Walk This Way

What Your Client's Gait Says About Their Muscles

by Theresa Miyashita, PhD, ATC, PES, CES

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Gait analysis is a dynamic assessment that can be completed through a variety of means: when the client walks into your setting, while they are walking on a treadmill, or while they are walking to their next exercise. This evaluation can supply a plethora of information and provide insight into compensations that could be occurring regularly. While there are a variety of high-tech instruments that can be used to analyze gait (accelerometers, gyroscopes, force plates, etc.), visual and/or video gait analysis is common in a clinical setting. However, the quality of the assessment is based on the assessor’s experience. The key step is knowing what to look for while conducting the analysis.

Remember that the human body is a kinetic chain; issues at one joint may manifest as a compensation at another joint. For example, altered biomechanics occurring at the hip may be noted as a compensation at the knee, ankle or foot. For this reason, it is important not to isolate an evaluation on a specific joint, but to look at the entire body. Gait compensations can occur for a number of different reasons: current/previous injury, neurological/orthopedic disorders, postural compensations, overactive/underactive musculature, footwear, etc. This article will address potential lower extremity compensations in an otherwise healthy, active client.

Assessment Tips

While conducting a gait analysis, it is important to take your time. Make note of deviations occurring and determine which muscles may be involved. It is important to take a thorough subjective evaluation prior, so you know if any compensations can be linked to other etiologies; e.g., joint replacement surgeries, osteoarthritis, bony malalignments, etc. If the client’s gait compensations are due to issues beyond over/underactive musculature, you may not be able to address them through a corrective exercise program. Should this be the case, it is important to refer to a licensed healthcare provider.

Check Ankle Dorsiflexion

A decrease in ankle dorsiflexion (moving the top of the foot toward the shin) can have an impact on the entire kinetic chain. A minimum of 10° of dorsiflexion is necessary for proper walking gait mechanics. (1) If someone does not possess the appropriate amount of ankle dorsiflexion, the most common compensation noted on a gait analysis is an early heel-off. (2) This is when an individual picks up their heel too soon, leading to an increased amount of time and pressure on the forefoot. (3) Overactivity of the gastrocnemius and soleus, plus tightness of the Achilles tendon are commonly linked to a decrease in dorsiflexion. The decreased amount of necessary movement between the tibia and talus, due to the overactivity of the aforementioned musculature, is also linked to excessive compensatory pronation during the gait cycle. (4,5) While in the gait cycle, the subtalar joint should pronate during the loading response of the stance phase to adapt to the ground. The concern with a pronated foot is that it is a sloppy foot—and too much time spent in a pronated position will predispose one to a variety of pathologies including, but not limited to, an assortment of overuse injuries. (3)

To address the decrease in dorsiflexion observed, one can incorporate an appropriate corrective exercise strategy into the client’s program design. Inhibition of the gastrocnemius complex can be achieved via self-myofascial release (SMR). (6) During this process it is important to “hold” over the tender spots (i.e., trigger points) until they are released, which may take 30 to 90 seconds. Following SMR, the next step is incorporating the appropriate lengthening strategies for the overactive musculature: gastrocnemius and soleus. This can be achieved via static or neuro-musclar (NM) stretching. (7) It is important to separate stretching strategies of the gastrocnemius and soleus via position of the knee—knee flexed to target the soleus and knee extended to target the gastrocnemius. Following the inhibition and lengthening phases, strengthening of the underactive muscles will assist in returning the over/underactive muscles to their proper length-tension relationships. The anterior tibialis and intrinsic foot muscles should be targeted via resisted dorsiflexion and inversion, marble pick-ups and towel scrunches (intrinsic foot muscles).

SMR Calves
 
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Calf Stretch
 

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Look for knock-knees

A common knee compensation observed in a gait analysis is genu valgum—knee adduction. During the stance phase of the gait cycle, we may note the knee(s) moving inward, creating a “knock-knee” posture. This may become immediately evident as soon as your client’s foot hits the ground, or it may become more pronounced when the body weight is completely over the stance leg (with the body and ground at a 90° angle). This type of posture is more evident in the pediatric, female and obese populations. (8,9) The long-term complications linked to genu valgum include joint cartilage degeneration and osteoarthritis. (8) While there are a number of different causes for genu valgum—injury, metabolic or syndromic conditions (9)—we will focus on potentially over/underactive musculature. Potentially overactive muscles linked to a genu valgum posture include adductor complex, biceps femoris, vastus lateralis and the lateral gastrocnemius. These muscles should be targeted via SMR and static/NM stretching. Potentially underactive muscles that should be targeted via strengthening include gluteus medius, gluteus maximus and the vastus medialis oblique.

SMR Adductors
 
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Observe Hip Rotation

There are many compensations that can occur at the hip joint leading to altered gait mechanics. These adjustments may also be noted lower in the kinetic chain as compensations occurring at the knee, ankle or foot. For example, external rotation at the hip joint may be viewed as a toe-out gait; while an internally rotated hip may present as a toe-in gait. If these hip rotations are due to musculature, and not bony malalignment, we can address the dysfunctions through corrective exercise. Femoral external rotation may be due to overactivity of the piriformis, gluteus maximus, gluteus medius (posterior fibers), and/or the tensor fascia latae (TFL). The gluteus medius (anterior fibers) and adductor complex are likely underactive; while the opposite is probably associated with femoral internal rotation. 

Our first step in addressing these muscular imbalances through a corrective exercise program is to inhibit and then lengthen the overactive muscles, followed by activation/strengthening of the underactive muscles.

Due to the sedentary lifestyles and occupations of many Americans, overactivity of the hip flexors leading to an anterior pelvic tilt is commonly viewed. During a gait analysis, we may note an increase in the lumbar curvature or the trunk leaning slightly forward. Targeting the hip flexors and the erector spinae with SMR and static/NM stretching will help to decrease the overactivity of these muscles. Strengthening the gluteus maximus and hamstring complex will assist in maintaining proper pelvic alignment. (10)

SMR Hip Flexors

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Evaluate each aspect of the body separately, but do not forget that compensations observed at one joint may be due to dysfunction at another joint.


Conclusion

Appropriate strength ratios between agonist and antagonist muscles can help to stabilize joints and allow for proper movement patterns. However, when these ratios are altered due to over/underactivity of the agonist/antagonist muscles, altered joint mechanics and gait compensations can occur. 

Dysfunction in walking patterns can lead to several problems including joint pain, injury, decreased force output and long-term complications. Proper identification of altered gait mechanics can allow for the development of an appropriate corrective exercise program.

For more details on corrective exercise programming and gait assessments, check out the NASM Corrective Exercise Specialization at www.nasm.org/ces. AF

REFERENCES:

1. SAHRMANN, S. MOVEMENT SYSTEM IMPAIRMENT SYNDROMES OF THE EXTREMITIES, CERVICAL, AND THORACIC SPINES. ST. LOUIS: MOSBY, 2011.
2. CORNWALL, M.W. AND MCPOIL, T.G. “EFFECT OF ANKLE DORSIFLEXION RANGE OF MOTION ON REARFOOT MOTION DURING WALKING.” JOURNAL OF THE AMERICAN PODIATRIC MEDICAL ASSOCIATION, 89, NO. 6 (JUN 1999): 272-77.
3. JOHANSON, M.A., ET AL. “HEEL LIFTS AND THE STANCE PHASE OF GAIT IN SUBJECTS WITH LIMITED DORSIFLEXION.” JOURNAL OF ATHLETIC TRAINING, 41, NO. 2 (APR 2006): 159-65.
4. MCPOIL, T.G. AND KNECHT, H.G. “BIOMECHANICS OF THE FOOT IN WALKING: A FUNCTION APPROACH.” THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY, 7, NO. 2 (1985): 69-72.
5. HINTERMANN, B. AND NIGG, B.M. “PRONATION IN RUNNERS. IMPLICATIONS FOR INJURIES.” SPORTS MEDICINE, 26, NO. 3 (SEP 1998): 169-76.
6. GRIEVE, R., ET AL. “THE IMMEDIATE EFFECT OF TRICEPS SURAE MYOFASCIAL TRIGGER POINT THERAPY ON RESTRICTED ACTIVE ANKLE JOINT DORSIFLEXION IN RECREATIONAL RUNNERS: A CROSSOVER RANDOMIZED CONTROLLED TRIAL.” 17, NO. 4 (OCT 2013): 453-61.
7. NAKAMURA, M., ET AL. “ACUTE EFFECTS OF STRETCHINGON PASSIVE PROPERTIES OF HUMAN GASTROCNEMIUS MUSCLE-TENDON UNIT: ANALYSIS OF DIFFERENCES BETWEEN HOLD-RELAX AND STATIC STRETCHING.” JOURNAL OF SPORT REHABILITATION, 24, NO. 3 (AUG 2015): 286-92.
8. BROUWER, G.M., ET AL. “ASSOCIATION BETWEEN VALGUS AND VARUS ALIGNMENT AND THE DEVELOPMENT AND PROGRESSION OF RADIOGRAPHIC OSTEOARTHRITIS OF THE KNEE.” ARTHRITIS AND RHEUMATISM, 56, NO. 4 (APR 2007): 1204-11.
9. FARR, S., ET AL. “FUNCTIONAL AND RADIOGRAPHIC CONSIDERATION OF LOWER LIMB MALALIGNMENT IN CHILDREN AND ADOLESCENTS WITH IDIOPATHIC GENU VALGUM.” JOURNAL OF ORTHOPAEDIC RESEARCH, 32, NO. 10 (OCT 2014): 1362-70.
10. KANG, S.Y., CHOUNG, S.D. & JEON, H.S. “MODIFYING THE HIP ABDUCTION ANGLE DURING BRIDGING EXERCISE CAN FACILITATE GLUTEUS MAXIMUS ACTIVITY.” MANUAL THERAPY, 22 (APR 2016): 211-15.

Meet our experts

AFM-author-Miyashita Theresa Miyashita, PhD, ATC, PES, CES, received her undergraduate degree in sports medicine from Canisius College, Buffalo, N.Y.; her master's degree in athletic training from University of North Carolina at Chapel Hill

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