Trendelenburg Gait: Difference between revisions

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'''Original Editor ''' - Emma De Moerloose  
'''Original Editor ''' - Emma De Moerloose  


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== Definition/ Description  ==
== Definition/ Description: ==


The trendelenburg gait is caused by the weakness of the hip abductors, mostly the gluteal musculature. This weakness could be due to [https://en.wikipedia.org/wiki/Superior_gluteal_nerve 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. <br>&nbsp;<ref>Hensinger RN. Limp. Pediatr Clin North Am. 1986; 33:1355.</ref> <ref>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.</ref>&nbsp;<ref>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.
The Trendelenburg gait is caused by unilateral weakness in the hip abductors, primarily affecting the gluteal musculature. This weakness may result from damage to the [https://en.wikipedia.org/wiki/Superior_gluteal_nerve superior gluteal nerve] or a lesion in the 5th lumbar spine. This condition makes it difficult to support the body’s weight on the affected side. During the normal [[gait]], each lower limb typically bears half of the body weight in some part of the stance phase. When one lower limb is lifted in the swing phase, the other bears the entire weight. '''In the stance phase''', the pelvis normally tilts downwards on the weight-bearing extremity and hikes up on the non-weight bearing extremity.  However, in the presence of hip abductor weakness,  an atypical response occurs: the pelvis tilts downwards on the non-weight bearing extremity instead of upwards. In an attempt to compensate for this effect, the individual engages in a lateral tilt of the trunk away from the affected hip. Consequently, the centre of gravity shifts predominantly onto the stance limb, reducing the pelvic drop. <br>&nbsp;<ref>Hensinger RN. Limp. Pediatr Clin North Am. 1986; 33:1355.</ref> <ref name=":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.</ref>&nbsp;<ref>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.
</ref><ref>Apley G. Apley’s system of orthopaedics and fractures. 6th edition, ELBS, 1986. p243.</ref><ref>Castro WH. Examination and diagnosis of musculoskeletal disorders: Clinical Examination - Imaging Modalities. Thieme, 2001</ref>  
</ref><ref>Apley G. Apley’s system of orthopaedics and fractures. 6th edition, ELBS, 1986. p243.</ref><ref name=":3">Castro WH. Examination and diagnosis of musculoskeletal disorders: Clinical Examination - Imaging Modalities. Thieme, 2001</ref>  


[[Image:Trendelenburg gait.jpg|center|400px]]  
[[Image:Trendelenburg gait.jpg|center|400px]]  


See also: [[Trendelenburg Test]]  
See also: [[Trendelenburg Sign]]  


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy: ==


The [[Hip|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. <ref>Poitout DG. Biomechanics and Biomaterials in orthopedics. Springer,2004. p528-530</ref><br>The [[Gluteus Medius|gluteus medius]] and [[Gluteus Minimus|gluteus minimus]] are the two main hip abductors,support the opposition of the pelvis and prevents the pelvis from dropping. <ref>McGee SR. Evidence- based physical diagnosis . Elsevier, 2007. p51.</ref><ref>Pai VS. Significance of the Trendelenburg test in total hip arthroplasty. J Arthroplasty, 1996; 11 (2): 174-179 1B</ref>  
The [[Hip|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. <ref name=":0">Moore, KL, Dalley, AF, Agur, AM. Clinically oriented anatomy. 7<sup>th</sup> ed. Baltimore, MD: Lippincott Williams & Wilkins, 2014</ref><ref>Poitout DG. Biomechanics and Biomaterials in orthopedics. Springer,2004. p528-530</ref><br>The [[Gluteus Medius|gluteus medius]] and [[Gluteus Minimus|gluteus minimus]] are the two main hip abductors, support the opposition of the [[pelvis]] and prevents the pelvis from dropping. <ref>McGee SR. Evidence- based physical diagnosis . Elsevier, 2007. p51.</ref><ref>Pai VS. Significance of the Trendelenburg sign in total hip arthroplasty. J Arthroplasty, 1996; 11 (2): 174-179 Level of evidence: 1b</ref> '''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 Anatomy|hip joint]], gluteus medius and minimus muscles and also [[Tensor Fascia Lata|tensor fascia lata]].<ref>Drake, RL, Vogl, W, Mitchell, AW, Gray, H. Gray's anatomy for Students 2nd ed.  Philadelphia : Churchill Livingstone/Elsevier, 2010</ref>  


[[Image:Posterior Hip Muscles.PNG|center|200px]]  
[[Image:Posterior Hip Muscles.PNG|center|200px]]  
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== Epidemiology/ Etiology ==
== Epidemiology/ Etiology ==


Trendelenburg gait occurs when a patient has paralysis/paresis of the hip abductors. <ref>Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> Hip abductor weakness may be caused due to neuronal injury of the superior gluteal nerve.<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>
The hip joint and its abductor mechanism behave like a class 3 lever with the effort and the load on the same side of the fulcrum. Any pathology of the fulcrum, load, effort, or the lever which binds all three will lead to a positive Trendelenburg gait.


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>
Failure of the fulcrum presents in the following conditions:


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>
* [[Avascular Necrosis|Osteonecrosis of hip]]
* [[Legg-Calve-Perthes Disease|Legg-Calve-Perthes disease]]
* [[Hip Dysplasia|Developmental dysplasia of the hip]]
* Chronically dislocated hips secondary to trauma
* Chronically dislocated hips secondary to infections like [[tuberculosis]] of the hip


== Characteristics/Clinical Presentation  ==
Failure of the lever is a feature in the following conditions:


A trendelenburg gait is characterized by trunk shift over the affected hip and is best visualized from behind or in front of the patient.
* Greater trochanteric avulsion
* Non-union of the neck of the [[femur]]
* [[Coxa Vara / Coxa Valga|Coxa Vara]]


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).
Failure of effort presents in the following conditions:


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).<ref>Richard J. Ham, et. Al, Primary care geriatrics: a case-based approach, Mosby Elsevier, 2007.</ref>  
* [[Poliomyelitis]]
* L5 [[radiculopathy]]
* Superior gluteal nerve damage
* Gluteus medius and minimus tendinitis
* Gluteus medius and minimus abscess
* Post total hip arthroplasty<ref>Gandbhir VN, Lam JC, Rayi A. [https://www.ncbi.nlm.nih.gov/books/NBK541094/ Trendelenburg gait.] StatPearls [Internet]. 2021 Feb 11.</ref>


== Differential Diagnosis  ==
* 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.<ref>David J. Magee, Orthopedic physical assessment, Musculoskeletal rehabilitation series, fifth edition, 2006.</ref>
* Bilateral weakness of the gluteus medius muscle: the gait shows accentuated side-to-side movement, resulting in a wobbling gait or “chorus girl swing”.<ref>J. Gross, J. Fetto, Elaine Rosen, Musculoskeletal Examination, 3rd Edition.</ref><br>Some people compensate this by flexing their trunk over the weight-bearing hip.<ref>McGee S., Evidence based physical diagnosis, 3rd edition, 2012.</ref><br>
These disturbances in the gait cycle is frequently observed in children with the development of congenital dislocation of the hip (CDH), [[Hip Dysplasia|dysplasia of the hip]] (DDH) and congenital [[Coxa Vara / Coxa Valga|coxa vara]]. 


Coxa vara can also occur from other disorders such as [[Legg-Calve-Perthes Disease|Legg-Calvé-Perthes disease]] or [[Slipped Capital Femoral Epiphysis|slipped capital femoral epiphysis]] (SCFE) - these are two of the most common causes of hip pain or limp.<ref>Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref>&nbsp;<ref>Kelsey JL. Epidemiology of slipped capital femoral epiphysis: a review of the literature. Pediatrics 1973.</ref>&nbsp;<ref>Yochum TR, Rowe LI. Essentials of skeletal radiology. Baltimore: Williams and Wilkins, 1987; 465-68.; 51: 1042-50.</ref>&nbsp;
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>Petrofsky J. The use of electromyogram biofeedback to reduce Trendelenburg gait. European Journal of Applied Physiology. 2001;85(5):491-495 </ref><ref>McGee SR. Evidence- based physical diagnosis. Elsevier, 2007.  p51-54</ref>  


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.<ref>Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.</ref>&nbsp;<ref>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.</ref> This nerve also supplies the gluteus medius, gluteus minimus and tensor fascia lata muscles.<ref>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.</ref>
Trendelenburg gait is also observed in patients with developmental [[Hip Dysplasia|dysplasia of the hip]], congenital [[Hip Dislocation|dislocation of the hip]] (CDH), congenital [[Coxa Vara / Coxa Valga|coxa vara, or coxa valga]] secondary to other disorders like  [[Legg-Calve-Perthes Disease|Legg-Calvé-Perthes disease]] or [[Slipped Capital Femoral Epiphysis|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>  


Other conditions in which a Trendelenberg gait may be observed include muscular dystrophy and hemiplegic cerebral palsy.<ref name="Flynn">Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg 2001;9:89-98.</ref>  
Trendelenburg gait is also seen after hip replacement surgery and femoral fixation with intra-medullary nail. In patients with hip replacement, Trendelenburg gait ensues due to the surgical dissection 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|wound healing]] improves<ref name=":1" />.  <br>Other conditions in which a Trendelenberg gait may be observed include [[Muscular Dystrophy|muscular dystrophy]] and hemiplegic [[Cerebral Palsy Introduction|cerebral palsy]].<ref name="Flynn">Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg 2001;9:89-98.</ref>  


== Characteristics/Clinical Presentation ==
A Trendelenburg gait is characterised by a trunk shift over the affected hip during the stance phase and away during the swing phase of [[gait]], best visualised from behind or in front of the patient. During gait, the pelvis tilts downwards on the non-weight bearing extremity instead of upwards. In an attempt to lessen this effect, the person compensates by lateral tilt of the trunk away from the affected hip. As a result, the centre of gravity shifts mostly onto the stance limb, causing a reduction of the pelvic drop<ref name=":2" /><ref name=":3" />. 
== Differential Diagnosis:  ==
* 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|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 [[foot drop]] 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).<ref>Richard J. Ham, et. Al, Primary care geriatrics: a case-based approach, Mosby Elsevier, 2007.</ref>
* Bilateral weakness of the gluteus medius muscle: the gait shows accentuated side-to-side movement, resulting in a wobbling gait or “chorus girl swing”.<ref>J. Gross, J. Fetto, Elaine Rosen, Musculoskeletal Examination, 3rd Edition.</ref>
* Some people compensate this by flexing their trunk over the weight-bearing hip.<ref>McGee S., Evidence based physical diagnosis, 3rd edition, 2012.</ref><br>
== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


The [[Trendelenburg Test|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. <ref>P. HardCastle, S. Nade, The significance of the trendelenburg test, J Bone Joint Surg Br November 1985 vol. 67-B no. 5 741-746.</ref>  
The [[Trendelenburg Sign|Trendelenburg sign]] 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. The test is negative when the hip of the leg that is lifted, will also go up i.e., hiking of hip or the pelvis tilts upwards. The test is positive, when there is a drop of the hip or a downwards tilt of the pelvis.  
 
X-ray is the best way to diagnose or confirm the Trendelenburg pathology. <ref>HardCastle P, Nade S. The significance of the trendelenburg sign. J Bone Joint Surg Br November. 1985; 67-B (5) :741-746.</ref>  


When the pain in the hip is diagnosed, the surgeon will base the diagnose on data obtained from clinical and &nbsp;[[Diagnostic Imaging of the Hip for Physical Therapists|X-ray assessments]]. These two data sources will provide an answer to:&nbsp;  
When pain in the hip is diagnosed, the surgeon will base the diagnose on data obtained from clinical and &nbsp;[[Diagnostic Imaging of the Hip for Physical Therapists|X-ray assessments]]. These two data sources will provide an answer to:&nbsp;  


*The level of the proximal osteotomy  
*The level of the proximal osteotomy  
*The amount of valgus, extension and derotation at the proximal osteotomy  
*The amount of valgus, extension and de-rotation at the proximal osteotomy
*The level of the distal osteotomy  
*The level of the distal osteotomy  
*The amount of varus and lengthening at the distal osteotomy.<ref>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.</ref>&nbsp;<ref>Paley D (2002) Normal lower limb alignment and joint orientation. In: Paley D (ed) Principles of deformity correction. Springer, Berlin, pp 1–18.</ref>&nbsp;<ref>Gage JR (1991) Gait analysis in cerebral palsy, 1st edn. Clinics in developmental medicine, vol 121. Mac Keith Press, London.</ref> Level of evidence: B
*The amount of varus and lengthening at the distal osteotomy.<ref>Saleh M, Milne A. Weight-bearing parallel-beam scanography for the measurement of leg length and joint alignment. J Bone Joint Surg Br. 1994; 76(1):156–157.</ref>&nbsp;<ref>Paley D. Normal lower limb alignment and joint orientation. In: Paley D (ed) Principles of deformity correction. Berlin:Springer. 2002. p. 1–18.</ref>&nbsp;<ref>Gage JR. Gait analysis in cerebral palsy. 1st edn. Clinics in developmental medicine, vol 121. London:Mac Keith Press, 1991.</ref> Level of evidence: B


== Examination  ==
== Examination  ==


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<br>  
The [https://www.researchgate.net/figure/Modified-criteria-of-McKay-for-clinical-evaluation-of-results-2_tbl1_5517597 modified McKay] criteria is useful to assess if a patient has Trendelenburg gait. These criteria measure [[Pain-Modulation|pain]] symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement.<br>  


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| Good  
| Good  
| Stable, painless hip; slight limp; slight<br>decrease in range of movement
| Stable, painless hip; slight limp; slight<br>decrease in [[Range of Motion|range of movement]]
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|-
| Fair  
| Fair  
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== Medical Management  ==
== Medical Management  ==


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.&nbsp;<ref>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.</ref>&nbsp;Level of evidence: A2
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.&nbsp;<ref>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.Level of evidence: 2a</ref>&nbsp;  
 
Pelvic support osteotomies cause a significant improvement in outcomes relating to posture, gait and walking tolerance in patients who had untreated congenital dislocations.<ref>Lance PM (1936) Osteotomies sous-trochanterienne dans le traitement des luxations congenitales inveterees de la hanche. Masson Cie, Paris.</ref>&nbsp;<ref>Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595.</ref>&nbsp;Level of evidence: B<br>
 
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.&nbsp;<ref>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.</ref> Level of evidence: C<br>


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.<ref>Fernandez DL, Isler B, Müller ME. Chiari’s osteotomy: a note on technique. Clin Orthop 1984;185:53-8.</ref> 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.<ref>Pafilas D, Nayagam S. The pelvic support osteotomy: indications and preoperative planning. ''Strategies in trauma and limb reconstruction''. 2008.DOI:10.1007/s11751-008-0039-7</ref>&nbsp;<ref>Emara K. Pelvic Support Osteotomy in the Treatment of Patients With Excision Arthroplasty. Clinical orthopaedics and related research. 2008; 466: 708-13. DOI 10.1007/s11999-007-0094-2.</ref>&nbsp;Level of evidence: B<br>


Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters for individuals with somatic dysfunctions, as measured by a [https://www.researchgate.net/figure/A-GaitMAT-II-System-B-Step-length-defined-as-the-distance-between-contacts-of-the_fig2_38015051 GaitMat II system].
== Physical Therapy Management  ==
== Physical Therapy Management  ==


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.  <ref>Andrews J., Harrelson G.,Wilk K., Physical rehabilitation of the injured athlete, Elsevier Saunders, 2012, 4th edition (LoE: 5)</ref> (LoE: 5) <ref name="Jerrold">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)</ref> (LoE: 2b)
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 minimise the secondary injuries.  <ref>Andrews J, Harrelson G, Wilk K. Physical rehabilitation of the injured athlete.4th edition. Elsevier Saunders. 2012. Level of evidence: 5</ref> <ref name="Jerrold">Petrofsky J. The use of electromyogram biofeedback to reduce Trendelenburg gait. European Journal of Applied Physiology. 2001; 85(5):491-495 <nowiki>http://link.springer.com/article/10.1007/s004210100466</nowiki> Level of evidence: 2b</ref>  


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 [[Therapy Exercises for the Hip|strengthen the rest of the leg]] on the affected side. Level of evidence: D.<br>
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 unaffected 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. Exercise can be progressed in terms of gravity, load and frequency.


{{#ev:youtube|mxWissvKVj0|300}}  
Other exercises in the treatment of Trendelenburg gait include functional [[Closed Chain Exercise|closed-chain exercises]], lateral step-ups and functional balance exercises. It is also important to [[Therapy Exercises for the Hip|strengthen the rest of the hip muscles]] on the affected side.<br>
 
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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.
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|{{#ev:youtube|mxWissvKVj0|300}}  
|{{#ev:youtube|watch?v=wFF7ntBI37E|300}}
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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.&nbsp;<ref>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)</ref> (LoE: 4).  
The use of an Electromyogram (EMG) [[biofeedback]] 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.&nbsp;<ref>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. Level of evidence: 4</ref> EMG device provides warning tones, giving feedback of improper gait through sensing the level of gluteus medius activity.


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. <br>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. <br>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.<ref name="Jerrold" /> (LoE: 2b) <ref>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)</ref> (LoE: 4) <ref>Davis C.M., Complementary therapies in rehabilitation, SLACK incorporated, 2009, 3th edition (LoE: 5)</ref> (LoE: 5)<br>  
<br>A research 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.<ref name="Jerrold" /> <ref>J. S. Petrofsky. Microprocessor-based gait analysis system to retrain Trendelenburg gait. Medical and Biological Engineering and Computing. 2001; 39(1): 140-143. DOI: 10.1007/BF02345278. Level of evidence: 4</ref> <ref>Davis CM. Complementary therapies in rehabilitation.  3th edition. SLACK incorporated, 2009. Level of evidence: 5</ref> <br>  


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.<ref>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</ref> (LoE: 4)    
Patients with Trendelenburg suffer from abnormal range of motion in hip and trunk; so, a wall mirror biofeedback  could also be used. This treatment is used to increase the hip and trunk range of motion. The patient get visual feedback about how he/she walks. The therapists watches and gives advise/correction to posture, so as to facilitate proper gait re-education.<ref>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</ref>     
== References  ==


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Definition/ Description:[edit | edit source]

The Trendelenburg gait is caused by unilateral weakness in the hip abductors, primarily affecting the gluteal musculature. This weakness may result from damage to the superior gluteal nerve or a lesion in the 5th lumbar spine. This condition makes it difficult to support the body’s weight on the affected side. During the normal gait, each lower limb typically bears half of the body weight in some part of the stance phase. When one lower limb is lifted in the swing phase, the other bears the entire weight. In the stance phase, the pelvis normally tilts downwards on the weight-bearing extremity and hikes up on the non-weight bearing extremity. However, in the presence of hip abductor weakness, an atypical response occurs: the pelvis tilts downwards on the non-weight bearing extremity instead of upwards. In an attempt to compensate for this effect, the individual engages in a lateral tilt of the trunk away from the affected hip. Consequently, the centre of gravity shifts predominantly onto the stance limb, reducing the pelvic drop.
 [1] [2] [3][4][5]

Trendelenburg gait.jpg

See also: Trendelenburg Sign

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]

The hip joint and its abductor mechanism behave like a class 3 lever with the effort and the load on the same side of the fulcrum. Any pathology of the fulcrum, load, effort, or the lever which binds all three will lead to a positive Trendelenburg gait.

Failure of the fulcrum presents in the following conditions:

Failure of the lever is a feature in the following conditions:

  • Greater trochanteric avulsion
  • Non-union of the neck of the femur
  • Coxa Vara

Failure of effort presents in the following conditions:

  • Poliomyelitis
  • L5 radiculopathy
  • Superior gluteal nerve damage
  • Gluteus medius and minimus tendinitis
  • Gluteus medius and minimus abscess
  • Post total hip arthroplasty[12]


Trendelenburg gait occurs when a patient has paralysis/paresis of the hip abductors. [6][13] Hip abductor weakness may be caused due to neuronal injury to the superior gluteal nerve either due to nerve entrapment or by iatrogenic factors.[14][15][16]

Trendelenburg gait is also observed in patients with developmental dysplasia of the hip, congenital dislocation of the hip (CDH), 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.[17][18]

Trendelenburg gait is also seen after hip replacement surgery and femoral fixation with intra-medullary nail. In patients with hip replacement, Trendelenburg gait ensues due to the surgical dissection of the gluteus medius muscle during surgery to expose the hip joint; thus the dysfunction in the abductor muscles.[17] This resolves as wound healing improves[14].
Other conditions in which a Trendelenberg gait may be observed include muscular dystrophy and hemiplegic cerebral palsy.[19]

Characteristics/Clinical Presentation[edit | edit source]

A Trendelenburg gait is characterised by a trunk shift over the affected hip during the stance phase and away during the swing phase of gait, best visualised from behind or in front of the patient. During gait, the pelvis tilts downwards on the non-weight bearing extremity instead of upwards. In an attempt to lessen this effect, the person compensates by lateral tilt of the trunk away from the affected hip. As a result, the centre of gravity shifts mostly onto the stance limb, causing a reduction of the pelvic drop[2][5].

Differential Diagnosis:[edit | edit source]

  • 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 foot drop 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).[20]
  • Bilateral weakness of the gluteus medius muscle: the gait shows accentuated side-to-side movement, resulting in a wobbling gait or “chorus girl swing”.[21]
  • Some people compensate this by flexing their trunk over the weight-bearing hip.[22]

Diagnostic Procedures[edit | edit source]

The Trendelenburg sign 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. The test is negative when the hip of the leg that is lifted, will also go up i.e., hiking of hip or the pelvis tilts upwards. The test is positive, when there is a drop of the hip or a downwards tilt of the pelvis.

X-ray is the best way to diagnose or confirm the Trendelenburg pathology. [23]

When 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 de-rotation at the proximal osteotomy
  • The level of the distal osteotomy
  • The amount of varus and lengthening at the distal osteotomy.[24] [25] [26] 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.

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. [27] 

Pelvic support osteotomies cause a significant improvement in outcomes relating to posture, gait and walking tolerance in patients who had untreated congenital dislocations.[28] [29] 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.

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 minimise the secondary injuries. [30] [31]

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 unaffected 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. Exercise can be progressed in terms of gravity, load and frequency.

Other exercises in the treatment 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 hip muscles on the affected side.

The use of an Electromyogram (EMG) biofeedback 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. [32] EMG device provides warning tones, giving feedback of improper gait through sensing the level of gluteus medius activity.


A research 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.[31] [33] [34]

Patients with Trendelenburg suffer from abnormal range of motion in hip and trunk; so, a wall mirror biofeedback could also be used. This treatment is used to increase the hip and trunk range of motion. The patient get visual feedback about how he/she walks. The therapists watches and gives advise/correction to posture, so as to facilitate proper gait re-education.[35]

References[edit | edit source]

  1. ↑ Hensinger RN. Limp. Pediatr Clin North Am. 1986; 33:1355.
  2. ↑ 2.0 2.1 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. ↑ 5.0 5.1 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 sign in total hip arthroplasty. J Arthroplasty, 1996; 11 (2): 174-179 Level of evidence: 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. ↑ Gandbhir VN, Lam JC, Rayi A. Trendelenburg gait. StatPearls [Internet]. 2021 Feb 11.
  13. ↑ Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
  14. ↑ 14.0 14.1 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
  15. ↑ Petrofsky J. The use of electromyogram biofeedback to reduce Trendelenburg gait. European Journal of Applied Physiology. 2001;85(5):491-495
  16. ↑ McGee SR. Evidence- based physical diagnosis. Elsevier, 2007. p51-54
  17. ↑ 17.0 17.1 Herring JA. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children. 5th Edition. Saunders Elsevier. 2013. Level of evidence: 1b
  18. ↑ 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.
  19. ↑ Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg 2001;9:89-98.
  20. ↑ Richard J. Ham, et. Al, Primary care geriatrics: a case-based approach, Mosby Elsevier, 2007.
  21. ↑ J. Gross, J. Fetto, Elaine Rosen, Musculoskeletal Examination, 3rd Edition.
  22. ↑ McGee S., Evidence based physical diagnosis, 3rd edition, 2012.
  23. ↑ HardCastle P, Nade S. The significance of the trendelenburg sign. J Bone Joint Surg Br November. 1985; 67-B (5) :741-746.
  24. ↑ Saleh M, Milne A. Weight-bearing parallel-beam scanography for the measurement of leg length and joint alignment. J Bone Joint Surg Br. 1994; 76(1):156–157.
  25. ↑ Paley D. Normal lower limb alignment and joint orientation. In: Paley D (ed) Principles of deformity correction. Berlin:Springer. 2002. p. 1–18.
  26. ↑ Gage JR. Gait analysis in cerebral palsy. 1st edn. Clinics in developmental medicine, vol 121. London:Mac Keith Press, 1991.
  27. ↑ 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.Level of evidence: 2a
  28. ↑ Pafilas D, Nayagam S. The pelvic support osteotomy: indications and preoperative planning. Strategies in trauma and limb reconstruction. 2008.DOI:10.1007/s11751-008-0039-7
  29. ↑ Emara K. Pelvic Support Osteotomy in the Treatment of Patients With Excision Arthroplasty. Clinical orthopaedics and related research. 2008; 466: 708-13. DOI 10.1007/s11999-007-0094-2.
  30. ↑ Andrews J, Harrelson G, Wilk K. Physical rehabilitation of the injured athlete.4th edition. Elsevier Saunders. 2012. Level of evidence: 5
  31. ↑ 31.0 31.1 Petrofsky J. The use of electromyogram biofeedback to reduce Trendelenburg gait. European Journal of Applied Physiology. 2001; 85(5):491-495 http://link.springer.com/article/10.1007/s004210100466 Level of evidence: 2b
  32. ↑ 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. Level of evidence: 4
  33. ↑ J. S. Petrofsky. Microprocessor-based gait analysis system to retrain Trendelenburg gait. Medical and Biological Engineering and Computing. 2001; 39(1): 140-143. DOI: 10.1007/BF02345278. Level of evidence: 4
  34. ↑ Davis CM. Complementary therapies in rehabilitation. 3th edition. SLACK incorporated, 2009. Level of evidence: 5
  35. ↑ 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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