematics in children with cerebral palsy
while walking with and without a floor reaction ankle-foot
orthosis
Lucareli PR, Lima Mde O, Lucarelli JG, Lima FP
Clinics 2007; 62(1): 63-68
Changes in muscle activity in children with hemiplegic cerebral
palsy while walking with and without ankle-foot orthoses
Romkes J, Hell AK, Brunner R
Gait Posture 2006; 24(4): 467-474
The effect of fixed ankle foot orthoses in children with
cerebral palsy
Butler PB, Farmer SE, Stewart C, Jones PW, Forward M
Disabil Rehabil Assist Technol 2007; 2(1): 51-58
A comparison of the thoracolumbosacral orthoses and
providence orthosis in the treatment of adolescent idiopathic
scoliosis: results using the new SRS inclusion and assessment
criteria for bracing studies
Janicki JA, Poe-Kochert C, Armstrong DG, Thompson GH
J Pediatr Orthop 2007; 27(4): 369-374
The effect of custom-made braces for the ankle and hindfoot
on ankle and foot kinematics and ground reaction forces
Kitaoka HB, Crevoisier XM, Harbst K, Hansen D,
Kotajarvi B, Kaufman K
Arch Phys Med Rehabil 2006; 87(1): 130-135
Effects of ankle-foot orthoses on ankle and foot kinematics
in patients with subtalar osteoarthritis
Huang YC, Harbst K, Kotajarvi B, Hansen D, Koff MF,
Kitaoka HB, Kaufman KR
Arch Phys Med Rehabil 2006; 87(8): 1131-1136
Effectiveness of foot orthoses to treat plantar fasciitis: a
randomized trial
Landorf KB, Keenan AM, Herbert RD
Arch Intern Med 2006; 166(12): 1305-1310
Effects of wearing foot orthosis with medial arch support on
the fifth metatarsal loading and ankle inversion angle in
selected basketball tasks
Yu B, Preston JJ, Queen RM, Byram IR, Hardaker WM,
Gross MT, Davis JM, Taft TN, Garrett WE
J Orthop Sports Phys Ther 2007; 37(4): 186-191

*Key word: orthoses (listed articles/abstracts published January 2006 – July 2011).

102
Section I  Building Baseline Knowledge
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104
5
WHY DO WE ANALYZE GAIT?
The first attempts to analyze gait, recorded in the Rig Veda
more than 3500 years ago, most likely was an attempt to
enhance mobility through early orthotic or prosthetic inter­
vention. This classic prose chronicles the story of Vispala, a
fierce female warrior whose leg, lost in battle, was replaced
by an iron prosthesis that enabled her return to the front to
fight again.1
Gait assessment describes the patterns of movement that
control the progression of the body in walking. Bipedal gait
requires a combination of automatic and volitional postural
components. This can result in either asymmetric reciprocal
movements of the lower limbs (seen in walking or running) or
symmetric, simultaneous two-legged hopping. Kangaroos are
bipeds that are successful two-legged hoppers.2 Homo sapi­
ens have reached the zenith of movement efficiency in bipedal
walking and running by using reciprocal patterns of motion.
Walking requires numerous physiological systems to work
congruently. Normal walking requires stability to provide
body weight support against gravity during stance, mobility
of body segments, and motor control to sequence multiple
segments while transferring body weight from one limb to
the other. The primary goal in gait is energy efficiency in for­
ward progression by using a stable kinetic chain of joints and
limb segments working congruently to transport its passen­
ger unit, consisting of the head, arms, and trunk (HAT) in a
continuously changing environment and task demands.
Understanding the process of walking is essential to crit­
ically evaluate examination findings and suggest effective
intervention plans to help patients improve their walking
ability. Clinical gait assessment identifies primary or path­
ological gait problems and helps differentiate them from
compensatory strategies. It is necessary for selection of appro­
priate orthotic or prosthetic components, alignment param­
eters, and identification of other variants that might enhance
an individual's ability to walk. Clinical gait assessment also
contributes to the development of a comprehensive treatment
plan, with the ultimate goal of optimal energy efficiency and
appropriate pathomechanical control, balancing cosmesis
and overall function.
KINEMATIC DESCRIPTORS OF HUMAN
WALKING
Step length, stride length, cadence, and velocity are important
quantitative, interrelated kinematic measures of gait. Step
length and stride length are not synonymous. Step length is the
distance from the floor-contact point of one (ipsilateral, origi­
nating) foot in early stance to the floor-contact point of the
opposite (contralateral) foot: in normal individuals the dis­
tance from right heel contact to left heel contact. Stride length
is the distance from floor contact on one side to the next floor
contact on that same side: the distance from right heel contact
to the next right heel contact. A reduction in functional joint
motion or the presence of pain or ­muscle weakness can result
in decreased stride or step length, or both. Pathological gait
commonly produces asymmetries in step length between the
two lower limbs.
Cadence is the number of steps taken in a given unit of
time, most often expressed in steps per minute. Velocity
is the distance traveled in a given unit of time (the rate of
­forward progression) and is usually expressed in centimeters
per ­second or meters per minute. Velocity is the best single
5
LEARNING OBJECTIVES
On completion of this chapter, the reader will be able to:
1. Describe the major functional tasks of the gait cycle and
their corresponding subphases.
2. Identify the muscle activity, ground reaction forces, and
joint angles during each of the subphases of the gait cycle.
3. Define the time and distance parameters used to describe
and assess normal gait.
4. Describe common pathological gait patterns, including
contributing factors, compensatory deviations, and when
these are likely to occur in the gait cycle.
5. Compare and contrast the type and quality of informa­
tion gathered with various quantitative, qualitative, instru­
mented, and function-based gait assessment tools.
6. Differentiate between pathological and compensatory gait
characteristics typically observed in patients with lower
motor neuron disease, hemiplegia, spastic diplegic cere­
bral palsy, and spina bifida.
7. Discuss how prosthetic components and alignment influ­
ence the efficacy and quality of gait for individuals with
amputation at the transtibial and transfemoral levels.
Clinical Assessment of Gait
Olfat Mohamed, Dana Craig, Heather Worden, and Edmond Ayyappa

Chapter 5  Clinical Assessment of Gait
105
index of walking ability. Decreased joint motion, pain and/
or muscle weakness can reduce cadence or velocity or both.
Velocity can also be qualitatively categorized as free, slow, or
fast. Free walking (self-selected) speed is an individual's nor­
mal self-selected (comfortable) walking velocity. Fast walking
speed describes the maximum velocity possible for a given
individual while being safe. Slow walking speed describes a
­velocity below the normal self-selected walking speed. For
healthy individuals, a fast walk velocity may be as much as
44% faster than free or self-selected walking speed.3 In people
with musculoskeletal and neuromuscular impairments that
affect gait, often much less difference is found between free
and fast gait velocity.
Double limb support is the period of time when both feet are
in contact with the ground. It occurs twice during the gait cycle,
at the beginning and the end of each stance phase. As velocity
increases, double limb support time decreases. When running,
the individual has rapid forward movement with little or no
period of double limb support. Individuals with slow walking
speeds spend more of the gait cycle in double support.
Step width, or width of the walking base, typically mea­
sures between 5 and 10 cm from the heel center of one foot
to the heel center of the other foot.4 A wide walking base may
increase stability but also reduces energy efficiency of gait.
Ground reaction force (GRF) vector is the mean load-­
bearing line, which takes into account the forces acting in all
three planes. It has magnitude as well as directional qualities.
The spatial relation between this line and a given joint center
influences the direction of its rotation. The rotational poten­
tial of the forces that act on a joint is called a torque or moment.
GAIT CYCLE
A variety of conceptual approaches describe the walking
­process. Saunders and colleagues5 and Inman and colleagues5
define the functional task of walking as translation of the cen­
ter of gravity through space in a manner that requires the
least energy expenditure. They identify six determinants, or
variables, that affect energy expenditure in sustained walk­
ing: pelvic rotation, pelvic tilt, knee flexion in stance phase,
foot interaction with the knee, ankle interaction with the
knee, and lateral pelvic displacement. Individually and collec­
tively, these determinants have an impact on energy expen­
diture and the mechanics of walking. Although they help us
understand the process of walking, the determinants do not
themselves offer a practical clinical solution to address the
problems of gait assessment.
A comprehensive system to describe normal and abnormal
gait has been developed by the Pathokinesiology and Physical
Therapy Departments at Rancho Los Amigos Medical Center
over the past several decades.4,7,8 The Rancho Los Amigos
system serves as the descriptive medium for this ­chapter
(Figure 5-1). Because velocity affects many parameters of walk­
ing, the description of normal gait assumes a comfortable
self-selected velocity. At free walking velocity, the individual
naturally recruits strategies and assumes the speed that provides
maximum energy efficiency for their physiological system.
The gait cycle is the period between any two identical events
in the walking cycle. Initial contact is traditionally selected as
the starting and completing event of a single cycle of gait. Each
cycle is divided into two periods: stance phase and swing phase.
Stance is the time when the foot is in contact with the ground; it
constitutes approximately 60% of the gait cycle. Swing denotes
the time when the foot is in the air; it constitutes the remaining
40% of the gait cycle. There are five subphases within the stance
period: initial contact (IC), loading response (LR), midstance
(MSt), terminal stance (TSt), and preswing (PSw). Swing phase
is divided into three subphases: initial swing (ISw), midswing
(MSw), and terminal swing (TSw). Because PSw prepares the
limb for swing advancement, many consider PSw to be a pre­
paratory component of swing phase.
Three functional tasks are achieved during these eight gait
phases: weight acceptance in early stance, single limb support
in mid-to terminal stance, and limb advancement ­during swing.
Functional Task 1: Weight Acceptance
IC and LR are the subphases of stance where weight accep­
tance is accomplished. Effective transfer of body weight onto
the limb as soon as it makes contact with the ground requires
initial limb stability, shock absorption, and the preservation
of forward momentum.
Initial Contact
IC is the instant that the foot of the leading lower limb
touches the ground. Most motor function during IC is
preparation for LR. At IC, the ankle is in neutral position,
the knee is close to full extension, and the hip is flexed 30
degrees. The sagittal plane GRF vector lies posterior to the
ankle joint, creating a plantar flexion moment (Figure 5-2).
Eccentric contraction of the pretibial muscles (tibialis ante­
rior and long toe ­extensors) holds the ankle and subtalar
joint in neutral position. At the knee, the GRF vector is ante­
rior to the joint axis, which creates a passive extensor torque.
Muscle contraction activity of the three vasti of the quadri­
ceps and hamstring muscle groups continues from the pre­
vious TSw to preserve the ­neutral ­position of the knee joint.
A flexion moment is ­present around the hip joint because the
Gait cycle (stride)
Stance
Swing
Limb
advancement
Single
limb
support
Weight
acceptance
IC
LR
MSt
TSt
PSw
ISw
MSw
TSw
FIGURE  5-1  A complete gait cycle divided into three functional
tasks of weight acceptance, single limb support, and limb advance­
ment. The gait cycle can also be described in phasic terms of ini­
tial contact (IC), loading response (LR), midstance (MSt), terminal
stance (TSt), preswing (PSw), initial swing (ISw), midswing (MSw),
and terminal swing (TSw). The PSw phase is a transitional phase
between single limb support and limb advancement.

106
Section I  Building Baseline Knowledge
GRF vector falls anterior to the joint axis. Gluteus maximus
and hamstring muscles are activated to restrain the resultant
flexion torque.
Loading Response
LR occupies approximately 10% of the gait cycle and con­
stitutes the period of initial double limb support (see
Figure  5-2B). Two functional tasks occur during LR: con­
trolled descent of the foot toward the ground and shock
absorption as weight is transferred onto the stance limb.
The momentum generated by the fall of body weight onto
the stance limb is preserved by the heel rocker (first rocker)
of stance phase. Normal IC at the calcaneal tuberosity cre­
ates a fulcrum about which the foot and tibia move. The bony
­segment between this fulcrum and the center of the ankle rolls
toward the ground as body weight is loaded onto the stance
foot, preserving the momentum necessary for forward progres­
sion. Eccentric action of the pretibial muscles regulates the rate
of ankle plantar flexion, and the quadriceps vasti contract to
limit knee flexion. The action of these two muscle groups pro­
vides controlled forward advancement of the lower extremity
unit (foot, tibia, and femur). During the peak of LR, the mag­
nitude of the vertical GRF exceeds body weight. To absorb the
impact force of body weight and preserve forward momentum,
the knee flexes 15 to 18 degrees and the ankle plantar flexes
to 10 degrees. The hip maintains its position of 30 degrees of
flexion. Contraction of the gluteus maximus, hamstrings, and
adductor magnus prevents further flexion of the hip joint.
A
B
FIGURE 5-2  The two subphases of gait involved with the functional task of weight acceptance are
initial contact (IC) and loading response (LR). A, At IC, the ground reaction force (GRF) line is pos­
terior to the ankle and anterior to the knee and hip with activation of pretibial, quadriceps, hamstring,
and gluteal muscles. Note that the length of the GRF line represents its magnitude. B, The LR phase
results in an increased magnitude of the vertical force, which ultimately exceeds body weight. Activity
of the same muscle groups elicited at IC increases steadily with the vertical force.

Chapter 5  Clinical Assessment of Gait
107
Functional Task 2: Single Limb Support
Two phases are associated with single limb support: MSt and
TSt. During this period, the contralateral foot is in swing
phase, and body weight is entirely supported on the stance
limb. Forward progression of body weight over the stationary
foot while maintaining stability must be accomplished during
these two subphases of stance.
Midstance
MSt begins when the contralateral foot leaves the ground and
continues as body weight travels along the length of the stance
foot until it is aligned over the forefoot at approximately 20% of
the gait cycle (Figure 5-3). This pivotal action of the ankle rocker
(second rocker) advances the tibia over the stationary foot.
Forward movement of the tibia over the foot is controlled by the
eccentric contraction of the soleus assisted by the gastrocnemius.
During this phase, the ankle moves from its LR position
of 10 degrees of plantar flexion to approximately 5 degrees
of dorsiflexion. The knee extends from 15 degrees of flexion
to a neutral position. The hip joint moves toward extension,
from 30 to 10 degrees of flexion. With continued forward
progression, the body weight vector moves anterior to the
ankle, creating a dorsiflexion moment. Eccentric action of
the plantar flexors is crucial in providing limb stability as
contralateral toe-off occurs, transferring body weight onto
the stance foot. By the end of MSt, the body weight vector
moves anterior to the knee (creating passive extensor sta­
bility at the knee) and posterior to the hip (reducing the
demand on the hip extensors). The gluteus maximus, active
in early MSt, ceases its activity and now stability relies on
passive structures as the hip nears vertical alignment over
the femur. Vertical GRF is reduced in magnitude at MSt
A
B
FIGURE 5-3  The subphases of gait involved in the functional task of single limb support are MSt and
TSt. A, In early MSt, the vertical force begins to decrease and the triceps surae, quadriceps, and glu­
teus medius and maximus are active. B, During TSt, there is a second peak in vertical force, exceeding
body weight, with high activity of the triceps surae, which maintain the third rocker. The tensor fascia
lata restrains the increasing posterior hip vector. MSt, Midstance; TSt, terminal stance.

108
Section I  Building Baseline Knowledge
because of the upward momentum of the contralateral
swing limb. In the coronal plane, activity of hip abductors
during MSt is essential to provide lateral hip stability and
almost a level pelvis.
Terminal Stance
TSt, the second half of single limb support, begins with
heel rise of the stance limb and ends when the contralat­
eral foot makes contact with the ground. As the body vec­
tor approaches the metatarsophalangeal joint, the heel rises
and the phalanx dorsiflexes (extends). The metatarsal heads
serve as an axis of rotation for body weight advancement (see
Figure 5-3B). This is referred to as the forefoot or toe rocker
(third rocker). The forefoot rocker serves as an axis around
which progression of the body vector advances beyond
the area of foot support, creating the highest demand on
calf muscles (gastrocnemius and soleus). During TSt, the
ankle continues to dorsiflex to 10 degrees. The knee is fully
extended, and the hip moves into slight hyperextension.
Forward fall of the body moves the vector further anterior to
the ankle, creating a large dorsiflexion moment. Stability of
the tibia on the ankle is provided by the eccentric action of
the gastrocsoleus muscles.
The trailing posture of the limb and the presence of the
vector anterior to the knee and posterior to the hip provide
passive stability at hip and knee joints. The tensor fascia lata
serves to restrain the posterior vector at the hip. At the end
of TSt, the vertical GRF reaches a second peak greater than
body weight, similar to that which occurred at the end of LR.
Functional Task 3: Limb Advancement
Four phases contribute to limb advancement: PSw, ISw, MSw,
and TSw. During these phases the stance limb leaves the
ground, advances forward, and prepares for the next IC.
Preswing
PSw, the second period of double limb support in gait, com­
prises the last 10% of the stance phase. It begins when the
contralateral foot makes contact with the ground and ends
with ipsilateral toe-off. During this period, the stance limb
is unloaded and body weight is transferred onto the contra­
lateral limb (Figure  5-4). The ankle moves rapidly from its
TSt dorsiflexion into 20 degrees of plantar flexion. During
this subphase, plantar flexor muscle activity decreases as the
limb is unloaded. Toward the end of PSw, the vertical force
is diminished such that plantar flexors rapidly decrease their
activity to complete quiescence. There is no active muscle con­
traction for “push off” in normal reciprocal free walk bipedal
gait.6 The knee also flexes rapidly to achieve 35 to 40 degrees
of flexion by the end of PSw. The GRF vector is at the metatar­
sophalangeal joints and posterior to the knee, creating passive
knee flexion with toe clearance. Knee flexion during this phase
prepares the limb for toe clearance in the swing phase. PSw hip
flexion is initiated by the rectus femoris and the adductor lon­
gus, which also decelerates the passive abduction created by
contralateral body weight transfer. The sagittal vector extends
through the hip as the hip returns to a neutral position.
Initial Swing
Approximately one third of the swing period is spent in
ISw. It begins the moment the foot leaves the ground and
continues until maximal knee flexion (60 degrees) occurs,
when the swinging extremity is directly under the body
(see Figure 5-4B). Concentric contraction of pretibial mus­
cles initiates foot dorsiflexion from its initial 20 degrees to
5 degrees of plantar flexion. This is necessary for toe and foot
clearance as swing phase begins. Knee flexion, resulting from
action of the short head of the biceps femoris, also assists in
toe clearance. The knee continues to flex until it reaches a
position of 60 degrees of flexion. Contraction of the iliacus
advances the hip to 20 degrees of flexion. Contraction of the
gracilis and sartorius muscles during this phase assists hip
and knee flexion.
Midswing
During MSw, limb advancement and foot clearance ­continue.
MSw begins at maximum knee flexion and ends when the
tibia is vertical. Knee extension, coupled with ankle dorsi­
flexion, contributes to foot clearance while advancing the
tibia (see Figure  5-4C). Continued concentric activity of
pretibial muscles ensures foot clearance and moves the foot
toward the neutral position. Momentum creates an exten­
sion moment, advancing the lower leg toward extension
from 60 degrees to 30 degrees of flexion, with the quadriceps
quiescent. Mild contraction of hip flexors continues to pre­
serve the hip flexion position.
Terminal Swing
In the final phase, TSw, the knee extends fully in prepara­
tion for heel contact (see Figure  5-4D). Eccentric contrac­
tion of the hamstrings and gluteus maximus decelerates the
thigh and restrains further hip flexion. Activity of the pretib­
ial muscles maintains the ankle at neutral to prepare for heel
contact. In the second half of TSw, the rectus femoris is quies­
cent but the rest of the quadriceps vasti become active to facil­
itate full knee extension. Hip flexion remains at 30 degrees.
DESCRIBING PATHOLOGICAL GAIT
Clinicians often use qualitative descriptive terms to charac­
terize gait deviations and compensations. Some of these terms
help identify specific primary problems; others describe com­
pensatory strategies used by patients to solve gait difficulties
created by various primary impairments.
Common Gait Deviations Observed During Stance
Trendelenburg gait occurs in the stance phase, when the trunk
leans to the same side as the hip pathology (ipsilateral lean).
This is a compensatory strategy used when the gluteus medius
muscle and its synergists (gluteus minimus and tensor fas­
cia lata) cannot adequately stabilize the pelvis during stance.9
Normally the drop of the contralateral pelvis is limited to
5 degrees by the eccentric control of the strong hip abductor
muscles. To support the pelvis, the hip abductor muscles must
generate a force that is 1.5 times the body weight.10 Weak or

Chapter 5  Clinical Assessment of Gait
109
A
B
C
D
FIGURE 5-4  The subphases of gait involved in the functional task of swing limb advancement include
preswing (PSw), initial swing (ISw), midswing (MSw), and terminal swing (TSw). A, During PSw, contra­
lateral loading results in limited muscle activity in the limb transitioning from stance to swing. The rectus
femoris and adductor longus initiate hip flexion. Knee flexion is passive, resulting from the planted fore­
foot and mobile proximal segments. B, During ISw, the pretibial muscles, short head of the biceps femo­
ris, and iliacus are active in initiating limb advancement and providing swing clearance. C, A vertical tibia
signals the end of the period of MSw. Here contraction of the iliacus preserves hip flexion while pretibial
muscle activity maintains foot clearance. D, At TSw, the gluteus maximus, hamstrings, quadriceps, and
pretibial muscles are active to prepare for limb placement and the ensuing loading response.

110
Section I  Building Baseline Knowledge
absent gluteus medius muscle leads to a postural substitution
of an ipsilateral trunk lean over the weight-bearing hip joint.
This reduces the external adductor moment created by a GRF
line that falls medial to the joint center. Without this postural
compensation, clearance becomes a problem for the swing­
ing contralateral limb. Rarely, Trendelenburg gait is caused by
overactive hip adductors (adductors longus, magnus, brevis,
and gracilis).
Vaulting is exaggerated heel elevation of the stance foot,
occasionally occurring with simultaneous stance limb hip
and knee extension, with the goal of raising the pelvis to clear
the contralateral swing limb. It occurs when the functional
length of the swing limb is relatively longer than that of the
stance limb. It also occurs when swing limb advancement is
impaired or delayed by inadequate motor control of hip or
knee flexion, or both, or in the presence of a plantar flexion
contracture of the swing leg. It may compensate for pelvic
obliquity or leg length discrepancy.
Antalgic gait is a strategy used to avoid pain during
­walking. It is frequently observed in LR when the patient
reduces single limb support time on the affected limb. If the
pain occurs during a particular interval in stance, that time
interval is avoided. Antalgic gait caused by pain that origi­
nates around the hip might translate into a lateral lean to
permit the patient to get the center of gravity over the sup­
port point, the head of the femur. If the pain occurs dur­
ing the extreme end range of a particular joint motion, that
motion is diminished. For example, if full extension pro­
duces pain, the knee would be maintained in slight flexion
throughout the gait cycle.
Common Gait Deviations Observed During Swing
Circumducted gait is a swing phase deviation in which hip
abduction is combined with a wide arc of pelvic rotation, most
often occurring as a compensatory pattern when there is a rel­
atively longer swing limb compared with the stance limb. This
action is most likely to happen when there is limited motion
or impaired motor control affecting ankle dorsiflexion, knee
flexion, or hip flexion. A plantar flexion contracture at the
foot or a stiff knee or hip joint can necessitate a circumduc­
tion pattern during swing in an effort to achieve toe and foot
clearance. This combination of abduction and pelvic rotation
is a compensatory strategy to advance the limb.
Circumduction can be observed as a lateral arc of the foot
in the transverse plane that begins at the end of PSw and ends
at IC on the same limb. The arc reaches the apex of its lat­
eral movement at MSw. The typical pattern is a mixture of
a wide base of support with the foot abnormally outset and
may include an ipsilateral pelvic drop. It is possible for a con­
tracture of the contralateral adductors to create this devia­
tion by pulling the pelvis toward the contralateral femur and
demanding a compensatory ipsilateral abducted position rel­
ative to the ­pelvis. A severe leg length discrepancy can result
in an exaggerated pelvic tilt from the contralateral stance leg,
which obligates the swing limb to an increased abduction
position. Circumduction and abduction create a significant
energy cost penalty, increasing lateral displacement of the
center of gravity.
Gait Deviations Associated with Abnormal
Muscle Tone
A variety of abnormal gait patterns are associated with abnor­
mal muscle tone (spasticity, rigidity, hypotonicity, or abnormal
motor control) or muscle weakness. Scissors gait describes a
pattern of poor control in limb advancement or tracking of the
swing leg often characterized by the crossing, or scissoring
(hip adduction, flexion and medial rotation), of the lower limbs.
It is most often observed in patients with spastic or paretic
pathological conditions such as hemiplegia, spastic diplegia,
and cerebral palsy. Steppage gait occurs when there is weakness
or paralysis of the dorsiflexor musculature, such as in persons
with peroneal palsy or peripheral neuropathy, demands exag­
gerated hip and knee flexion of the proximal joints to accom­
plish swing clearance. It is most easily observed in late MSw.
In crouch gait exaggerated knee and hip flexion occurs
throughout the gait cycle. Crouch gait is often seen in com­
bination with a toe-walking stance in children and adults
with spastic diplegic cerebral palsy. It has been attributed to a
combination of overactivity of the hamstrings and weakness
of calf muscles. Although orthosis use can successfully con­
trol abnormal motion in the sagittal plane (e.g., in steppage
gait), orthoses are less effective in controlling the abnormal
transverse, rotational, or coronal limb placement problems
observed in scissoring or crouched gait pattern.
In ataxic gait there is a failure of coordination or irregular­
ity of muscular action of the limb segments commonly caused
by cerebellar dysfunction. Ataxia often becomes accentuated
when the eyes are closed or vision is impaired or distracted.
QUALITATIVE GAIT ASSESSMENT
Qualitative methods for identification and recording of gait
deviations have played a role in patient care for decades.
In 1925, Robinson11 described pathological gait patterns and
attempted to correlate them with specific disease processes.
In 1937, Boorstein12 identified 14 disease processes that could
be diagnosed with gait assessment. He described seven major
gait deficit groups, attributing the term steppage gait to the
French physician Charcot and the identification of waddling
gait in hip dysplasia to Hippocrates. In the late 1950s, Blair
Hangar, the founder of Northwestern University's School of
Prosthetics and Orthotics, and Hildegard Myers, a physical
therapist at Rehabilitation Institute of Chicago, collaborated
to develop the first comprehensive system of clinical gait
analysis for persons with transfemoral amputation.13 They
identified 16 gait deviations and suggested numerous clini­
cal and prosthetic causes for each. Their work, developed into
an educational film and handbook in 1960, has been a model
for subsequent instructional videos and assessment systems
in prosthetics.14 Brunnstrom's15 comprehensive gait analysis
form for hemiplegic gait, published in 1970, is a checklist of
28 deviations seen at the ankle, knee, and hip that are com­
mon after stroke.
Early work in observational gait analysis received a significant
impetus from Perry16 as an outgrowth of basic research data pub­
lished in 1967. In the late 1960s, Perry and a group of physical
therapists from the Rancho Los Amigos Medical Center Physical

Chapter 5  Clinical Assessment of Gait
111
Therapy Department developed an organized format for system­
atically applied observational gait analysis. Their work initially
focused on the development of an in-house training program
for students and personnel who were new to the rehabilitation
hospital. The first Normal and Pathological Gait Syllabus was
published by the Professional Staff Association of Rancho Los
Amigos Hospital in 1977.7 Subsequent revisions have included
additional gait data and gait interpretation.17 This syllabus uses
parameters of normal gait as a comparative standard for abnor­
mal or pathological gait. It focuses on identifying gait deviations
that affect the three functional tasks of walking: weight accep­
tance, single limb support, and swing limb advancement. A form
listing the most commonly occurring gait deviations in each
subphase of gait is used to record any observed gait deviations
that interfere with these functional tasks (Figure 5-5). Problems
in each of the six major body segments are noted with a check in
one of the boxes, beginning with the toes, then the ankle, knee,
hip, pelvis, and trunk. This format allows the clinician to con­
sider systematically the following questions:
• Are the toes up, inadequately extended, or clawed?
• Is there forefoot-only contact (toe walking), foot-flat con­
tact, foot slap, excess plantar flexion, or dorsiflexion? Is
heel-off, foot drag, or contralateral vaulting present?
• Is knee flexion adequate, absent, limited, or excessive? Is
extension inadequate? Does the knee wobble, hyperextend,
or produce an extension thrust (recurvatum)? Is varus or
valgus present, or is excessive contralateral flexion seen?
• Is hip flexion adequate, absent, limited, or excessive? Is ade­
quate extension seen? Is retraction of the thigh during TSw
from a previously attained degree of flexion seen? Can inter­
nal or external rotation, abduction, or adduction be observed?
• Does the pelvis hike? Does it tilt anteriorly or posteriorly?
Is forward or backward rotation seen? Does it drop to the
ipsilateral or contralateral side?
• Does the trunk lean or rotate backward or forward? Does
it lean laterally to the right or left?
Qualitative gait assessment is an important component of
preorthotic assessment because it assists the clinician in iden­
tifying the functional task and the subphase of gait that are
problematic and can be addressed with orthotic intervention.
Similarly, deviations observed during gait analysis can iden­
tify the need for adjustment of prosthetic alignment.
INSTRUMENTED GAIT ANALYSIS
Instrumented gait analysis records the process of walking with
measurable parameters collected through the use of equip­
ment. Such basic techniques would have enabled measure­
ment of walking velocity (distance traversed per unit of time)
and cadence (steps per unit of time). Marks,18 a New York
City prosthetist, offered a more precise qualitative description
of pathological gait in 1905, when he described the gait pro­
cess in eight organized phases and discussed the implications
of prosthetic component design on walking function. Marks
praised “kinetoscopic” photography as a potential diagnostic
tool for optimizing pathological gait.
Today we record gait parameters with instruments as
common as a stopwatch or as complex as the simultaneous
integration of three-dimensional kinematics, kinetics, and
electromyographic (EMG) methods. The primary emphasis
of clinical assessment has been on accessible techniques and
inexpensive technologies. A simple, inexpensive footprint mat
has been used for decades to record barefoot plantar pres­
sures. Clinics use individual or multiple mats to record step
and stride length as well as walking base width. Early on, video
technology with slow-motion capabilities made more precise
qualitative description of the gait cycle possible. The contin­
ued development of inexpensive video gait assessment software
has made clinical quantitative applications more practical as
well. Most quantitative and qualitative video systems, however,
measure joint angles in two dimensions, which does not offer
a complete analysis of the ­three-­dimensional walking activity.
Technology in Gait Assessment
The high-tech side of quantitative gait analysis has traversed
a surprisingly long road. The birth of instrumented kine­
matic, EMG, and temporal performance analysis began in
the 1870s with E. J. Marey, who first performed movement
analysis of pathological gait with photography.19 He also
developed the first myograph for measuring muscle activ­
ity and the first foot-switch collection system for measuring
gait events related to the temporal parameters. The foot-
switch system was an experimental shoe that measured the
length and rapidity of the step and the pressure of the foot
on the ground. Eadweard Muybridge,20 working at Stanford
University in the 1880s, used synchronized multiple camera
photography with a scaled backdrop to record on film and
assess the motion of subjects walking. Scherb made other
major advances in instrumented gait analysis in 1920 by per­
forming manual muscle palpation on individuals while using
a treadmill. Additionally, in 1925 Adrian advocated the use of
EMG to study the dynamic action of muscles.21
Modern gait technology began in 1945, when Inman and
colleagues initiated the systematic collection of gait data for
individuals without impairment and with amputation in
the outdoor gait laboratory at the University of California at
Berkeley.5 Since then, researchers and clinicians have increas­
ingly used the wide array of gait technologies to measure the
parameters of human performance in normal and pathologi­
cal gait. A full-service gait laboratory gathers information on
six performance parameters in walking: temporal, metabolic,
kinematic, kinetic, EMG, and pressure.22
Measuring Temporal and Distance Parameters
Temporal (time, distance) parameters enable the ­clinician to
summarize the overall quality of a patient's gait. Temporal data
collection systems might be one of the most effective compo­
nents available for assessment in the clinical setting. In the gait
laboratory, microswitch-­embedded pads taped to the bottom
of a patient's shoes or feet can record the amount of time that
the patient spends on various ­anatomical landmarks over a
measured distance. Portable pressure-sensitive gait mats, con­
nected to a laptop computer with gait analysis software for time
and distance parameters are also commercially available to use
in clinical settings (Figure 5-6).23,24 For example, the GAITRite
system, which consists of an electronic walkway connected to

112
Section I  Building Baseline Knowledge
FIGURE 5-5  The Rancho gait analysis system facilitates recording any observable activity that inter­
feres with the three functional tasks of walking: weight acceptance, single limb support, and swing
limb advancement. (Reprinted with permission from Los Amigos Research and Education Institute,
Rancho Los Amigos Medical Center. Observational Gait Analysis Handbook. Downey, CA: Los
Amigos Research and Education Institute, Rancho Los Amigos Medical Center, 1989. pp. 55.)

Chapter 5  Clinical Assessment of Gait
113
a computer, records the temporal and spatial characteristics of
patients while walking as well as while performing other func­
tional or occupational tasks. The GAITRite mat is flexible and
can be rolled and transported in a hard case, which enables data
collection at different clinics or sites. Wening and colleagues
used the GAITRite system to validate the effect of using an
ankle-foot orthosis (AFO) on the walking pattern of patients
with stroke.25 In this study, they compared stride length, veloc­
ity, cadence, percentage of the gait cycle spent in single and
double limb support, as well as general stance progression pat­
terns. Gait deviations related to excessive inversion, eversion,
or prolonged heel-only time can be recognized and considered
when modifying the alignment or components of prostheses
or orthoses. A temporal data collection system is particularly
cost effective and clinically meaningful. Temporal data are
usually a product of another measuring system such as EMG
or motion analysis. Temporal data systems are commercially
available covering a wide range of cost, technical sophistica­
tion, and time required to analyze the summarized data. Some
of the temporal parameters, however, can be recorded, to a
lesser degree of accuracy using a stopwatch and video camera.26
Assessing the Energy Cost of Walking
Metabolic data reflect the physiological “energy cost” of
walking. The traditional measures of energy cost are oxygen
consumption, total carbon dioxide generated, and heart rate.
Other relevant factors include volume of air breathed and
respiratory rate. All these parameters are viewed in relation
to velocity and distance walked over the collection period.
Historically, metabolic data were collected while the patient
walked on a treadmill, wearing umbilical devices. In recent
years, because of the known influence of treadmill collection
in altering normal gait velocity, energy cost data are more
likely to be obtained on an open track of a measured distance
with the patient ambulating in a free walk or natural cadence
(Figure 5-7). With the cardiopulmonary device market con­
tinually growing and advancing, there is a wide array of versa­
tile testing equipment to choose from. This equipment allows
the patient to negotiate their normal environments with little
or no interruption due to the testing and collection setups.
Some of the newest products on the market couple the tradi­
tional oxygen and carbon dioxide (Vo2 and Vco2) measure­
ment with the capability of collecting telemetry data, indirect
calorimetry, and integrated electrocardiogram among other
add-ons to standard systems. The primary limitation of energy
cost as an assessment tool is that, although it can inform the
investigator about body metabolism relative to the patient's
gait, it cannot explain why or how an advantage or disadvan­
tage was obtained. Waters27 demonstrated that an individual
with Syme's level amputation uses less oxygen to traverse a
given distance than someone with a transtibial amputation
but could not explain why. For that explanation, other gait
parameters must be examined. Energy cost measures cannot
easily identify widely variant prosthetic foot designs worn by
the same patient, whereas kinematic, kinetic, and EMG data
typically can.28 The Oxycon Champion respirometry sys­
tem has been used in many studies; one involved measuring
the step-by-step metabolic consumptions of amputees. This
FIGURE 5-6  A, The GAITRite system is an example of a portable pressure-sensitive walkway used to assess temporal and distance param­
eters of gait. B, The walkway is connected to a laptop computer, and the operator is able to quickly generate values for velocity, stride and step
lengths, cadence, time and percent of cycle spent in stance, single and double limb support, and swing.
A
Walk # / footfall #
Step time (sec)
Cycle time (sec)
Swing time (sec)
/ %GC
Stance (sec)
/ %GC
Single support (sec)
/ %GC
Double support (sec)
/ %GC
Step length (cm)
Stride length (cm)
Base of support (cm)
Toe in / out (deg)
L/R
Mean (%CV)
All ages
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
0.494 (2)
0.504 (3)
0.994 (3)
1.007 (1)
0.356 (2) /35.8
0.382 (2) /37.9
0.638 (3) /64.2
0.625 (0) /62.1
0.382 (2) /38.4
0.356 (2) /35.4
0.269 (3) /27.1
0.269 (3) /26.7
56.587 (5)
56.229 (3)
113.665 (2)
112.429 (1)
9.56 (36)
11.41 (17)
7 (33)
11 (13)
0.53
0.59
1.06
1.18
36
44
56
64
42
38
24
16
58
85
170
116
281.9
2.50
112.7
1.44
Distance (cm)
Ambulation time (sec)
Velocity (cm/sec)
Mean normalized velocity
Parameters
Functional ambulation profile: 99
120.0
0.01
0.36
0.01
Cadence (steps/min)
Step time differential (sec)
Step length differential (cm)
Cycle time differential (sec)
B

114
Section I  Building Baseline Knowledge
system allowed for unrestricted locomotion which made the
data collection easier and more relevant to everyday situations
of the participant.29 The CPX by Medgraphics, a breath-by-
breath analysis system for cardiopulmonary exercise testing,
was used to record similar data relating to the biomechanics
of lower-limb amputee gait and metabolic data.30
Perhaps the best kept secret in the energy cost arsenal is the
physiological cost index (PCI). It is easily calculated as follows:
The PCI is one of the most sensitive indicators of energy
cost of gait. Winchester and colleagues31 compared two differ­
ent orthotic designs by measuring a wide variety of metabolic
parameters as well as the PCI. Their results demonstrated
statistically significant difference in PCI between the two
devices when all other measured parameters failed to produce
such differences. Pulse and respiratory rate taken at rest and
after timed intervals during normal comfortable gait can also
help assess exertion levels.
Kinematic and Kinetic Systems
Most kinematic systems provide joint and body segment
motion in graphic form. This information includes sagit­
tal, coronal, and transverse motions that occur at the ankle,
knee, hip, and pelvis. The patient is instrumented with reflec­
tive spheres that are placed on well-recognized anatomical
landmarks (Figure  5-8). Typically, an infrared light source
is ­positioned around each of several cameras. This light is
directed to the reflective spheres, which in turn are reflected
into the cameras. Each field of video data is digitized, an
operator manually identifies the markers, and the coordinates
of the geometric center of each marker are calculated with
computer software. Resultant data are displayed as animated
stick figures that represent the actual motions produced by
the patient. The operator can freeze any frame and enlarge the
image at any joint to examine gait patterns in greater depth.
The operator can extract raw numbers that represent joint
placement and motion in space or produce a printout show­
ing joint motion in all planes plotted against the percentage of
the gait cycle (Figure 5-9). Angular velocities, accelerations,
and joint and segment linear displacements can be calculated.
Data from other systems (force platforms and EMG) collected
during the same time sequence as the motion data are often
integrated with the kinematics. Advanced systems like these
can be a very expensive component of the gait lab, but the data
collected provides some of the most in-depth and valid data.
In the gait lab or a clinical lab, the motion system setup serves
as the technological core. A variety of Vicon motion systems
have been used to evaluate the joint motion in patients with
spastic diplegic cerebral palsy and various other patient pop­
ulations.32 Similarly the EvaRT motion analysis system has
been used to collect data comparing mechanical and micro­
processor knees in patients with gait and balance deficits.33
PCI
(walking pulse
resting pulse)/gait speed
=
−
FIGURE 5-7  The Cosmed K4b2 method is an example of a por­
table pulmonary gas exchange system, which records and analyzes
data on a breath-by-breath basis. Heart rate and other metabolic
variables are monitored through integrated telemetry. (Courtesy of
COSMED-Pulmonary Function Equipment, Rome, Italy.)
FIGURE 5-8  This individual is wearing reflective spheres. An infra­
red camera system can track limb segment motion as the patient
walks across the field of view.

Chapter 5  Clinical Assessment of Gait
115
Left vs. right kinematics—barefoot
Trunk obliquity
Pelvic obliquity
Hip abduction-adduction
Knee varus-valgus
Knee flexion-extension
Plantar-dorsiflexion
Hip flexion-extension
Pelvic tilt
Trunk tilt
Trunk rotation
Pelvic rotation
Hip rotation
Knee rotation
Foot progression
30
Up
deg
Dn
–30
20
Up
deg
Dn
–20
20
Add
deg
Abd
–20
30
Var
deg
Val
–30
Gait cycle
25%
50%
75%
Gait cycle
25%
50%
75%
Gait cycle
25%
50%
75%
40
Ant
Pos
–20
35
Ant
Pos
0
60
Flx
Ext
–20
80
Flx
Ext
–20
40
Dor
deg
Pla
–40
40
Int
Ext
–40
40
Int
Ext
–40
40
Int
Ext
–40
40
Int
Ext
–40
40
Int
Ext
–40
FIGURE 5-9  The output generated by a computer-based motion analysis system includes graphs of
the mean range of motion at each body segment or joint (trunk, pelvis, hip, knee, and ankle) in coro­
nal (left column), sagittal (middle column), and transverse (right column) planes as the individual
being evaluated progresses through multiple gait cycles. This is the output of an 8-year-old child with
spastic diplegic cerebral palsy. (Courtesy of the Center for Motion Analysis, Connecticut Children's
Medical Center, Hartford, Conn.)

116
Section I  Building Baseline Knowledge
The Dartfish system is another motion analysis tool that is
used in gait laboratories and clinical settings.34 The Dartfish
system allows for two- and three-dimensional joint motion
analysis. It is portable, less expensive, and requires less time
to set up when compared with other motion analysis sys­
tems. Dartfish has been used to record and immediately
evaluate the effects of various prosthetic feet on knee flexion
during ­normal walking. These tools can allow for improved
­technique and transmission of information to patients and
optimally a decrease in recovery time.35
When an individual takes a step, he is exerting force
against the surface he is walking on. This kinetic information
is obtained from one or more force platforms, which collect
data on the three components of the ground reaction force:
vertical, fore-aft (anterior-posterior), and medial-lateral
(Figure 5-10). The contribution of kinetic data can be signifi­
cant. Fore-aft shear is quite useful in establishing appropriate
transtibial prosthetic alignment in the sagittal plane. For this
purpose the clinician would anticipate a balanced magnitude
and timing of the braking and propulsive patterns. Data col­
lection from two consecutive steps, one gait cycle, requires
dual force plates. Some kinetic software packages also offer
specialized programs for specific purposes such as stability
analysis, which provides information about center of gravity
shift relative to time.
While the typical force platform system provides data
about forces and moments occurring at the ground, or center
of pressure progression, it can be combined with kinematic
data to provide additional information. By combining these
two data sets, the moments and power acting at the joints
can be calculated. This information is useful in measuring
the dynamic joint control of an individual throughout stance,
particularly when used in conjunction with EMG. Similarly,
information about joint moments, sometimes referred to
as torque, is also often reported as an outcome measure in
research studies. While this information can be potentially
important in the evaluation of pathological gait, it is also nec­
essary to have a basic understanding of how these values are
derived. As mentioned, as an individual ambulates, the indi­
vidual exerts force on the walking surface; differing degrees
of this force are similarly exerted on each of the joints in the
lower extremity. With the exertion of these forces comes an
associated moment that is also acting at the joint, along with
a power value. In its most basic form, a moment is the result
of a force multiplied by a distance or lever arm.6 Joint power
is then calculated by multiplying the moment acting at a joint
by the joint's angular velocity. Additionally, the moment act­
ing on a particular segment is most frequently calculated with
reference to the center of mass of that segment. This means
that the lever arm is the distance from where the forces are act­
ing at the joint to the center of mass of the segment. In order
to calculate these values, the lower extremity must be broken
down into segments, often the ankle, shank or calf, and thigh.
By doing this, a link-segment model is being applied and the
parameters of interest can be calculated.36
To further illustrate, the interrelated nature of these mea­
sures, the calculation path for forces, moments, and power is
also presented (Figure 5-11). It is important to note within
the diagram where the different data sources originate. There
are very few directly measured values that are then combined
with biomechanical models to calculate these variables.
The calculation process begins with the determination of
the ground reaction forces, which are obtained through the
direct measurement of an individual stepping on a force plat­
form. Once that information is available, it is combined with
kinematic data, derived from a two- or three-dimensional
motion capture system for each lower extremity body seg­
ment, so that the joint reaction forces can be calculated. As
the forces at each of the joints are determined, then the associ­
ated moments acting on each segment can also be calculated.
Ultimately, the power can be calculated as well (Figure 5-12).
In many cases, instrumented kinetic and kinematic sys­
tems have included an inverse dynamics model that is applied
to determine the forces acting at each of the lower extrem­
ity joints. Like virtually all biomechanics models, certain
assumptions must be made in order for the calculation to be
carried out in a practical manner. With assumptions come
the opportunity for additional error introduction through­
out the process. This is why it is important to understand the
limitations associated with them. A fundamental point is that
frequently these calculations all rely upon data that are cal­
culated using general body proportions and anthropometric
models for whole bodied individuals. Because of this, certain
assumptions are made about the mechanical properties of the
segments and joints being evaluated. For example, many of
the commonly used models assume that the subject has no
limb deficiencies and essentially normal musculature. While
this may be acceptable for evaluations of individuals without
pathology, these assumptions can become a source of error
when evaluating an individual with an amputation or other
limb dysfunction. There is also the issue that the knee and
ankle joints are frequently modeled as simple hinge joints.
By doing this it makes the calculations more practical to
perform but does not completely represent the anatomical
­reality. Particularly in the case of the knee, the joint center
does not stay in a fixed position during stance, but many of
the models for calculating joint moments assume that it does
(Figure 5-13). As a result, there can be variation in the distance
used to calculate the moment at the knee. Considering the
physical location, even a small variation in the estimated joint
center could result in a significant change in the value calcu­
lated. Because many of the calculations rely upon the model
assumptions, the inherent errors can be easily compounded.
This is not to say that these variables should be ignored but
that their value should be tempered with an understanding of
the process for obtaining them.
Electromyography
Muscle action beneath skin and subcutaneous tissue cannot
be directly measured, but through the use of EMG, the ­activity
can be approximated and studied in relation to the action,
size of muscle, and signals obtained. EMG records the mus­
cle activity by the electrical signal detected from the contrac­
tion and chemical stimulation of the respective ­musculature.6

Chapter 5  Clinical Assessment of Gait
117
900
800
700
600
500
400
300
200
100
0
–100
–200
0.0
20.0
40.0
60.0
80.0
100.0
% Stance
Force (newtons)
900
800
700
600
500
400
300
200
100
0
–100
–200
0.0
20.0
40.0
60.0
80.0
100.0
% Stance
Force (newtons)
900
800
700
600
500
400
300
200
100
0
–100
–200
0.0
20.0
40.0
60.0
80.0
100.0
% Stance
Force (newtons)
A
B
C
FIGURE 5-10  Example of output generated by a forceplate as the individual being tested progresses through
stance phase. A, The anteroposterior component of the ground reaction force (GRF). B, The medial lateral
component of the GRF. C, The vertical component of the GRF. (Output courtesy of the Motion Analysis
Laboratory, Department of Physical Therapy and Human Movement Science, Sacred Heart University,
Fairfield, Conn.)

118
Section I  Building Baseline Knowledge
EMG instrumentation can vary, such as is seen with surface
EMG or fine-wire EMG. With surface EMG the electrode pad
is adhered to the skin above the muscle being studied, while
fine-wire EMG uses wire electrodes directly inserted into the
belly of the respective muscle. Intrasocket EMG is a relatively
new technique employing traditional surface EMG techniques
as well as the use of transcutaneous electrical nerve stimulation
(TENS) techniques to allow for EMG to be worn by amputees
underneath their prosthesis. This technique allows for EMG
information to be gathered on amputees during walking and
other dynamic activities.37 EMG data may be the single most
important technology in terms of understanding the direct
physiological effect of gait variants.
EMG records the motor unit activation of muscle fibers in
the specific muscle being studied. This is very useful but can
be problematic with surface electrode applications, in that
they can pick up the signal from surrounding musculature
during testing. EMG characterization allows for timing, rela­
tive intensity of muscular effort, as well as resultant muscle
force, all of which are necessary to understand normal and
pathological gait. EMG data are normalized against maxi­
mum contraction data for each respective muscle. Without
normalization, the data collected may be invalid and can lead
to erroneous interpretation. Maximum contraction is depen­
dent on joint angle as well as the duration of the contrac­
tion, both of which are influential to the overall information
extracted from analysis.
Subject Marker
Placement
Measurement of
Surface Markers
Anthropometric
Modeling
Anthropometric
Modeling
Anthropometric
Modeling
Calculation of
Joint Power
Calculation of
Joint Moments
Calculation of
Joint Forces
Kinematic Data
(Calculated Joint
Center Data and
Joint Angle Data)
Kinetic Data
(Three Dimensional
Ground Reaction
Force and Moment
Values)
Forceplate
Measurement
FIGURE 5-11  Calculation flowchart: the kinematic data collected from the motion analysis system
is entered into series of calculations based on the person's anthropometric data to produce the instan­
taneous position of every joint and segment. These data are then combined with force plate data col­
lected at the same time to calculate joint forces, moments, and powers.
FIGURE 5-12  Example of joint moment calculation. A, Vertical and
anteroposterior ground reaction forces recorded from a force plate.
B, Joint moments are calculated by combining ground reaction forces
and kinematic data, taking into account the segment's center of mass.

Chapter 5  Clinical Assessment of Gait
119
Patterns of muscle activity in patients with abnormal
gait are compared with well-established norms. Knowledge
of the timing and intensity of the muscle activity through­
out the gait cycle may guide gait training, orthotic or pros­
thetic prescription, and dynamic orthotic or prosthetic
alignment aimed at reduction of excessive, ill-timed, or
prolonged muscle activity. EMG is exceedingly adaptable
with the most basic function of superficial muscle activity
data to intramuscular fine wire sensor technology, which is
all cohesive to the implementation of many other complex
clinical or gait lab technologies.26 EMG data are also help­
ful in guiding decisions about surgical intervention (dorsal
rhizotomy, tendon lengthening, or osteotomy) in children
with cerebral palsy.
Pressure-Sensing Technology
Pressure-sensing technologies offer the clinician tremendous
insights into the treatment of patients at risk for amputation
because of vascular disease and diabetic neuropathy. They can
also assist vascular surgeons and orthopedic foot specialists
in limb salvage through more appropriate custom-designed
prophylactic orthoses. In some systems, a thin plastic array
can slip nearly unnoticed between the plantar surface of the
foot and an orthosis or insole of the shoe (Figure 5-14). This
array, connected to a computer by a lead wire, can measure
dynamic pressure patterns and record critical events through­
out the walking cycle. A prosthetic version can provide vari­
ous measurements at 60 individual sites within a socket and
record those measurements during multiple events of the gait
cycle. Pressure is expressed in terms of a force over the area at
which the force is acting.
Cavanaugh and colleagues state that “Pressure mea­
surement offers a way to help the clinician break out of the
cycle of trial and error that is so often necessary to find the
correct solution to a patient's problem.”38 Currently sur­
face pressure measurement systems exist in various forms
ranging from in-shoe, barefoot, seating and position­
ing, joint, and prosthetic and orthotic floor-based mod­
els. Over the years, Perry and colleagues have collected
data on the most common types of pressure testing sys­
tems that consist of a “force plate” that uses ink and paper
to record the areas of peak pressures during ambulation.
This type of system is inexpensive and provides reliable,
easily interpreted data. Instrumented insoles, however,
are positioned inside the patient's shoes and worn during
ambulation and activity performance. The insoles record
pressures and various forces on the plantar surface of the
foot through an integrated array of sensors.6 The diversity
of treatment applications has promoted these systems to
one of the most valuable in the laboratory setting.26 An
example of the application of pressure sensing technol­
ogy is the development of the dynamic gait stability index,
which is based on plantar pressure and utilized the F-Scan
insole sensors from Tekscan Inc. The compiled data was
used to evaluate dynamic gait stability through six dif­
ferent parameters and were then indexed across different
walking conditions, terrains, and speed.39–41 This area is
one of the more recent and clinically promising technologies
for the assessment team.
Pressure
Force/Area
=
FIGURE 5-13  Soft tissues and joint geometry differences between
the anthropometric model and the actual individual being, intro­
duce a potential error in calculating joint moments. In this ­example,
the outer circle indicates the potential range of location of the actual
joint center, compared to where the model ultimately defines it
(inner circle).
FIGURE 5-14  An in-shoe pressure-sensing array can help identify
areas of high pressure concentration. This information assists in the
design of an orthosis to modify pressure dynamics during the stance
phase of gait.

120
Section I  Building Baseline Knowledge
CHOOSING THE APPROPRIATE
ASSESSMENT TOOL
Over the past several decades, technologies have advanced and
aided in providing a significantly improved understanding of
pathological gait. They have also assisted clinicians in providing
strong evidence for the efficacy of various treatment approaches
and ultimately helped enhance patient care. Advocates of a more
universal application of the high-end technologies in the clinical
setting have made a compelling case for implementation in gait
laboratories and clinical settings alike across the field of reha­
bilitative care. Determining the extent and necessity for various
high-end devices, such as full featured motion analysis systems,
in the clinical setting can be a very extensive process requiring
the evaluation of the advantages and disadvantages to both the
patient and the clinic, particularly in the current climate of cost
containment. Perhaps the strongest argument for gait technol­
ogy in our present era lies in its use for outcome measurement
to justify legitimate therapeutic treatment approaches as well as
orthotic and prosthetic applications.
Recognizing the need, benefits, and drawbacks of tech­
nology in the clinical setting is very important. Appropriate
instrumented evaluations will need to be made by the reha­
bilitation team to help optimize patient outcomes.
FUNCTION-BASED ASSESSMENT
Task-oriented tests or functional measures are performance
based tools directly related to specific activities and linked to
“real-world” domains of function. For example walking in the
community requires meeting the demand of varied distance,
terrain, illumination, obstacles, stair-climbing, and ­multitasking.
These tests usually measure performance of the individual
against established norms for a specific population. Results of
functional measures serve as a baseline to establish goals and
benchmarks and evaluate progress after intervention.
Holden and colleagues42 suggest that gait performance goals
for patients with neurological impairments are best measured
against values from impaired rather than healthy ­subjects.
Treatment goals are adjusted for the individual patient's diagno­
sis, etiologic factor, ambulation aid, and functional category. In
separate studies, Brandstater and colleagues43 and Holden and
colleagues42 found that patients with the greatest number of gait
deviations did not have the lowest temporal values. A great deal
of energy is often expended by physical therapists, prosthetists,
and orthotists in an attempt to help patients achieve optimal gait
patterns. Holden and colleagues42 suggest that hard-won qual­
itative gait improvements may cause secondary losses in time-
distance parameters, such as slower velocity and reduced step
length. The fundamental issue is whether temporal gait effi­
ciency or cosmesis should be the preferred goal. Certainly, in
cases in which patients are nominal walkers and in which ther­
apy, surgery, and orthotics or prosthetics have optimized, gait
efficiency is far more important than reducing in compensatory
gait deficits.
In the past, symmetry and reciprocal movement patterns
have been significant treatment goals. Wall and Ashburn44
maintain that “an ideal objective in the functional ­rehabilitation
of hemiplegia is the reduction of the asymmetrical nature
of movement patterns.” Measuring pathological gait against
normal gait values is a useful means of providing an overall
clinical picture. In setting treatment goals, however, measur­
ing a patient's performance against their own best possible
outcome is more reasonable. How can a given patient's best
possible outcome be anticipated? This requires collection of
accurate data to establish pre-treatment and post-­treatment
profiles for a wide variety of involvement levels within
each pathological condition. Olney and Richards45 suggest
that large groups of instrumented studies be undertaken to
identify clusters of biomechanical features associated with
­functional performance during walking
Time-distance parameters have enormous potential for
setting outcome goals. Variations in time-distance values
are often specific to pathological condition. Asymmetries in
hemiplegia, for example, are obviously greater than in most
other types of pathological conditions. Variables that are
reported to affect temporal measurements in normal healthy
subjects include age, gender, height, orthotic use, or type of
assistive device. In separate studies of patients with pathologi­
cal conditions, Brandstater and colleagues43 and Holden and
colleagues42 found no significant difference in temporal per­
formance based on gender or age.
Corcoran and colleagues46 measured temporal param­
eters of subjects with hemiplegia under two gait conditions:
with and without their AFO. Patients with hemiplegia had
significantly faster gait velocity when wearing their orthoses
than when walking without them.46 Another similar study of
healthy unimpaired subjects wearing AFOs found reduced
step length. Apparently subjects without central nervous sys­
tem involvement altered their movement strategy to decrease
movements at the knee in an effort to minimize shearing forces
in the AFO.47 Reduced step length can minimize force exerted
by the brace along the posterior aspect of the calf band.48
Functional Measures
A wide variety of functional measures are available to pro­
vide information about ambulatory function of individuals
with neuromuscular, musculoskeletal, cardiopulmonary, or
metabolic diseases and conditions. Most of these measures
do not require specialized equipment or instrumentation.
Some of the principal functional measures currently in use
are (1)  Functional Ambulation Classification System (FAC);
(2)  Functional Independence Measure locomotion and
mobility subscales (FIM); (3) Gait Abnormality Rating Scale
(GARS); (4) Timed Up and Go Test (TUG); and (5) Dynamic
Gait Index (DGI). These measures provide information about
how gait impairments affect function in the person's environ­
ment, rather than about specific gait problems or deviations.
Most of these measures require some degree of practice or
training so that testers may develop accuracy in using the tool
and can apply all of its psychometric implications.
Walking Speed
Walking speed (WS) (or gait velocity) is the fundamental
walking measure which defines the person's basic walking
ability.6 It is the time required for a person to traverse a specific

Chapter 5  Clinical Assessment of Gait
121
distance. The term velocity indicates not only the speed of
travel but also the specific direction of travel. Since ­walking
is usually measured in the forward direction, the ­distinction
between speed and velocity is not significant. On level ground
people without pathology consistently walk at a preferred/
comfortable or “self-selected” walking speed. This speed is the
most efficient for that person; faster or slower speed will cost
more energy.49,50 In the gait laboratory, this preferred speed is
referred to as “free walking velocity” to be distinguished from
“fast walking velocity.”
Walking speed as a functional measure is highly reliable
and sensitive regardless of the method of measurement. In a
group of frail elderly individuals, Van Iersel demonstrated
that 5% change in walking speed had a sensitivity of 92% to
detect clinically relevant change.51 Walking speed also cor­
relates with functional ability and physiological changes.52
Several studies demonstrated that walking speed is a predictor
of important aspects of health status and future events includ­
ing hospitalization, discharge location, and mortality.53–57
Numerous factors contribute to walking speed including
joint mobility, muscle strength, sensory function, neural con­
trol, cognitive status, and energy level, so it can reflect overall
health. Fritz and Lusardi suggested considering walking speed
as the “sixth vital sign” in older adults. The NIH Toolbox for
the Assessment of Neurological and Behavioral Function
includes walking speed as a measure of motor function.58
In gait laboratory, researchers have used a variety of state-of-
the-art equipment including portable computerized walkways,
motion analysis systems, and foot switches to measure walking
speed. Clinicians, however, can reliably measure walking speed
in almost any clinical setting using a stopwatch and a walkway.
Most published reports measured walking speed for the middle
6 m of a 10-m walkway to avoid the acceleration and decelera­
tion phases and capture the steady walking speed. Suggested
walkway distance varied greatly between studies, however; a
walkway as short as 6 m (recording zone is the central 4 m) is
still a reliable measure (NIH). Fritz and Lusardi suggest a 10-m
test with added 5 m for acceleration and 5 m for deceleration.59
In people without pathology, several factors affect walk­
ing, including age, gender, lower extremity length, strength,
and spontaneous variability between individuals.59 To fol­
low the International Standards of Measurement, Gait Speed
should be expressed in m/sec. Collectively the range for nor­
mal walking speed for adults is between 1.2 and 1.4 m/sec.
Others reported walking speeds in m/min to be compatible
with other energy and cadence measurement. Waters and
­colleagues reported a similar average of 82 m/min for adults.60
Functional Ambulation Classification
Holden and colleagues42 suggest that grouping subjects by
motor ability or functional category is more important than
grouping by other indicators of gait. They have developed the
Massachusetts General Hospital (MGH) FAC.61 Six functional
categories are defined in their system. A score of 0 indicates
nonfunctional ambulation. Patients who require significant
and constant assistance of another person for support and bal­
ance receive a score of 1. A score of 2 indicates that light touch
or intermittent physical assistance is required, and 3 means
that the patient needs verbal cueing or occasional safety assis­
tance. To be scored as a 4, the patient must be independent in
ambulation on level surfaces, and a score of 5 means the patient
is independent in ambulation on level and nonlevel surfaces,
including stairs and inclines. Although the FAC is a general
ambulation test, its scores showed a positive linear relation­
ship with such variables as gait velocity and step length.
The FAC has been used most extensively in the assess­
ment of functional locomotion and as a rehabilitation out­
come measure for individuals recovering from stroke.62–64 In a
Rausch analysis of discriminant validity of measures used to
assess outcome of stroke rehabilitation intervention, however,
FIM motor scores and walking speed were better discrimina­
tors of outcome than FAC scores.65 The FAC has also been
helpful in assessing concurrent reliability of new mobility
measures in stroke rehabilitation and portable instrumented
pressure-sensitive monitors.66,67
Functional Independence Measure
Initially developed to assess burden of care for staff caring for
patients in acute care settings, the FIM is a multidimensional
scale that assesses locomotion as one dimension of overall
functional status.68 In the last decade, it has come into wide
use as a tool to assess outcomes of rehabilitation interventions
for patients with musculoskeletal conditions such as hip frac­
ture and total joint replacement and for those with neuromus­
cular conditions such as spinal cord injury, myelopathy from
spinal stenosis, and stroke.69–75 The WeeFIM is a version of the
FIM intended for use with children with cerebral palsy and
other developmental disabilities, acquired brain injury, and
other neuromuscular and musculoskeletal impairments.76–79
The reliability and validity of the FIM have also been assessed
in home care and assisted living settings for frail and dis­
abled older adults.80,81 There is both a performance-based and
­interview-based version of the FIM.82,83
The FIM has two domains of function: motor and cogni­
tive.82 The motor subscale has four dimensions: self-care (eat­
ing, grooming, bathing, dressing upper body, dressing lower
body, and toileting), sphincter control (bladder and bowel
management), ability to transfer (bed-chair-wheelchair, toilet,
tub or shower), and locomotion (ambulation or wheelchair
use, stair management). The cognitive subscale includes com­
munication (comprehension and expression) and social cogni­
tion (social interaction, problem solving, and memory). The
range of possible scores for each component of the subscales
is 1 (total assistance required) to 7 (completely independent
without any assistive device). Each component has specifi­
cally defined criteria. The scoring criteria for the ambula­
tion component of the locomotion subscale are summarized
in Table 5-1. The evidence of the measure's validity is stron­
gest when a composite FIM score or motor/cognitive subscale
scores are used, although component scores are sometimes
used in documentation and record keeping.81
Gait Abnormality Rating Scale
Wolfson and colleagues84 developed the original GARS in an
effort to quantify abnormal gait performance of frail institution­
alized older adults and identify those most at risk of falling. The

122
Section I  Building Baseline Knowledge
scale has since been modified (GARS-M) by VanSwearingen
and colleagues85 for use in community settings.
In the GARS-M, a videotape of a patient walking on a level
surface is scored on seven dimensions: variability, guarded­
ness, staggering, foot contact, hip range of motion, shoulder
extension, and synchrony of arm movement and heel strike.
The measure uses a four-point criterion-based rating scale
(0 to 3). Total GARS-M scores range from 0 to 21, with high
scores indicating less efficient or safe performance. Gait vari­
ability is one of the unique measures of the GARS-M, which
has been linked to increased fall risk in older adults. Huang
and colleagues86 documented the validity of the GARS-M by
comparing its scores with those recorded on a computerized
walkway. Evidence of interrater and intrarater reliability, and
concurrent validity (compared with temporal and distance
parameters of gait) and discriminate validity (between fallers
and nonfallers) have been reported.85,87
Timed Up and Go
The TUG test is commonly used with frail older adults with
limited mobility. Patients are asked to rise from a seated
­position in a standard height chair, walk 3 m on a level sur­
face, turn, walk back to the chair, and return to a seated posi­
tion, moving as quickly as they are safely able. Although the
original get up and go test used a somewhat subjective 0 to 5
rating to score each component of the task, performance is
now based on total time to complete the task.88,89 In both ver­
sions, individuals being evaluated are instructed to move as
quickly as they are safely able to move. Importantly, the TUG
is a measure of overall functional mobility, assessing the abil­
ity to transfer, walk, and change direction.
Several studies documented reference ranges for the TUG
in community-dwelling older adults.90–93 Bohannon consol­
idated data from 21 studies for meta-analysis on the TUG
reference values in people older than 60 years of age.94 The
mean TUG time for individuals at least 60 years of age was 9.4
(8.9 to 9.9) seconds. When the data were divided into three
age subgroups, the mean for those 60 to 69 years was 8.1 sec­
onds, for 70 to 79 years was 9.2 seconds, and for 80 to 99 years
was 11.3 second. Several other studies documented the higher
mean of the TUG values as age increased and for women
compared to men.92,93 Intrarater and interrater reliability of
the TUG is excellent, Intraclass Correlation Coefficients
range between 0.97 and 0.99.90 Although the TUG does not
­specifically assess walking speed, it assesses the more func­
tional components of mobility and transfer from sit to stand.95
The TUG times increased when healthy older adults
were tested using an assistive device.96,97 Reference range for
the TUG times in patients who use assistive devices is not
available. Higher TUG times are associated with functional
impairment in individuals with arthritis, amputation, hip
fracture, and Parkinson's disease.98–104
Dynamic Gait Index
The dynamic gait index (DGI) is a useful test in patients
with vestibular and balance problems.105 It includes eight
items, walking on level surfaces, changing speeds, head turns
in horizontal and vertical directions, walking and turning
180 degrees to stop, stepping over and around obstacles, and
stair ascent and descent. Each item is scored on a scale of 0 to 3,
with 3 indicating normal performance and 0 representing
severe impairment. The best possible score on the DGI is a
24. Several studies demonstrated its high intrarater and inter­
rater reliability in older adults and in different patient popula­
tions.106–108 A score of less than 19 indicates a risk for falling.107
A short form of the DGI includes only four items: walking
on level surfaces, changing speeds, and head turns in hori­
zontal and vertical directions.109 Anything less than the maxi­
mum score of 12 on the short form identified individuals with
balance deficit and those who scored less than 10 were at risk
for falls.95
CHOOSING AN ASSESSMENT STRATEGY
Recognizing similarities and differences in purpose and design
of the various gait assessment methods is important. Gait-
based methods, such as the Rancho Los Amigos observational
gait assessment, seek to identify and differentiate pathologi­
cal versus compensatory mechanisms and therefore guide the
specific surgical, therapeutic, orthotic, or prosthetic interven­
tions for a particular patient. Functional indexes, such as the
MGH FAC, the FIM, or the TUG, may be a means of evaluat­
ing treatment efficacy, disease-related decline, or improvement
over time. The cost of gait assessment through comprehensive
instrumented procedures often precludes its general use in
the clinical arena. Observational analysis through gait-based
assessment will remain a viable and important contribution to
clinical care for many years to come.
TABLE 5-1  Scoring Criteria for the Locomotion Component of the Functional Independence Measure
Score
Score Criteria
7
Able to walk at least 150 feet (50 m) completely independently, without any type of assistive device or wheelchair, safely and
within a reasonable (functional) period of time
6
Able to walk at least 150 feet (50 m) independently, but requires an assistive device (orthosis, prosthesis, wheelchair, special shoes,
cane, crutches, walker), or takes more than reasonable time, or has safety concerns
5
Requires standby supervision, cueing, or coaxing to walk or propel wheelchair at least 150 feet (50 m)
4
Requires minimum contact assistance (patient contributes 75% effort) to walk or propel wheelchair at least 150 feet (50 m)
3
Requires moderate assistance (patient contributes 50% to 74% effort) to walk or propel wheelchair a minimum of 150 feet (50 m)
2
Requires maximal assistance of one person (patient contributes 25% to 49% effort) to walk or propel wheelchair 50 feet (17 m)
1
Requires total assistance (patient contributes less than 25% effort) or requires assistance of more than one helper, or is unable
to walk or propel wheelchair at least 50 feet (17 m)

Chapter 5  Clinical Assessment of Gait
123
CLINICAL EXAMPLES OF GAIT DEFICIENCIES:
IMPACT OF FUNCTIONAL TASKS DURING GAIT
The following case examples illustrate gait deficiencies associ­
ated with pathological conditions that commonly alter gait per­
formance: pretibial flaccid paralysis, hemiplegia, cerebral palsy,
and spina bifida. As might be expected, each example demon­
strates common gait characteristics specific to the particular
pathological condition while presenting variants from that pro­
file. The discussion is based on information gathered by foot-
switch stride and kinematic and observational gait analysis.
CASE EXAMPLE 1
A Patient with Flaccid Paralysis of Pretibial Muscles
J. J. is a 37-year-old man with inherited sensorimotor neu­
ropathy (Charcot-Marie-Tooth disease) who has been
referred to the gait assessment clinic for evaluation of his
orthotic intervention. Examination of muscle function and
strength reveals relatively symmetrical distal impairment.
Manual muscle test scores include “trace” activity of dor­
siflexion muscles bilaterally, “poor” plantar flexion on the
left, and “fair+” plantar flexion on the right. Knee and hip
strength is “normal.”
Questions to Consider
• Given J. J.'s pattern of weakness, what types of primary
difficulties or deviations might you predict during the
functional task of (1) weight acceptance (IC and LR),
(2) single limb support (MSt and TSt), and (3) swing
limb advancement (PSw, ISw, MSw, and TSw)?
• Given J. J.'s pattern of weakness, what compensatory
strategies (pathological gait deviations) might he use to
accomplish these functional tasks of gait?
• What quantitative measures, indicators of energy cost,
qualitative measures, or function-based assessments
would you use to determine whether a change in ortho­
ses would be warranted? Why would you select those
measures?
Examination and Evaluation
During a foot-switch stride analysis, J. J. walks without his
usual orthoses. In the trailing left limb, the posterior com­
partment fails to support the forefoot lever arm so that the
tibia progresses forward with limited heel-off in late stance
(Figure 5-15). This creates excessive knee flexion and limits
the step length of the contralateral limb. The net effect of this
A
B
FIGURE  5-15  A patient with Charcot-Marie-Tooth disease demonstrates shortened right stride
length because of inadequate support at the foot and ankle in late stance of the left limb (A), and the use
a compensatory steppage gait to ensure swing clearance in the presence of dorsiflexion weakness (B).
Continued

124
Section I  Building Baseline Knowledge
Clinical Characteristics of Gait in Hemiplegia
For most patients who are recovering from stroke—
cerebrovascular accident (CVA)—improvement in the quality
of gait is related to the natural history of the pathological pro­
cess and the impact of gait retraining in rehabilitation. In the
week immediately after CVA, only 24% to 38% of patients are
able to ambulate independently.110 After weeks of rehabilita­
tion, more than 50% are able to walk without assistance, espe­
cially if using an appropriate AFO and assistive device.111 At
the 6-month mark, more than 80% of patients with CVA are
functionally independent in ambulation.112
The many variations of limb control observed during
the gait of patients who are recovering from a CVA can be
explained by one or more of the following factors: primitive
locomotor patterns, impaired postural responses, abnormal
postural tone with various degrees of spasticity and rigidity,
inappropriately timed muscle contractions, and diminished
muscle strength. One of the primary determinants of gait dys­
function in post-CVA hemiplegia is whether the patient has
some degree of selective control of specific muscles rather
than activation of abnormal synergy patterns (mass flexion
or extension). Patients with hemiplegia often have difficulty
grading the magnitude of a particular muscle contraction with
respect to other muscle contractions. Because of hyperactiv­
ity of muscle spindle/stretch reflex in the presence of spas­
ticity, the ability to move toward dorsiflexion with forward
progression of the tibia during stance may be counteracted
by contraction of plantar flexors into a position of equinus.
Spasticity, although difficult to measure, can be described for
clinical purposes with the Ashworth Spasticity Scale.113 The
baseline level 0 indicates no measurable tone. A designation
of level 1, mild tone, is given when a muscle “catches” with an
abrupt passive movement into flexion or extension. A level
2 designation indicates marked abnormal tone but flexible
range of motion and level 3 is characterized by pronounced
tone and difficult passive movement. Level 4 denotes a limb
that is held rigidly in either flexion or extension.
The orthotic goal for patients with hypertonicity of the
lower extremity after a CVA is to control ankle motion and
preposition for tibial advancement. Two orthotic strategies
are commonly used: (1) provision of an AFO with a locked
ankle component set in slight dorsiflexion or (2) use of an
articulated AFO that allows slight ankle motion around
the neutral position. When ankle joint motion is limited or
blocked by an orthosis, stability in stance improves; however,
forward progression of the tibia is compromised, and step
length is reduced. Modifications to the shoe, such as applica­
tion of a rocker bottom sole or elevation of the heel, can com­
pensate by mimicking the second rocker of gait.
Over the course of rehabilitation, the patient with hemi­
plegia often experiences changes in tone, joint flexibil­
ity, pain or discomfort, fear or confidence, motor strength
or weakness, and quality of proprioception. Six stages
of motor recovery in hemiplegia have been identified by
Brunnstrom.15 In the  first stage, no voluntary movement
of limbs is present. In the ­second, movement reappears
but is limited by pronounced muscle weakness or spastic­
ity, or both. The patient is usually not yet ready for func­
tional ambulation. In the third stage, spasticity coexists
with limb synergy motion. Typically a mass extensor pat­
tern is seen in the lower limb. As the patient continues to
improve in the fourth stage, spasticity may be reduced as the
patient begins to move out of stereotypical synergy patterns.
In stage 5, selective control outside mass synergy patterns
becomes more consistent and more functional. With recov­
ery complete, in stage 6 the patient may achieve ­coordinated
inadequate forefoot rocker is a reduction in velocity. Lack
of support of the trailing forefoot allows depression of the
center of gravity. At the same time, dorsiflexion weakness
on the right creates early, abrupt plantar flexion (foot slap)
with premature contact of the first metatarsal. The variance
between plantar flexor strength of the left and right limbs
is demonstrated by difference in single-limb support times.
The stronger right calf participates in 39.8% (0.416 sec) of
the gait cycle, whereas the weaker left calf commits itself to
only 31.4% (0.328 sec). This subtle timing discrepancy in
gait was not readily identifiable in observational analysis.
In right MSw, while the left foot is in a supporting pos­
ture, the classical steppage gait characteristics of a flail
forefoot are observed: Compensatory swing clearance is
accomplished through excessive hip and knee flexion (see
Figure 5-12B).
When J. J. wears his orthoses (a dorsiflexion assist ther­
moplastic AFO on the right and a dorsiflexion stop–­plantar
flexion resist thermoplastic AFO on the left), results of
foot-switch temporal analysis are quite different. Velocity,
cadence, and stride length increase slightly. The asymmetry
between right and left single limb support times decreases
because the AFO provides external support of the trailing
left limb. The energy-inefficient steppage gait and unsightly
foot slap are diminished as well.
Questions to Consider
• What specific problems do the examination and eval­
uation identify in each of the functional tasks of gait:
weight acceptance (IC and LR), single limb support
(MSt and TSt), and swing limb advancement (PSw, ISw,
MSw, and TSw)?
• In what ways do J. J.'s orthoses address the functional
problems observed when he walks without his orthoses
in each of the functional tasks of the gait cycle: weight
acceptance (IC and LR), single limb support (MSt and
TSt), and swing limb advancement (PSw, ISw, MSw, and
TSw)? In what ways do his orthoses potentially limit each
of the functional tasks of gait? Do the benefits outweigh
the limitations?

Chapter 5  Clinical Assessment of Gait
125
controlled movement. Because of the dynamic nature of the
recovery process, the ability to adjust or alter orthotic align­
ment or characteristics is very desirable. It is not unusual
that an orthosis prescribed early in rehabilitation becomes
inappropriate or creates further gait dysfunction at a later
stage. Once rehabilitation is complete and the patient has
achieved stability in walking patterns, definitive biome­
chanical needs are identified and the adjustability of the
orthosis is less important.
The extension synergy pattern places the lower extrem­
ity in excessive extension at the hip and knee and the foot in
equinovarus. This reduces the amount of knee flexion and
dorsiflexion during swing, necessitating a compensatory
strategy, such as circumduction, to provide swing phase
clearance.114 Rigidity of the ankle leaves the patient with
inadequate dorsiflexion mobility as well as vastly reduced
plantar flexion excursion during PSw and early swing. Stance
time is considerably reduced on the hemiplegic/paretic
side, and the quadriceps, gastrocnemius, gluteus maxi­
mus, and semitendinous muscles are inappropriately active
throughout stance.115 Activity of lower limb muscle groups
on the hemiplegic/paretic side is increased compared with
normal patterns of muscle activation. Excessive hip flexion
at MSt on the hemiplegic/paretic side shifts the GRF line
anteriorly, producing a knee extension moment that inter­
feres with forward progression. The hemiplegic/paretic
side also displays less hip adduction in single limb support,
which compromises lateral shift toward the affected side.116
Brandstater and colleagues42 describe reduced velocity,
cadence, stride length, and single limb support time on the
affected side, with consequent increased single limb sup­
port and reduced step length on the sound side. Hirschberg
and Nathanson115 demonstrated that an appropriate AFO
improves the quality of gait by increasing step length and
stance time as well as reducing swing time of the affected
side. Velocity of gait improves when the AFO is placed in
slight dorsiflexion. When spasticity is not problematic, an
AFO that permits some plantar flexion normalizes IC to LR
timing and prevents an unstable knee flexion moment in
early stance. Because knee extensor strength often equals or
exceeds hip extensor strength after CVA, most patients with
hemiplegia can be effectively managed with an AFO rather
than a knee-ankle-foot ­orthosis.116 Muscle strengthening is
less important in achieving improved walking characteris­
tics in hemiplegia than is the retraining of normal move­
ment patterns in gait.117
CASE EXAMPLE 2
A Patient with Hemiplegia
M. G. is a 67-year-old man referred to the gait laboratory for
evaluation 13 months after a CVA damaged the sensorimo­
tor cortex of the left hemisphere. Currently he is a commu­
nity ambulator (MGH functional ambulation classification
level 6) who walks with the aid of an AFO and quad cane
(FIM locomotion score 6). In the clinical examination, his
spasticity becomes apparent when his ankle moves toward
a neutral position (Ashworth spasticity scale level 3). The
orthosis he received early in rehabilitation, and continues to
use, is a traditional double upright, which locks his ankle in
slight plantar flexion. Although this ankle angle delays tibial
advancement and forward progression in stance, the patient
has come to rely on its contribution to stability at proximal
joints.
Questions to Consider
• Given M. G.'s pattern of spasticity and weakness, what
types of primary difficulties or deviations might you pre­
dict, when he is not wearing his orthosis, during the func­
tional task of weight acceptance (IC and LR)? Of ­single
limb support (MSt and TSt)? Of swing limb advance­
ment (PSw, ISw, MSw, and TSw)?
• Given M. G.'s pattern of spasticity and weakness,
what compensatory strategies (pathological gait devi­
ations) might he use to accomplish these functional
tasks of gait?
• What additional quantitative measures, indicators of
energy cost, qualitative measures, or function-based
assessments would you use to determine if a change in
orthosis would be warranted? Why would you select
those measures?
Examination and Evaluation
M. G.'s gait with the AFO is evaluated by foot-switch test­
ing. Extensor synergy patterns contribute to function by
providing a degree of stability in stance but also reduce effi­
ciency of gait by limiting normal stance progression begin­
ning with the first rocker period (Figure  5-16). Duration
heel-only time of the first rocker (IC to the foot-flat position
at the end of LR) is approximately one sixth of a second on
the hemiplegic side, which is significantly less than normal
heel-only time. Heel-only time on the intact side is roughly
three times greater than that on the hemiplegic side. Forward
progression during MSt is halted at the second rocker when
spasticity prevents the necessary dorsiflexion of the ankle
(see Figure 5-13). As M.G. moves into TSt, when metatar­
sophalangeal break (concurrent with heel-off) should allow
progression onto the forefoot, the third rocker is also rela­
tively blocked. This lack of mobility of the metatarsophalan­
geal joints, and inadequate third rocker, result in a loss of
knee flexion, necessary for an effective PSw, for which the
patient is unable to compensate. Of the 60 degrees of knee
Continued

126
Section I  Building Baseline Knowledge
Clinical Characteristics of Gait in Spastic Diplegic
Cerebral Palsy
Children with spastic diplegic cerebral palsy often have signifi­
cant spasticity and marked weakness of the antigravity mus­
cles in both lower extremities. This combination is a precursor
of joint contracture. The clinical term often used to describe
the typical gait of a patient with diplegia is crouched gait. In
crouched gait, marked internal rotation of the femur and tibia
occurs throughout the gait cycle, the knees remain in flexion
throughout stance, and the ankles remain in plantar flexion dur­
ing stance (toe walking) and swing. Gage118 clearly documented
the high energy cost of flexed knee gait. The pathological
combination of an equinus ankle, positive Trendelenburg hip,
and stiff knee gait often produces various combinations of
compensatory hiking of the pelvis, external rotation of the foot,
and circumduction of the swing limb. This pattern has been
attributed to tightness and overactivity of the distal hamstrings,
alone or in combination with the hip flexors.119
Some patients with diplegia ambulate with a jump gait
pattern, using somewhat less hip and knee flexion than
do patients with crouch gait but with excessive ankle dor­
siflexion rather than plantar flexion.120 Jump gait is often
a postoperative manifestation of bilateral Achilles tendon
lengthening without concurrent release of hip and knee
flexion necessary for the swing phase clearance, 35 degrees
should be achieved passively during PSw. For patients with
hemiplegia, the loss of this positional flexion is an additional
challenge to clearance, beyond that produced by the equinus
position of the ankle. Any attempts to compensate by “hip hik­
ing” are likely to be inefficient and unsuccessful. These rocker
limitations reduce step length of the sound side, leading to
premature double limb support. The corresponding MSw
knee flexion on the hemiplegic side is also reduced. MG
demonstrates a much reduced stance time on the affected
side (62% gait cycle) versus the sound side (71% gait cycle)
and a reduced single limb support time on the affected side
(28% gait cycle) versus the sound side (38% gait cycle).
Questions to Consider
• What specific problems has the examination and eval­
uation identified in each of the functional tasks of gait:
weight acceptance (IC and LR), single limb support
(MSt and TSt), and swing limb advancement (PSw, ISw,
MSw, and TSw)? How do these problems relate to his
abnormal tone and motor control?
• In what ways does M. G.'s orthosis address or constrain
each of the functional tasks of the gait cycle: weight
acceptance (IC and LR), single limb support (MSt and
TSt), and swing limb advancement (PSw, ISw, MSw,
and TSw)?
A
B
FIGURE 5-16  A patient with hemiplegia after cerebral vascular accident, the first rocker from initial con­
tact to foot flat (A) is abrupt as a result of extensor patterns and limb rigidity. Extensor pattern at the ankle
(B) translates into a failure to yield into dorsiflexion toward the end of the second rocker. Third rocker heel
elevation will also be reduced, and lack of mobility reduces the step length of the contralateral limb.

Chapter 5  Clinical Assessment of Gait
127
contractures. Common compensatory strategies in jump
gait include vaulting and circumduction. In crouch and
jump gait, the GRF line falls progressively behind the knee
joint center during single limb support of the stance phase.
This creates an excessive demand on the quadriceps for
stance phase stability. One surgical strategy used to cor­
rect jump gait combines hip flexion releases, hip flexion
release lengthening of the distal hamstrings, and correc­
tion of external rotation. Postoperatively, the patient is fit­
ted for floor reaction AFOs.121 Ideally, the Achilles ­tendon
is lengthened to neutral dorsiflexion position and the
patient protected in AFOs for 1 year postoperatively.
The scissoring pattern, which is also a common gait devi­
ation in children with diplegia, is aggravated by spastic hip
flexors and adductors because the smaller base of support
reduces the efficiency of their line of pull. Orthotic solu­
tions provide limited assistance in limb tracking and rota­
tional control. Those that attempt to control rotation must
cross the hip joint, adding significant weight and bulk and
increasing difficulty in donning and doffing.
CASE EXAMPLE 3
A Patient with Spastic Diplegic Cerebral Palsy
K. E. is a 10-year-old boy with spastic diplegic cerebral palsy
who has been referred to the gait laboratory for evaluation
to assist his orthopedist in deciding whether corrective sur­
gery is indicated. The boy currently ambulates indepen­
dently, without assistive devices, wearing bilateral solid
ankle AFOs (WeeFIM locomotion score of 6).
Questions to Consider
• Given K. E.'s pattern of spasticity and weakness, what
types of primary difficulties or deviations might you pre­
dict when he is not wearing his orthoses during the func­
tional task of weight acceptance (IC and LR)? Of single
limb support (MSt and TSt)? Of swing limb advance­
ment (PSw, ISw, MSw, and TSw)?
• Given K. E.'s pattern of spasticity and weakness, what
compensatory strategies (pathological gait devia­
tions) might he use to accomplish these functional
tasks of gait?
• What additional quantitative measures, indicators of
energy cost, qualitative measures, or function-based
assessments might help determine whether surgical ortho­
pedic intervention is warranted? Why would you select
those measures?
Examination and Evaluation
K. E. is fitted with reflective markers for three-dimensional
motion analysis of this gait. A typical crouch gait pattern is
observed during observational gait analysis while his gait
is being recorded for more detailed kinematic and kinetic
analysis by computer software. Foot-switch analysis con­
firms diminished heel contact with no heel-only time on
the left and no heel contact at all on the right.
Clinical examination of K. E.'s lower extremity func­
tion reveals a combination of overactive hamstrings
and weak gastrocnemius and soleus (Figure  5-17). The
flexion of hips and knees increases the need for proxi­
mal stabilization, resulting in compensatory hyperex­
tension of the trunk and posterior arm placement (see
Figure 5-14B). Because the ankles are held in equinus, the
final rocker propels tibial advancement despite limitation
in ankle mobility. K. E. spends most of the stance phase
in TSt and PSw; consequently, double limb support time
is vastly increased.
K. E. has not had previous surgical release of his gas­
trocnemius muscles. Even with surgery, impairment of
motor control may continue to be problematic, so that
dorsiflexion may not work in concert with the knee flex­
ion to provide a heel-toe gait pattern. Gastrocnemius
release without concurrent release of the hip and knee
contractures usually leads to short step lengths with a
compensatory increase in cadence. Spastic hip flexors,
also serving as adductors, create a mild scissors effect
during each swing limb advancement. Ambulation with
bilateral AFOs, which the patient prefers, increases step
length and reduces knee flexion compared with ambula­
tion with no orthosis.
A
B
FIGURE  5-17  A child with spastic diplegia, classic crouch gait
(A) is characterized by increased hip and knee flexion in combina­
tion with toe walking. Postural substitutions in crouch gait (B) may
include increased lumbar lordosis, trunk extension, and posterior
arm placement.
Continued

128
Section I  Building Baseline Knowledge
Clinical Characteristics of Gait in Children
with Spina Bifida
Spina bifida (myelomeningocele) occurs when vertebral
arches fail to unite very early in gestation. Clinically, this
leads to partial or complete paralysis at or below the level
involved. The most common impairment is a flaccid paral­
ysis, with loss of proprioception and exteroception (pain,
temperature sensation, light touch, and pressure sensation).
Many children with spina bifida have significant ambu­
latory deficiencies; more than 50% require an orthosis of
some kind to ambulate.122 Assessment for orthotic support
begins as soon as the child attempts to gain an erect posture.
Severity of gait dysfunction depends on the level of
involvement of the spinal cord. When the L-5 and S-1 nerve
roots are affected, the gluteus maximus, hip abductors, and
triceps surae are lost; the hamstrings are present but weak;
and sensory loss is limited to the plantar surface of the feet.
The plantar flexor deficit requires setting limits to dorsi­
flexion range of motion through orthotic joint control. This
limitation of dorsiflexion allows the patient to establish hip
stability through hip extension accomplished with exagger­
ated trunk lordosis. Without it, the patient would fall forward
unopposed. Lateral stability is achieved through crutches and
a wide walking base.
When the L-3 and L-4 root nerves are affected, hamstring
function, hip extension, knee flexion, plantar flexion, and
dorsiflexion are completely lost. The resulting foot drop can­
not be adequately compensated for in swing by hip and knee
flexion. Hip flexion, adduction, and knee extension are intact
but may be weak. At the L-3 level, weak knee flexion from
the gracilis may also be present. These children benefit early
from standing frames; later, they often are able to ambulate
with orthotic assistance . Adequate stabilization of the foot
and ankle is achieved through orthotic application of a locked
ankle in neutral or slight dorsiflexion. Trunk lordosis is a
compensatory strategy used to stabilize the hip during stance.
The muscular imbalance at the hip increases the likelihood
of flexion contracture, which in turn amplifies the need for
even more compensatory lordosis. Extreme hip flexion con­
tracture may ultimately preclude ambulation. If contractures
at the hip, knee, and ankle are minimal and the child gains
trunk control, he or she will be able to stand erect but will rely
on trunk alignment for static balance and forearm crutches
for further stability.
A child with lesions that involve L-1 and L-2 levels has
little lower limb function other than weak hip flexors.
Such children often begin upright function with a para­
podium or swivel walker and can later progress to recip­
rocal gait orthoses. The swing-through gait with bilateral
hip-knee-ankle-foot orthosis has been shown to be less
efficient than a reciprocal gait orthosis for thoracic level
spinal bifida.123
CASE EXAMPLE 4
A Child with Spina Bifida
N. P. is an active 9-year-old boy with myelomeningocele at
L-5 who returns to the gait laboratory as part of an ongoing
research study to document changes in gait characteristics
over time. He currently ambulates wearing bilateral AFOs
set in a neutral ankle position, using Loftstrand crutches in
a four-point reciprocal gait pattern.
Questions to Consider
• Given N. P.'s pattern of weakness and sensory loss, what
types of primary difficulties or deviations might you
predict when he is not wearing his orthoses, during the
functional task of weight acceptance (IC and LR)? Of sin­
gle limb support (MSt and TSt)? Of swing limb advance­
ment (PSw, ISw, MSw, and TSw)?
• Given N. P.'s pattern of weakness and sensory loss,
what compensatory strategies (pathological gait devi­
ations) might he use to accomplish these functional
tasks of gait?
• What additional quantitative measures, indicators of
energy cost, qualitative measures, or function-based
assessments might help determine if surgical orthopedic
intervention is warranted? Why would you select those
measures?
Examination and Evaluation
Comparative foot-switch testing reveals that, without
crutches, stride length and velocity are reduced. External
rotation of both limbs is present throughout the gait cycle
Questions to Consider
• What specific problems does the examination and eval­
uation identify in each of the functional tasks of gait:
weight acceptance (IC and LR), single limb support
(MSt and TSt), and swing limb advancement (PSw, ISw,
MSw, and TSw)? How do these problems relate to K. E.'s
abnormal tone and motor control?
• In what ways do K. E.'s orthoses address or constrain
each of the functional tasks of the gait cycle: weight
acceptance (IC and LR), single limb support (MSt and
TSt), and swing limb advancement (PSw, ISw, MSw,
and TSw)? What is the interaction of his abnormal
tone and impaired motor control with his orthoses on
the efficacy and energy cost of his walking?

Chapter 5  Clinical Assessment of Gait
129
GAIT PATTERNS IN INDIVIDUALS WITH
AMPUTATION
Qualitative observational gait analysis is a broadly accepted
approach to achieving a clinically optimal gait in individu­
als with amputation. Instrumented gait analysis provides a
more repeatable accurate assessment of prosthetic function.
In its broadest scope, the data derived increasingly serve as
foundation guidelines for both prosthetic design and clini­
cal application. The daily practice of assessment and manage­
ment of prosthetic gait, however, depends on the subjective
skills of the prosthetist and the targeted treatment protocol
of the therapist.
The University of California at Berkeley prosthetic project,
which began in the mid 1950s, represented the most concen­
trated period of prosthetic advancement. The comprehensive
basic gait studies and their application to the biomechanics
of amputee gait for transtibial and transfemoral amputations
established fundamental design criteria.124 Contributions of
subsequent investigators continue to be largely based on the
Berkeley criteria.
Extensive
calculations
and
interpretations
were
required to relate normal and prosthetic gait data to the
problems of prosthetic design. Data reduction was a slow
process before relatively recent technological advance­
ments because all motion measurements had to be
­performed by hand. There were no automated film ana­
lyzers to identify the motion patterns and no computers
to perform rapid data processing. Therefore, the number
of subjects studied was limited. The project also had the
additional depth of considering all three planes of motion,
in contrast to prior studies that analyzed only the sagit­
tal plane of gait progression.6,125 Subsequent investigators,
with the aid of more advanced instrumentation, have rep­
licated and expanded the Eberhart-Inman work but have
not found it in error.
Transtibial Prosthetic Gait
In 1957 the Berkeley project was specifically commissioned
to reconsider transtibial prosthetic gait and biomechan­
ics; with that goal, an advisory conference was held.126 Basic
transtibial prosthesis at that time was attached to the limb
with a thigh lacer that included articulated knee joints and a
foot with an articulated ankle. Detailed review of the normal
and transtibial amputee-gait data resulted in a totally new
approach that led to two developments: the patellar tendon-
bearing (PTB) prosthesis and the solid-ankle, cushion heel
foot.127–129 The improved transtibial socket was a PTB design
that closely followed the contours of the proximal tibia.130
The PTB prosthesis replaced the thigh lacer with supra­
condylar fixation, again with the advantage of anatomical
­contour and total contact.
(Figure 5-18). With or without crutches, he has no mea­
surable fifth metatarsal or toe contact on either limb in
his typical stance phase weight-bearing patterns. Passive
external rotation is present at the hip as well as abducted
limb placement as he advances over the forefoot. His
abducted limb placement and wide-based gait provide
increased stability at a cost of excessive loading on the
posteromedial aspect of the feet (see Figure 5-15B). Like
many children with spina bifida, he spends excessive time
in heel contact, largely to the exclusion of lateral fore­
foot weight bearing. This loading and shear pattern often
leads to callusing and eventual neuropathic breakdown in
adult life. His fastest gait velocity (55 m/min) is approx­
imately 60% of normal free-gait velocity. During swing
phase, external rotation of the limb is marked. The flail
foot is held in slight dorsiflexion during TSw through the
support of the AFO.
Questions to Consider
• What specific problems does the examination and eval­
uation identify in each of the functional tasks of gait:
weight acceptance (IC and LR), single limb support
(MSt and TSt), and swing limb advancement (PSw, ISw,
MSw, and TSw)? How do these problems relate to N. P.'s
flaccid paralysis and sensory impairment?
• In what ways do N. P.'s orthoses address or constrain
each of the functional tasks of the gait cycle: weight
acceptance (IC and LR), single limb support (MSt and
TSt), and swing limb advancement (PSw, ISw, MSw, and
TSw)? What is the interaction of his flaccidity and sen­
sory with his orthoses on the efficacy and energy cost of
his walking?
A
B
FIGURE 5-18  In this child with myelomeningocele, weakness at
the hip results in external rotation of the limbs in both stance and
swing phase (A), which contributes to altered forward progres­
sion from the heel to the medial forefoot, with minimal weight
bearing on the lateral foot (B).

130
Section I  Building Baseline Knowledge
Prosthetic Feet During Stance
Compressible heel prosthetic feet have a solid plastic keel
embedded in the proximal portion of a stiff foam foot that
allows a slight degree of forefoot flexibility while the cushion
heel lessens the impact of initial floor contact and through
vertical compression simulates articulated ankle plantar flex­
ion. Material compressibility replaced the mechanical joint of
the single-axis foot. Foot contour, alignment, and elasticity
facilitated progression onto the forefoot. This design followed
careful analysis of the essential degrees of mobility. The com­
pressible heel foot has become the standard terminal device
for most individuals with amputation, though hybrids incor­
porating both low- and high-performance feet with multidi­
rectional articulated ankles hold a significant place in clinical
use as well.
Transtibial Alignment
The positional relation between the socket and prosthetic
foot is critical to achieve optimal progression in stance, yet
also highly subjective. The goal is to encourage tibial pro­
gression in stance and place the knee in a stable (minimally
flexed) weight-bearing posture without causing hyperexten­
sion in late stance and to have the lower limb follow a normal
path of motion in swing.
Static or "bench" alignment uses the subcutaneous crest of
tibia (tibial blade) to establish alignment of the residual limb
within the prosthesis. In the sagittal plane, this landmark, at
its origin at the tibial tubercle, is typically angled approxi­
mately 5 degrees forward of the perpendicular to the tibial
plateau that serves as the supporting surface for the knee
joint. Hence, if the socket is aligned by the tibial blade, the
socket is set so that the tibia is tilted slightly forward to avoid
a backward thrust during stance. This angular posture of the
prosthetic socket, in conjunction with a deliberate anterior
displacement (translation) of the socket relative to the foot,
generally succeeds in encouraging tibial progression.
Even with this alignment, the individual with dysvascu­
lar transtibial amputation who typically exhibits some degree
of weakness will shift the weight line anterior to the knee by
simply leaning forward during LR in a postural movement
akin to a quad avoidance gait. This results in reduced knee
flexion throughout stance phase and delayed flexion in swing
(Figure  5-19). A hesitation of stance progression (the MSt
dead spot) is a common phenomenon. A delay in the rollover
pattern, common to the dysvascular transtibial amputee, is
reflected in the shear pattern (see Figure 5-19B).
Final positioning of the socket-foot relation is deter­
mined by observational analysis of the subject's gait and
feedback from the individual with an amputation. This pro­
cess, referred to as dynamic alignment, examines smooth­
ness of the rollover pattern and medial-lateral verticality of
the foot, avoiding both extremes of inversion or eversion
during progression. The absence of abnormal motions in
swing such as a whip, compensatory motions to avoid scuff­
ing the foot in swing (e.g., degree of pelvic elevation or vault­
ing), and an erect trunk posture are additional observational
criteria used for assessment. Comfort and ease of walking
are criteria of the individual with amputation. A one-sub­
ject study of repeated realignment by an experienced pros­
thetist over a 2-year period documented inconsistencies
in the alignment accepted as being good, a decision con­
firmed each time by three other prosthetists.131,132 A range of
alignment variation satisfactory to both the prosthetist and
amputee was defined.
In optimizing the alignment in the coronal plane, there
is an attempt to mimic the slight varus moment seen at
the knee during MSt of normal human locomotion. This
moment is usually achieved by a slight medial inset of the
prosthetic foot relative to the socket, taking advantage of
the good weight-bearing areas in the proximal-medial and
lateral-distal regions of the residual limb. Pressure in these
areas is well tolerated. Inadequate inset of the foot, or worse,
outset of the foot will generally result in excessive pressure
on the very superficial cut end of the tibia (medial-distal)
and the perineal nerve and bony prominence of the head of
the fibula (lateral-proximal). Although observational analy­
sis is appropriate for general clinical care, the alignment of
individuals with amputation with complex fitting problems
is best resolved through objective confirmation with force­
plate and motion data.
40
35
30
25
20
15
10
5
0
–5
–10
Angle
% Stance
Ext.
Flex.
Transtibial knee flexion/extension
10
20
90
30
40
50
60
70
80
Force (N)
% Stance
Anterior/posterior force
10
20
90
30
40
60
70
80
200
150
100
50
0
–50
–100
–150
–200
50
A
B
FIGURE 5-19  A, Patients with dysvascular transtibial amputation
typically shift the weight line anterior to the knee early in stance,
which results in reduced knee flexion throughout stance phase and
delayed flexion in swing. B, Patients with dysvascular transtibial
amputation typically shift the weight line anterior to the knee early
in stance, which results in typical midstance (MSt) hesitation in the
progression of rollover, reflected in the shear pattern. (Courtesy of
VA Long Beach Gait Laboratory.)

Chapter 5  Clinical Assessment of Gait
131
Studies of Transtibial Prosthetic Gait
Most instrumented studies of individuals with transtibial
amputation have focused on foot design, with the general
exclusion of alignment. Prosthetic foot designers attempt
to passively reproduce, by material quality, the normal
dynamic functional balance between mobility and ­stability
provided by the anatomical foot. The greatest difference
is between the relatively rigid compressible heel–type feet
and the mobile hinge of the single-axis foot.133 Motion anal­
ysis has shown that the articulated ankle improves weight
acceptance ­stability by providing significant plantar flex­
ion, allowing an earlier foot flat posture134 however, the arc
of knee flexion and the timing and intensity of the quad­
riceps do not differ from that of the compressible heel–
type foot.135 Stance phase limb progression is enhanced by
an articulating ankle in two ways. In footswitch analysis,
the mobile ankle had a longer period of single limb stance
time, whereas total stance time was shorter compared
with solid-ankle designs.135 In addition, there was more
prolonged hamstring action with the compressible heel
foot; this implies that a forward lean was used to improve
progression over the less yielding foot. These functional
advantages of a mobile prosthetic foot would be signifi­
cant in a marginal walker, but the heaviness of a single-
axis foot creates an energy-cost penalty that also must be
considered.
Beginning in the 1980s, the use of elastic materials and
designs has been increasingly applied to prosthetic feet.
The initial objective was to facilitate running because the
presence of normal knee control gives the transtibial indi­
viduals with amputation considerable functional poten­
tial.136 Foot designs all emphasize controlled dorsiflexion
mobility for greater push-off. It has been assumed that these
dynamic, elastic prosthetic feet would be ­advantageous
for the average walker by reducing the greater-than-
normal energy cost currently experienced by individuals
with amputation.137 The most mobile designs, in terms of
dorsiflexion range, are those with a long-bladed shaft such
as the Flexfoot and Springlite. These bladed shaft designs
have not lessened the muscular demands of weight accep­
tance. Their simulated “ankle plantar flexion” during limb
loading is no better than the solid-ankle, cushion-heel
foot. Both result in a plantar flexion that is markedly less
than the normal controlled, yet rapid, ankle plantar flexion
of 12 degrees used to reduce the propulsive effect of the
heel rocker by allowing early forefoot contact. Both pros­
thetic feet cause a significant delay in attaining the ­stability
of foot flat.138
The intact limb uses a modest arc (15 to 20 degrees)
of knee flexion to absorb the shock of floor contact.4
Prosthetic feet rely on a cushion heel. The time needed for
adequate cushion compression delays the drop of the fore­
foot to the floor. This perpetuates an unsteady, heel-only
source of support that requires increased active muscular
control of the knee and hip to ensure weight-bearing sta­
bility. This subtle source of instability is obscured by two
findings. Displacement of the customary heel marker gives
a false reading of plantar flexion.139 Heel cushion compres­
sion delays the rate of initial tibial advancement, resulting
in reduced weight acceptance knee flexion for the trans­
tibial amputee compared with normal. This difference is
reflected in calculations of subnormal moments and pow­
ers.140,141 These findings have been interpreted as a sign
of reduced muscle demand, and a corresponding con­
servation of energy has been attributed to the dynamic
­elastic-response feet. Direct EMG recordings, however,
show significantly higher than normal muscle demand for
five different feet tested.142
CASE EXAMPLE 5
A Patient with a Unilateral Transtibial Amputation
W. T. is a 59-year-old transtibial amputee secondary to
peripheral vascular disease. He underwent the amputation in
September 2009 and subsequently experienced a fall, caus­
ing secondary injuries to the residual limb. Previously, he
underwent bilateral total knee arthroplasty, most recently on
the right side in 2007. W. T. started physical therapy for gait
training in March 2010 and completed it in July 2010. He has
been referred for a gait evaluation due to complaints of right
knee pain as he has continues to become ambulatory with
the prosthesis.
Questions to Consider
• Considering the gait deviations associated with transtib­
ial amputees, how could this impact his affected side in
conjunction with the total knee arthroplasty?
• What type of options could be considered to minimize
the impact on his intact joints? With this, consider
the role of patient education and possible compliance
issues.
• What type of qualitative and quantitative information
would you use to support your decision(s)?
Examination and Evaluation
On the day of evaluation, W. T. presented using a single
point cane and after discussion with the staff complained
of intermittent pain at the distal end of his residual limb.
A further chart review revealed that since the time that he
completed physical therapy multiple prosthetic feet have
been trialed, along with additional modifications to the
prosthetic socket to help increase comfort. There were also
documented issues of patient noncompliance, particularly
in terms of the prosthesis wear schedule. The patient had
periodically developed areas of redness on his residual limb
Continued

132
Section I  Building Baseline Knowledge
Transfemoral Prosthetic Gait
Initial research of transfemoral amputation by the Berkeley
group focused upon unilateral amputation because
the problems of this group appeared more critical at
that time.124
Motion analysis showed a fully extended knee starting in
TSw and continuing through stance. The inadequate ankle
plantar flexion that followed heel strike and threatened knee
stability was attributed to dependence on an ankle bumper
in place of the lost pretibial muscle control. Active ipsilateral
thigh control and postural adaptation by the sound limb and
trunk were identified as the variable mechanisms used by the
individual with transfemoral amputation to ensure knee exten­
sion stability. Rotation of the fully extended limb rolling over
the ankle before heel rise causes a maximum rise of the hip
(and thus center of gravity), which was interpreted as vault­
ing. Compensatory actions by the sound limb were identified.
In swing, the inability of the prosthetic foot to generate a
propelling force to initiate limb advancement was interpreted
as a need to restrict the weight of the prosthesis so that the
work of hip flexors would not be excessive. The individual
with transfemoral amputation also demonstrated rapid hip
extension in TSw to use tibial inertia as a means of complet­
ing knee extension in preparation for stance. These findings
of excessive knee extension in stance and excessive hip action
in swing formed the basis for others to design more sophis­
ticated knee joints to replace the then-dominant single-axis
constant friction joint.
The biomechanical response to the problem of resid­
ual limb discomfort was twofold. Torque absorbers were
designed, but the solution was the combination of improved
socket design in addition to more normal joint mechanics.
The loss of knee control creates compensatory kinematic
and kinetic changes that result in asymmetries reflected
in a variety of gait parameters. As the individual wearing
transfemoral prosthesis with a compressible heel-type foot
levers over the heel rocker during LR, the knee may be at
an increased risk of destabilization. When challenged by
the potential for knee instability, the prosthetic wearer will
attempt to preposition the hip before LR with a change in
body mechanics to shift the GRF to a more anterior posi­
tion. These typical compensatory patterns can be measured
directly through EMG, kinematics, or kinetics or inferred
by measuring heel-only load-bearing time through a tem­
poral analysis.
Temporal Values
There are a several temporal values for which individuals
with transfemoral amputation differ compared with those
without amputation. A retrospective footswitch gait study
­conducted at the National VA Prosthetics Gait Lab, Long
Beach, California, measured the self-selected velocity in
10 individuals with traumatic transfemoral amputation
and compared it with the self-selected velocity of indi­
viduals without amputation. The individuals with ampu­
tation demonstrated a mean stride length of 1.16 meters
compared with an average of 1.59 meters for individuals
without amputation.143 Overall timing of the transfemoral
prosthetic gait cycle was slower for the individuals with
amputation, requiring a mean of 1.25 seconds from IC to
subsequent IC compared with 1.08 seconds for individu­
als without amputation. The mean velocity of the individ­
uals with amputation was 55.8 m/min versus 88.3 m/min
for individuals without amputation. James and Oberg144
found that a longer, slower gait cycle on the prosthetic
side combined with a reduced step length on the sound
side resulted in a velocity that was only 38% of non-ampu­
tee velocity. As profound as these differences are, they are
probably still subtle enough to remain unremarkable in
a typical clinical environment. Murray145 measured trans­
femoral gait with a younger group of individuals with
amputation and found similar but slightly more subtle dif­
ferences between individuals with amputation and those
without amputation.
and was advised to pay particular attention this area and to
document it when it occurred.
An initial assessment with video-based data collection
was determined to be an appropriate first step. During the
evaluation, the patient was asked to walk multiple times
over level ground at his self-selected walking speed while
being videotaped. The principal findings were as follows:
(1) Periodic knee hyperextension during midstance on the
involved side, (2) the involved side knee is often not fully
extended at initial contact, and (3) for the times that the knee
is flexed going into stance there is a rapid extension during
midstance.
Taking into consideration the patient's history and cur­
rent complaints about exacerbated knee pain with ambula­
tion, it was determined that a trial of a custom knee brace
modified to fit in conjunction with his prosthesis would be
the next alternative. He was subsequently casted over the
prosthesis to help ensure that the device would contour
appropriately and not interfere with its function. By doing
this, the brace would provide additional support when com­
bined with the single point cane.
Questions to Consider
• Given the situation with this patient, would further, instru­
mented, kinetic, and kinematic testing be warranted?
• If so, how would you conduct the testing session
and in which specific variables would you look for
changes?

Chapter 5  Clinical Assessment of Gait
133
Initial Contact and Loading Response
The initiation of heel contact at the beginning of stance
phase in transfemoral gait has been reported to be character­
istically delayed on the prosthetic side, which typically dem­
onstrates a longer swing phase.145 Contemporary hydraulic
knee units, particularly those that provide a programmable
chip that can establish optimal swing phase timing char­
acteristics, have the potential to overcome this limitation.
However, probably because of cost, they do not represent a
typical prosthetic. Early gait studies of single-axis prosthetic
feet showed that as the prosthetic limb made contact with
the ground and began to load, an exaggerated knee ­extension
was seen in the prosthetic limb that continued throughout
early stance.145 This phenomena depends somewhat on knee
design. There is ­little evidence that polycentric knees, such
as four- and six-bar linkage knee units, and others that have
been designed to be stable with a few degrees of built-in
flexion compliance during stance, provide normal kinemat­
ics of the knee in stance. Most individuals with transfemo­
ral amputation who use the polycentric designs walk with a
nearly extended knee.
The total vertical forces occurring on the prosthetic
side are less during the initial double limb support period
than on the contralateral side during the terminal double
limb ­support period. It has been theorized that this load­
ing restraint requires costly compensations of the sound
limb.146 Knee instability, which produces these costly com­
pensations, generally results from inappropriate position­
ing of the knee joint relative to the socket and prosthetic
foot. The individual with transfemoral amputation relies
on hip extensor strength and the reduced lever arm of
the transected femur to stabilize the prosthetic knee by
restraining the limb during LR. Profound hip extensor
weakness can be catastrophic and preclude functional
ambulation. Anterior translation of the prosthetic socket
relative to the knee and foot has the effect of shifting the
GRF anterior to the knee joint axis, thereby increasing sta­
bility. Socket flexion affects knee stability as well. Because
efficient use of the gluteus maximus as a hip extensor
requires the muscle group to be on stretch, the prosthetist
deliberately places the socket in a position of flexion. Five
degrees of socket flexion are generally considered clini­
cally optimal in a patient with no contracture at the hip. In
cases of hip contracture, the amount of flexion is limited
by the length of the femoral remnant.124
Stability of the knee joint is unquestionably the most
important factor in considering a knee unit. Uncontrolled
knee flexion renders an otherwise perfect prosthesis use­
less. Thiele and colleagues147 investigated possible neu­
rophysiological reasons for weakness in individuals with
transfemoral amputation by recording EMG activity of the
quadriceps during gait. His team did not find abnormal
recordings and concluded that muscle weakness is caused
by biomechanical, rather than neurophysiological, factors.
This supports the long-held clinical view that apart from
the patient's general muscle tone, residual limb length is a
crucial factor because of its effect as a lever arm against the
socket wall and as a result of intact or ablated insertions
of the hamstring tendons and their obvious detrimental
effect on extensor strength. A  slight degree of socket flex­
ion is also a factor affecting stability because socket flex­
ion slightly elongates hip extensors, rendering them more
effective. The relative positions of the prosthetic foot,
knee, and socket to this line significantly affect stability of
the knee when the patient walks. When the ground reac­
tion line passes posterior to the knee center, the knee will
collapse unless resisted by another force, usually the hip
extensors forcing the femur against the socket wall.
Another potential destabilizing factor is limitation of
free plantar flexion at heel contact, which may produce a
knee flexion moment in early stance. This is why an artic­
ulated prosthetic foot (as opposed to a prosthetic foot,
which attains a plantar grade position by means of heel
­compression) provides increased stability for those with
transfemoral amputation. A general clinical guideline on a
patient who demonstrates minimal knee stability is that the
prosthetic foot should reach foot-flat position (mimicking
plantar flexion during LR) as quickly as possible, short of
demonstrating a foot slap characteristic. As soon as the foot
plantarflexes fully during stance phase, the ground reaction
line moves anteriorly from the point of foot-floor contact at
the heel to approximately midfoot, enhancing stability at the
knee. Because of this, a single or multiaxis foot with a soft
plantar flexion bumper is preferred for those with a short
transfemoral residual limb, who have limited muscular con­
trol for knee stability. At times, the single-axis function can
be combined with that of dynamic response, such as with
the College Park foot.
Midstance
As the individual using a transfemoral prosthesis moves
into MSt, sound side hip elevation and trunk lean toward
the affected side provide balance, limit the force on the lat­
eral aspect of the residual limb, and reduce the demands of
the residual limb abductors. The transition from braking to
propulsive shear on the ipsilateral limb is characteristically
delayed and unsteady (Figure 5-20).
When both limbs are intact, the momentum of the con­
tralateral swing limb results in a reduced vertical force at
MSt of the stance limb. This is not so, however, for those
with dysvascular transfemoral amputation, in which the
reduced upward velocity and momentum of the contra­
lateral swing limb does not have the vigor necessary to
decrease vertical force of the prosthetic limb during MSt
(see Figure 5-20B). Even in those with traumatic amputa­
tion, maximum knee flexion of the sound side during swing
phase reaches only 51 degrees, approximately 10 degrees
less than normal gait.148
Stance phase knee flexion of the affected side is sig­
nificantly reduced throughout stance (see Figure  5-20 C).
During PSw, delayed and reduced knee flexion and conse­
quent reduced heel rise on the ipsilateral limb are character­
istic of the transfemoral amputee. Except in the case of those
fitted with microprocessor stance control knees, it can be

134
Section I  Building Baseline Knowledge
anticipated that many individuals with transfemoral amputa­
tion will progress through MSt with a nearly extended knee.
Microprocessor-controlled hydraulic knees, particularly the
Otto Bock version, have shown a trend toward improve­
ments in stance knee flexion as well as increased velocity in
stair descent.149,150 This is an important development because
it may provide increased energy efficiency in gait and avoid
compensatory mechanisms such as prepositioning of the
femur before LR and MSt.
Terminal Stance
TSt on the prosthetic limb is noted for its premature ces­
sation. The prosthetic side generally shows a decrease in
single-limb support time, whereas the sound side shows a
concurrent increase in single-limb support time.148 There is
a persistence of knee extension on the prosthetic limb dur­
ing contralateral sound side deceleration.151 Delayed and
reduced knee flexion, and consequent reduced heel rise on
the ipsilateral limb, are characteristic of transfemoral pros­
thetic gait (see Figure 5-17C). A failure to limit dorsiflexion
in a single-axis foot at this juncture will have a destabilizing
effect on the prosthetic knee joint during TSt. Without an
appropriately placed dorsiflexion stop, nothing will dampen
the forward progression of the tibia, and the tibial section
may continue its anterior progression to the point of knee
collapse.
Preswing
During PSw in transfemoral gait, the vertical force of the
sound side is abnormally high and greater than that of the
prosthetic side.146 Abrupt reversal from hip extension to
hip flexion occurs because some hip extension is required
for knee stability until the moment when the prosthetic
knee has to flex to initiate swing. In normal gait, half the
knee flexion required for swing phase is obtained passively
­during PSw.
During prosthetic PSw, inadequate forefoot support can
lead to costly compensations in the double limb support
period.146 PSw is characterized by a rapid transfer of body
weight to the contralateral limb. In normal gait this transfer
begins at 50% of the gait cycle and continues until the end of
stance phase (approximately 62% of the gait cycle).
Individuals with transfemoral amputation often have a
shortened sound side step length. This may be aggravated by
insufficient socket flexion because the individual with trans­
femoral amputation uses any and all available lumbar lordo­
sis to advance the sound limb. Failure to place the socket in
flexion limits the availability of lumbar lordosis and prohib­
its a sound side step length that is at least somewhat close to
normal. Even in an optimal prosthetic gait, typical sound side
step length is reduced compared with the prosthetic side or
the normal side.
Swing Phase
Gait characteristics during swing phase when wearing
a transfemoral prosthesis can be profoundly influenced
by prosthetic alignment and design variations. The most
Force (N)
% Stance
Characteristic fore & aft shear
Transfemoral amputation
10
20
90
30
40
60
70
80
200
150
100
50
0
–50
–100
–150
–200
50
Force (N)
% Stance
Characteristic transfemoral vertical force
10
20
90
30
40
60
70
80
1200
1000
800
600
400
200
0
50
Angle
% Stance
Transfemoral knee flexion/extension
10
20
90
30
40
60
70
80
35
30
25
20
15
10
5
0
50
Flex.
Ext.
A
B
C
FIGURE  5-20  A, The transition from braking to propulsive
shear on the ipsilateral limb during transfemoral prosthetic
gait is characteristically delayed and unsteady. B, Although
there is a reduction in vertical force at midstance (Mst) of the
sound limb as the prosthetic limb advances in swing, the pros­
thetic transfemoral limb demonstrates reduced upward veloc­
ity because the momentum of the contralateral swing limb lacks
the vigor to lessen the vertical force of the affected stance limb
during MSt. C, Knee flexion of transfemoral prosthetic limb is
reduced throughout stance. During preswing (PSw), delayed and
reduced knee flexion and consequent reduced heel rise on the
ipsilateral limb is characteristic. (Courtesy of VA Long Beach
Gait Laboratory.)

Chapter 5  Clinical Assessment of Gait
135
challenging factor in achieving a functional swing phase is
the lack of active dorsiflexion in most prosthetic designs. The
Stewart-Vicars knee developed in 1947 and the more recent
Hydracadence knee couple knee flexion with ankle dorsiflex­
ion. However, this design concept has been largely ignored in
recent years. With the prosthetic incorporation of active dor­
siflexion in early swing, many costly postural substitutions,
including vaulting and abducted or circumducted gait, could
be minimized.
The swing velocity of the prosthetic limb is often slower
than that of the sound limb.144 The presence or lack of fluid
control mechanisms variations in alignment stability, exten­
sion assist, and joint friction alignment mechanisms can all
influence swing phase timing. During MSw, the individual
with transfemoral amputation demonstrates exaggerated hip
elevation of the prosthetic side to enable swing clearance.
In TSw, prosthetic swing time is much greater than sound
limb swing time or normal swing time.151 Excessive prosthetic
swing flexion is one of the commonly reported transfemoral
prosthetic gait deviations.151 Zuniga,148 however, reports that
prosthetic knee flexion reaches a mean of only 45 degrees.
This contradiction in results can easily be attributed to the
wide variety of prosthetic dampening and extension assist
designs as well as other variations in prosthetic adjustment.
James and colleagues144 and Murray151 performed gait
laboratory investigations of transfemoral stride parameters
and their relation to knee flexion/extension angles at various
cadences. They confirmed stance and swing phase asymme­
try between the prosthetic and sound side, regardless of the
speed of walking. Zuniga148 used electrogoniometers attached
to the knee and foot to document asymmetry during stance
and swing phases, comparing prosthetic and sound limbs.
A  lack of symmetrical cadence response on the prosthetic
side is seen as partially responsible. Most prosthetic designs
permit only one walking speed. No matter how fast the
patient walks, the prosthetic wearer must wait for the leg to
return from the normal 65 degrees of swing phase flexion to
full extension before safely loading the prosthesis for weight
bearing in stance.
Common Gait Deviations in Transfemoral
Prosthetic Gait
Our understanding of transfemoral prosthetic gait ­deviations
and the dynamic alignment process has evolved over many
decades. The important early work of Inman,6 described
­previously, served as a basis for subsequent ­development.
In  1951, New York University published a method for
observing amputee gait and described eight commonly seen
gait deviations.152 Years later, Hangar and associates14 at
Northwestern University, under a grant from the Veterans
Administration, developed an educational film that incor­
porated the eight deviations defined by NYU and expanded
upon these. A brief description of each of these transfemoral
gait deviations is given in Table 5-2.13
TABLE 5-2  Common Deviations in Transfemoral Prosthetic Gait
Deviation
Description
Foot slap
Rapid, uncosmetic plantar flexion movement at heel contact. Most commonly caused by insufficient
plantar flexion resistance.
Knee instability
Uncontrollable knee flexion at LR. May be caused by anteriorly placed knee unit, excessive durometer of
cushion heel or plantar flexion bumper, or weakness of hip extensors.
Delayed progression
Hesitation or delay in rollover of prosthetic forefoot between MSt and TSt. May be the result of a long toe
lever, a plantarflexed prosthetic foot, or shoes with low heel.
Unequal step length
Sound side step length is visibly shorter than the prosthetic step length. May be caused by inadequate
preflexion of socket, hip flexion contracture. Associated with excessive lumbar lordosis and low
back pain.
External rotation
Foot externally rotates at heel contact. May be caused by excessively firm heel cushion or a tight prosthetic
socket (especially on a residual limb with extra soft tissue).
Lateral trunk bend
Significant leaning of the body over the hip during prosthetic MSt. Often caused by excessively outset
prosthetic foot, distal lateral femoral discomfort, short prosthesis, excessively abducted socket, or
gluteus medius weakness.
Abducted gait
Wide walking base throughout the gait cycle, often caused by pressure or discomfort on medial pubic
ramus, small socket, or excessively long prosthesis.
Pelvic elevation
"Hip hiking" on prosthetic side from ISw to MSw, associated with increased energy cost of gait. Often
caused
by long prosthesis or inadequate knee flexion as swing begins.
Knee hyperextension
Seen at MSt to compensate for perceived knee instability. Often caused by short forefoot lever or
dorsiflexed prosthetic foot.
Lateral whip
The heel of the prosthetic foot moves in a lateral arc as swing begins, often caused by excessive internal
rotation of the knee bolt.
Medial whip
The heel of the prosthetic foot moves in a medial arch as swing begins, often from excessive external
rotation of the knee bolt or improper donning of prosthesis.
(Continued)

136
Section I  Building Baseline Knowledge
Deviation
Description
Excessive heel rise
Prosthetic foot rises abnormally upward during ISw, typically a result of inadequate resistance to knee
flexion.
Inadequate heel rise
Heel-off is diminished in ISw, usually because of excessive knee flexion resistance.
Circumduction
A wide lateral arch of the prosthetic limb during swing phase. Often the result of inadequate knee flexion,
excessive medial brim pressure, or long prosthesis.
Pistoning
A sense that residual limb slips slightly out of the socket in swing and descends into the socket in stance.
Often the result of inadequate fit or suspension.
Vaulting
Rising up on the sound forefoot during MSt in an effort to enhance prosthetic swing limb clearance.
May result from a long prosthesis, excessive knee friction, or fear of letting the knee flex.
TSw impact
An audible click at the end of TSw as knee unit fully extends with insufficient resistance or by forceful knee
extension by the prosthetic wearer.
Reduced velocity
An adaptation typically observed during initial training or with new components, often related to pain, fear, or
insecurity.
ISw, initial swing; LR, loading response; Mst, midstance; MSw, midswing; Tst, terminal stance.
CASE EXAMPLE 6
A Patient with a Hemipelvectomy Amputation
L. is a 38-year-old woman with a right hemipelvectomy
amputation secondary to osteosarcoma. She has been
referred to the gait laboratory for evaluation as a possible
candidate for a microprocessor controlled knee unit. For the
past several years she has been ambulatory without the use
of assistive devices.
Questions to Consider
• Considering L.'s level of amputation what types of diffi­
culties or deviations might you expect during the course
of level over ground ambulation?
• What quantitative measures would serve as indicators of
the likely gait deviations?
Examination and Evaluation
L. was fitted with reflective markers and underwent three-
dimensional kinetic and kinematic testing. This testing was
performed at her self-selected walking speed and she was given
a suitable amount of time to become acclimated to the testing
environment before data collection. Observational assess­
ment indicates a significant amount of vaulting and excessive
pelvic movement, but no indication of circumduction.
The temporal data shows that she walks at a rate of 92
steps per minute and a velocity of 0.96 m/sec. Along with
this, her step length on the left side is 0.58 m, while the
right side is 0.70 m, even though the total stride length for
both sides is 1.24 m. Similarly, the total stride time for both
sides was 1.3 seconds; however, the single limb support
time was 0.55 seconds on the left side and 0.41 seconds on
the right. The step time for the left was 0.59 seconds, while
the right was 0.71 seconds. Similarly, toe-off occurred at
68.8% of the gait cycle on the left side, while it occurred at
57.9% on the right.
Kinematic data at the ankle showed a consistent pat­
tern of abnormal plantar-flexion on the left side occur­
ring from approximately 14% of the gait cycle through
60% of the gait cycle. Overall knee flexion on the left
side was within the overall expected range, as was hip
flexion in swing. The right side knee flexion showed
approximately 5 degrees of knee flexion during loading
response and a peak average knee flexion of 53 degrees.
Exaggerated anterior-posterior pelvic tilt was also docu­
mented (Figure 5-21).
Kinetically, the left side consistently showed greater
anterior/posterior shear forces compared to the contra­
lateral side, usually twice as much force exerted on the
left compared to the right. Along with this there was no
clear twin peak maximum in the vertical component
of the ground reaction force. Instead, there were mul­
tiple maxima over the course of a single stance phase
(Figure 5-22).
Questions to Consider
• Based on what is presented here, what possible advan­
tages could a microprocessor controlled knee unit
have over a conventional mechanical unit? When con­
sidering this bear in mind that the specific micropro­
cessor knee unit she is being evaluated for is designed
to allow for adjustments in both flexion and exten­
sion resistance based upon the individuals walking
velocity.
• What kinematic, kinetic, and temporal changes could
you expect to see with a change in knee unit?
• Considering that the potential improvements are not
absolute, do the potential benefits warrant the issuance
of the device?
TABLE 5-2  Common Deviations in Transfemoral Prosthetic Gait—cont'd

Chapter 5  Clinical Assessment of Gait
137
A
B
Ankle Dorsi/Plantar
70
Dors
deg
Plan
–50
Hip Flexion/Extension
70
Flex
deg
Ext
–50
Hip Ab/Adduction
30
Add
deg
Abd
–15
Knee Flexion/Extension
95
Flex
deg
Ext
–45
Pelvic Obliquity
40
Up
deg
Down
–20
Knee Ab/Adduction
30
Var
deg
Val
–30
Pelvic Tilt
40
Ant
deg
Post
–20
Ankle Dorsi/Plantar
40
Dors
deg
Plan
–20
Hip Flexion/Extension
40
Flex
deg
Ext
–20
Hip Ab/Adduction
30
Add
deg
Abd
–15
60
Flex
deg
Ext
–10
30
Var
deg
Val
–30
40
Ant
deg
Post
–20
Knee Flexion/Extension
40
Int
deg
Ext
–20
Pelvic Rotation
Knee Ab/Adduction
Pelvic Tilt
FIGURE 5-21  A patient with right hemipelvectomy amputation: average motion data results for the left (A)
and right side (B). Particularly note the ankle motion on the left side indicating the vaulting pattern.
Continued

138
Section I  Building Baseline Knowledge
SUMMARY
The examples of gait deficiencies typical of neuromuscular condi­
tions and in prosthetic gait that we have considered demonstrate
the complexity and variety that challenge orthotists, prosthe­
tists, and physical therapists working with individuals with gait
problems. Each patient presents unique combinations of patho­
logical and compensatory deficits that require a combination of
the essential tools of simple quantitative measure (cadence and
velocity, step length, stride length and width, and double support
time), systematic qualitative gait analysis (Rancho Los Amigos
observational gait assessment protocol), measures of energy
cost (PCI), level of assistance (the FAC or FIM), and functional
measures (the TUG or GAR-M). These tools help the clinician
differentiate primary pathological conditions from secondary
compensations, guide orthotic prescription and therapeutic
intervention, and assess efficacy of treatment. Instrumented gait
assessment is an important part of preoperative assessment and
research in orthotic and prosthetic design. In addition, the data
collected in gait laboratories are building a database that can pro­
vide information necessary to build accurate outcome estima­
tions for many groups of patients. The current challenge is for
the clinic team to gain the broadest possible knowledge base in
analytical gait assessment and to serve the patient as a team, con­
sidering each patient as an individual.
ACKNOWLEDGMENTS
The authors are grateful to Sue Rouleau, PT, and the Physical
Therapy Department of Rancho Los Amigos Medical Center for
assistance in identifying patient models and to Jacquelin Perry,
MD, and Los Amigos Research and Education Institute for per­
mission to duplicate the Rancho full-body gait analysis form.
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