Trendelenburg Gait: Difference between revisions

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== Epidemiology/ Etiology  ==
== Epidemiology/ Etiology  ==


Trendelenburg gait occurs when a patient has paralysis/paresis of the hip abductors. <ref name=":0" /><ref>Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> Hip abductor weakness may be caused due to neuronal injury to the superior gluteal nerve either due to nerve entrapment or by iatrogenic factors.<ref>Craig A. Nerve Compression/Entrapment Sites of the Lower Limb. Nerves and Nerve Injuries: Pain, Treatment, Injury, Disease and Future Directions. 2015, 2:755-77 https://doi.org/10.1016/B978-0-12-802653-3.00097-X
Trendelenburg gait occurs when a patient has paralysis/paresis of the hip abductors. <ref name=":0" /><ref>Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> Hip abductor weakness may be caused due to neuronal injury to the superior gluteal nerve either due to nerve entrapment or by iatrogenic factors.<ref name=":1">Craig A. Nerve Compression/Entrapment Sites of the Lower Limb. Nerves and Nerve Injuries: Pain, Treatment, Injury, Disease and Future Directions. 2015, 2:755-77 https://doi.org/10.1016/B978-0-12-802653-3.00097-X
</ref><ref>European Journal of Applied Physiology * September 2001, Volume 85, Issue 5, pp 491-495 * The use of electromyogram biofeedback to reduce Trendelenburg gait *Jerrold Petrofsky</ref><ref>McGee SR. Evidence- based physical diagnosis. Elsevier, 2007.  p51-54</ref>  
</ref><ref>European Journal of Applied Physiology * September 2001, Volume 85, Issue 5, pp 491-495 * The use of electromyogram biofeedback to reduce Trendelenburg gait *Jerrold Petrofsky</ref><ref>McGee SR. Evidence- based physical diagnosis. Elsevier, 2007.  p51-54</ref>  


Trendelenburg gait is also observed in patients with developmental dysplasia of the hip, congenital coxa vara, or coxa valga secondary to other disorders like  Legg-Calvé-Perthes disease or slipped capital femoral epiphysis. In these aforementioned conditions, the abductor muscles are normal but they have a mechanical disadvantage. Patients with Slipped capital femoral epiphysis also have a muscular weakness that leads to trendelenburg gait.<ref name="Tachdjan">Tachdjan's. (sd). Pediatric orthopeadics. Elsevier. P79,p80,p95</ref><ref>Use of Osteopathic Manipulative Treatment to Manage Compensated Trendelenburg Gait Caused by Sacroiliac Somatic Dysfunction ,Adam C. Gilliss, DO; Randel L. Swanson II, OMS III;  Deanna Janora, MD; Venkat Venkataraman, PhDfckLRThe journal of of the americal osteopathic association , 3B</ref>  
Trendelenburg gait is also observed in patients with developmental dysplasia of the hip, congenital coxa vara, or coxa valga secondary to other disorders like  Legg-Calvé-Perthes disease or slipped capital femoral epiphysis. In these aforementioned conditions, the abductor muscles are normal but they have a mechanical disadvantage. Patients with Slipped capital femoral epiphysis also have a muscular weakness that can lead to trendelenburg gait.<ref name="Tachdjan">Herring JA. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children. 5th Edition. Saunders Elsevier. 2013. Level of evidence: 1B</ref><ref>Gilliss AC, Swanson RL, Janora D, Venkataraman V. Use of Osteopathic Manipulative Treatment to Manage Compensated Trendelenburg Gait Caused by Sacroiliac Somatic Dysfunction. The journal of of the americal osteopathic association. 2010;110(2):81-6. </ref>  


Trendelenburg gait is also seen after medical surgery. In patients with hip replacement, trendelenburg gait can be noticed because the gluteus medius muscle must be cut to expose the joint. It leads to dysfunction in the abductor muscles.  Level of evidence: 1B.<ref name="Tachdjan" /><br>  
Trendelenburg gait is also seen after Hip replacement surgery and femoral fixation with intramedullary nail. In patients with hip replacement, trendelenburg gait ensues due to the surgical dissecction of the gluteus medius muscle during surgery to expose the hip joint; thus the dysfunction in the abductor muscles.<ref name="Tachdjan" /> This resolves as wound healing improves<ref name=":1" />.  <br>  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==

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Definition/ Description[edit | edit source]

The trendelenburg gait is caused by the weakness of the hip abductors, mostly the gluteal musculature. This weakness could be due to superior gluteal nerve damage or in 5th lumbar spine lesion. This condition makes it difficult to support the body’s weight on the affected side. During normal gait, both lower limbs bear half of the body weight is some part of stance phase. When one lower limb is lifted in swing phase, the other takes the entire weight. During the stance phase of gait, the pelvis tilts downwards on the weight-bearing extremity and hikes up on the non-weight bearing extremity. But when there is a hip abductor weakness, the pelvis tilts downwards instead of upwards on the non-weight bearing extremity. In an attempt to lessen this effect, the person compensates by lateral tilt of the trunk away from the affected hip, thus center of gravity is mostly on the stance limb causing a reduction of the pelvic drop.
 [1] [2] [3][4][5]

Trendelenburg gait.jpg

See also: Trendelenburg Test

Clinically Relevant Anatomy[edit | edit source]

The hip joint is composed of the acetabulum and the femoral head. These structures are surrounded by soft tissues and twenty-two muscles. These muscles provide the stability and the force required for movement of the femur during activity. [6][7]
The gluteus medius and gluteus minimus are the two main hip abductors,support the opposition of the pelvis and prevents the pelvis from dropping. [8][9] The superior gluteal nerve arises from contributions from the L4- S1 nerve roots. This nerve exits the pelvis through the sciatic notch to supply the hip joint, gluteus medius and minimus muscles and also Tensor fascia lata.[10]

Posterior Hip Muscles.PNG


[11]

Epidemiology/ Etiology[edit | edit source]

Trendelenburg gait occurs when a patient has paralysis/paresis of the hip abductors. [6][12] Hip abductor weakness may be caused due to neuronal injury to the superior gluteal nerve either due to nerve entrapment or by iatrogenic factors.[13][14][15]

Trendelenburg gait is also observed in patients with developmental dysplasia of the hip, congenital coxa vara, or coxa valga secondary to other disorders like Legg-Calvé-Perthes disease or slipped capital femoral epiphysis. In these aforementioned conditions, the abductor muscles are normal but they have a mechanical disadvantage. Patients with Slipped capital femoral epiphysis also have a muscular weakness that can lead to trendelenburg gait.[16][17]

Trendelenburg gait is also seen after Hip replacement surgery and femoral fixation with intramedullary nail. In patients with hip replacement, trendelenburg gait ensues due to the surgical dissecction of the gluteus medius muscle during surgery to expose the hip joint; thus the dysfunction in the abductor muscles.[16] This resolves as wound healing improves[13].

Characteristics/Clinical Presentation[edit | edit source]

A trendelenburg gait is characterized by trunk shift over the affected hip and is best visualized from behind or in front of the patient.

Observation of the patient’s gait from the side enables the examiner to detect stride and step length deficiencies as well as motion of the trunk and lower extremity in the sagittal plane, including the extensor or gluteus maximus lurch in which the patient thrusts the trunk posteriorly to compensate for weak hip extensors (gluteus maximus muscle).

Observation from the side also enables detection of ankle dorsiflexor weakness and footdrop leading to the inability of the foot to clear the ground, which is compensated for by excessive lower extremity flexion to facilitate the floor clearance (steppage gait).[18]

Differential Diagnosis[edit | edit source]

  • Weak hip abductor muscles: no stabilizing effect of these muscles during the stance phase. The patient exhibits an excessive lateral tilt in which the thorax is thrust laterally to keep the center of gravity over the stance leg.[19]
  • Bilateral weakness of the gluteus medius muscle: the gait shows accentuated side-to-side movement, resulting in a wobbling gait or “chorus girl swing”.[20]
    Some people compensate this by flexing their trunk over the weight-bearing hip.[21]

These disturbances in the gait cycle is frequently observed in children with the development of congenital dislocation of the hip (CDH), dysplasia of the hip (DDH) and congenital coxa vara.

Coxa vara can also occur from other disorders such as Legg-Calvé-Perthes disease or slipped capital femoral epiphysis (SCFE) - these are two of the most common causes of hip pain or limp.[22] [23] [24] 

The Trendelenburg gait can also occur as the result of a neuronal injury. A lesion of the superior gluteal nerve (SGN), which is the main nerve stimulating the hip abductors, can lead to weakness.[25] [26] This nerve also supplies the gluteus medius, gluteus minimus and tensor fascia lata muscles.[27]

Other conditions in which a Trendelenberg gait may be observed include muscular dystrophy and hemiplegic cerebral palsy.[28]

Diagnostic Procedures[edit | edit source]

The Trendelenburg test determines the integrity of hip abductor muscle function. The therapist can use this test when there is no X-ray taken but there are signs of Trendelenburg. The person has to stand on one leg and tilt the other one up. The test is negative when the hip of the leg that is lifted, will also go up i.e, hiking of hip. The test is positive, when there is the drop of the pelvis that is lifted.X-ray is the best way to diagnose or confirm the trendelenburg pathology. [29]

When the pain in the hip is diagnosed, the surgeon will base the diagnose on data obtained from clinical and  X-ray assessments. These two data sources will provide an answer to: 

  • The level of the proximal osteotomy
  • The amount of valgus, extension and derotation at the proximal osteotomy
  • The level of the distal osteotomy
  • The amount of varus and lengthening at the distal osteotomy.[30] [31] [32] Level of evidence: B

Examination[edit | edit source]

The modified McKay criteria is useful to assess if a patient has Trendelenburg gait. These criteria measure pain symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement. Level of evidence: A2

Grade Criteria
Excellent Stable, painless hip; no limp; negative
Trendelenburg sign; full range of movement
Good Stable, painless hip; slight limp; slight
decrease in range of movement
Fair Stable, painless hip; limp; positive
Trendelenburg sign; and limited range of
movement, or a combination of these
Poor Unstable or painful hip or both; positive
Trendelenburg sign

Medical Management[edit | edit source]

For patients with compensated Trendelenburg gait, medical management can attempt to deal with the causes underlying a Trendelenburg gait. Open reduction and Salter innominate osteotomy (SIO) without preoperative traction is effective in the management of developmental dysplasia of the hip in children younger than 6 years. [33] Level of evidence: A2

Pelvic support osteotomies cause a significant improvement in outcomes relating to posture, gait and walking tolerance in patients who had untreated congenital dislocations.[34] [35] Level of evidence: B

Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters for individuals with somatic dysfunctions, as measured by a GaitMat II system. Further research is needed for better understanding of the relationship between somatic dysfunctions and gait deviations. [36] Level of evidence: C

There is a significant difference in the incidence of a positive Trendelenburg gait between surgical approaches, using trochanteric osteotomy or not. This shows the effectiveness of distal trochanteric transfer.[37] Level of evidence: A2

Physical Therapy Management[edit | edit source]

Trendelenburg gait can result in the development of other pathologies of the bones in the hip and knee such as arthritis or premature wear in the hip joints. Therefore it is of great importance to find out a form of physical therapy that will cause a reduction in the degree of Trendelenburg gait to minimize the secondary injuries. [38] (LoE: 5) [39] (LoE: 2b)

Trendelenburg gait is an abnormal gait caused by weakness of the hip abductors. Therefore, the main purpose of physical therapy with regards to this impairment is to strengthen the abductors of the hip. An appropriate exercise to strengthen the hip abductors is to have the patient lie in side-lying on the less affected side and abduct the upper leg towards the ceiling. To make the exercise more challenging, a weight or theraband can be placed around the active limb. Other exercises in the revalidation of Trendelenburg gait include functional closed-chain exercises, lateral step-ups and functional balance exercises. It is also important to strengthen the rest of the leg on the affected side. Level of evidence: D.

Research has shown the importance of strengthening the muscles. Not only the M. gluteus medius, but also the quadriceps and the hamstrings. These increases in strength of the muscles, results in a reduction of the degree of Trendelenburg gait.

The use of an Electromyogram (EMG) reduces the Trendelenburg gait by an average of 29 degrees. The average stride length has been shown to increase from 0,32 ± 0,3m to 0,45 ± 0,2m and the speed of gait has been shown to increase from 1,6 ± 0,4 kmh−1 to 3,1 ± 0,5 kmh−1. [40] (LoE: 4).

During the treatment, EMG biofeedback has been used. As weakness of the gluteus medius muscles is the prime contributor to Trendelenburg gait, the device provides warning tones giving feedback of improper gait through too little gluteus medius activity.
In every day life the therapist isn’t constantly with the patient. So, when the patient walks incorrectly, trunk shift over the affected hip, during the day, the positive effects of the therapy can be reversed.
With this in mind, researchers investigated the usefulness of a two-channel EMG biofeedback training device that patients could wear at home. The conclusion of this study was that the group that used the home training device, showed almost normal gait after two months. This goal is only achievable when patients are doing exercises which strengthen the hip abductors in combination with the two-channel EMG biofeedback device.[39] (LoE: 2b) [41] (LoE: 4) [42] (LoE: 5)

Patients with trendelenburg suffer from abnormal range of motion in hip and trunk. The purpose of the treatment is to increase the range of motion. The people get visual feedback about how the walk. They get advises from the therapists so they will think about you must walk correctly. This kind of treatment is good for increasing the range of motion of the hip and the trunk.[43] (LoE: 4)

  1. ↑ Hensinger RN. Limp. Pediatr Clin North Am. 1986; 33:1355.
  2. ↑ Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18(2):222-227.
  3. ↑ Vasudevan PN, Vaidyalingam KV, Nair PB. Can Trendelenburg's sign be positive if the hip is normal?J Bone Joint Surg Br. 1997;79(3):462-6.
  4. ↑ Apley G. Apley’s system of orthopaedics and fractures. 6th edition, ELBS, 1986. p243.
  5. ↑ Castro WH. Examination and diagnosis of musculoskeletal disorders: Clinical Examination - Imaging Modalities. Thieme, 2001
  6. ↑ 6.0 6.1 Moore, KL, Dalley, AF, Agur, AM. Clinically oriented anatomy. 7th ed. Baltimore, MD: Lippincott Williams & Wilkins, 2014
  7. ↑ Poitout DG. Biomechanics and Biomaterials in orthopedics. Springer,2004. p528-530
  8. ↑ McGee SR. Evidence- based physical diagnosis . Elsevier, 2007. p51.
  9. ↑ Pai VS. Significance of the Trendelenburg test in total hip arthroplasty. J Arthroplasty, 1996; 11 (2): 174-179 1B
  10. ↑ Drake, RL, Vogl, W, Mitchell, AW, Gray, H. Gray's anatomy for Students 2nd ed.  Philadelphia : Churchill Livingstone/Elsevier, 2010
  11. ↑ Roda D. The gait cycle: a breakdown of each component. Available from: http://www.youtube.com/watch?v=5j4YRHf6Iyo [last accessed 2013/11/24]
  12. ↑ Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
  13. ↑ 13.0 13.1 Craig A. Nerve Compression/Entrapment Sites of the Lower Limb. Nerves and Nerve Injuries: Pain, Treatment, Injury, Disease and Future Directions. 2015, 2:755-77 https://doi.org/10.1016/B978-0-12-802653-3.00097-X
  14. ↑ European Journal of Applied Physiology * September 2001, Volume 85, Issue 5, pp 491-495 * The use of electromyogram biofeedback to reduce Trendelenburg gait *Jerrold Petrofsky
  15. ↑ McGee SR. Evidence- based physical diagnosis. Elsevier, 2007. p51-54
  16. ↑ 16.0 16.1 Herring JA. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children. 5th Edition. Saunders Elsevier. 2013. Level of evidence: 1B
  17. ↑ Gilliss AC, Swanson RL, Janora D, Venkataraman V. Use of Osteopathic Manipulative Treatment to Manage Compensated Trendelenburg Gait Caused by Sacroiliac Somatic Dysfunction. The journal of of the americal osteopathic association. 2010;110(2):81-6.
  18. ↑ Richard J. Ham, et. Al, Primary care geriatrics: a case-based approach, Mosby Elsevier, 2007.
  19. ↑ David J. Magee, Orthopedic physical assessment, Musculoskeletal rehabilitation series, fifth edition, 2006.
  20. ↑ J. Gross, J. Fetto, Elaine Rosen, Musculoskeletal Examination, 3rd Edition.
  21. ↑ McGee S., Evidence based physical diagnosis, 3rd edition, 2012.
  22. ↑ Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
  23. ↑ Kelsey JL. Epidemiology of slipped capital femoral epiphysis: a review of the literature. Pediatrics 1973.
  24. ↑ Yochum TR, Rowe LI. Essentials of skeletal radiology. Baltimore: Williams and Wilkins, 1987; 465-68.; 51: 1042-50.
  25. ↑ Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.
  26. ↑ Jacobs LG, Buxton RA. The course of the superior gluteal nerve in the lateral approach to the hip. J Bone Joint Surg [Am] 1989;71:1239-43.
  27. ↑ Bülbül M, Ayanoğlu S, Öztürk K, İmren Y, Esenyel C, Yeşiltepe R, et al. How reliable is the safe zone of Hardinge approach for superior gluteal nerve? Trakya Univ Tıp Fak Derg 2009;26:134-6.
  28. ↑ Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg 2001;9:89-98.
  29. ↑ P. HardCastle, S. Nade, The significance of the trendelenburg test, J Bone Joint Surg Br November 1985 vol. 67-B no. 5 741-746.
  30. ↑ Saleh M, Milne A (1994) Weight-bearing parallel-beam scanography for the measurement of leg length and joint alignment. J Bone Joint Surg Br 76(1):156–157.
  31. ↑ Paley D (2002) Normal lower limb alignment and joint orientation. In: Paley D (ed) Principles of deformity correction. Springer, Berlin, pp 1–18.
  32. ↑ Gage JR (1991) Gait analysis in cerebral palsy, 1st edn. Clinics in developmental medicine, vol 121. Mac Keith Press, London.
  33. ↑ Bohm P, Brzuske A. Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am 2002;84:178–86.
  34. ↑ Lance PM (1936) Osteotomies sous-trochanterienne dans le traitement des luxations congenitales inveterees de la hanche. Masson Cie, Paris.
  35. ↑ Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595.
  36. ↑ Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults [published online ahead of print October 25, 2005]. Neuroepidemiology. 2006;26:52-60.
  37. ↑ Fernandez DL, Isler B, Müller ME. Chiari’s osteotomy: a note on technique. Clin Orthop 1984;185:53-8.
  38. ↑ Andrews J., Harrelson G.,Wilk K., Physical rehabilitation of the injured athlete, Elsevier Saunders, 2012, 4th edition (LoE: 5)
  39. ↑ 39.0 39.1 European Journal of Applied Physiology * September 2001, Volume 85, Issue 5, pp 491-495 * The use of electromyogram biofeedback to reduce Trendelenburg gait *Jerrold PetrofskyfckLRhttp://link.springer.com/article/10.1007/s004210100466 (LoE: 2b)
  40. ↑ J. S. Petrofsky. Microprocessor-based gait analysis system to retrain Trendelenburg gait. Medical and Biological Engineering and Computing , Volume 39, Number 1, 140-143, DOI: 10.1007/BF02345278. (LoE: 4)
  41. ↑ J. S. Petrofsky. Microprocessor-based gait analysis system to retrain Trendelenburg gait. Medical and Biological Engineering and Computing , Volume 39, Number 1, 140-143, DOI: 10.1007/BF02345278. (LoE: 4)
  42. ↑ Davis C.M., Complementary therapies in rehabilitation, SLACK incorporated, 2009, 3th edition (LoE: 5)
  43. ↑ D. Hamacher, D. Bertram, C. Fölsch, L. Schega, Evaluatiob of a visual feedback system in gait retraining: A pilot study, Elsevier, 2012. Level of evidence: 4


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