Classification and Prioritisation of Multiple Gait Deviations

Original Editor - Stacy Schiurring based on the course by Damien Howell

Top Contributors - Stacy Schiurring, Jess Bell, Kim Jackson and Lucinda hampton

Introduction

What do you do when you have a client that has several gait deviations? The way we walk and run is likely related to the development of musculoskeletal pain syndromes. In previous modules, we identified different gait deviations associated with musculoskeletal pain syndromes. And then we looked at musculoskeletal pain syndromes and what gait deviations are associated with those syndromes. Some of those gait deviations, there's 28 gait deviations, can occur independent of other gait deviations and some of those gait deviations occur together. So, is there a gait deviation that is more important when dealing with musculoskeletal pain syndromes? Or if you cluster or sub-classify gait deviations, does that improve our analysis? Our responsiveness to potential interventions? So there's a need to develop and refine our diagnostic labels and classifications and sub-classifications related to our movement expertise. And proper sub-classification should improve our outcomes and we end up treating the correct diagnosis or the better problem

Literature Review

So we're going to review the literature related to running injuries, gait deviations, and pain syndromes. But the principles I think, will apply to some of our patients that are walkers.

is there a walking or running gait deviation that's more important when dealing with musculoskeletal pain syndromes?

• Christopher Bramah et al. in 2018 asked, is there a pathological gait associated with common soft tissue running injuries? They retrospectively looked at 72 injured runners against 36 controls. The injuries included patellofemoral arthralgia, IT band syndrome, medial tibial stress syndrome and Achilles pain. This is a pathologic, excuse me, a pathokinesiological approach. Given a tissue diagnosis, are there gait deviations, common gait deviations? The injured runners, compared to the controls, with soft tissue injuries showed contralateral pelvic drop, forward lean of the trunk at mid-stance, more extended knee and a dorsiflexed ankle at initial contact or what I described as an increased angle of foot relative to the ground, and too long a step. Later, Christopher Bramah and colleagues in 2021 did a retrospective looking at kinematic characteristics or gait deviations of runners with a history of recurring calf muscle strain, a different diagnosis. They retrospectively included 15 runners with a history of calf injury against 15 controls. The runners with calf injury again, demonstrated contralateral pelvic drop, increased anterior pelvic tilt, too long a step/stride and increased stance time.
• Seyed Mousavi and colleagues, in 2019, did a systematic meta-analysis of the literature, looking at kinematic risk factors for lower limb tendinopathies in runners. Again, is there a gait deviation that's more important? Is there a common gait deviation for tendinopathies? They found peak rearfoot eversion or pronation was the only factor reported in all lower limb tendinopathies. Pronation was statistically significant factor for IT band, patellofemoral tendinopathy and posterior tibial tendinopathy. However, pronation occurred for achilles problems, plantar heel pain syndrome, but was not statistically significant.

So if you cluster or sub-classify gait deviations, does that improve our analysis and responsiveness of interventions?

Clustering or sub-classifying gait patterns based on neurologic diagnosis, it's already occurring. We cluster a gait deviation, we call it a hemiplegic gait or a Parkinson's gait. However, there's limited amount of clustering or sub-classifying in terms of walking patterns or deviations that are related to musculoskeletal pain syndromes. So there are clustering and sub-classifying that's occurring for global running form. You may be familiar with the pose technique of running or the Chi running technique. And I recently found an interesting classification called the aerial versus the terrestrial running pattern, and it's popular in the triathlon community and they've changed the name to running like a gazelle versus a glider.

• So what are we talking about here? This is based on a French group called the Voldalen method, V O L D A L E N. And Cyrille Gindre, in 2015, published a paper describing this. A terrestrial runner versus an aerial runner using five movement patterns. The movement patterns were vertical oscillation of centre of mass, movement of the arms, pelvic position at ground contact, and foot position at ground contact, and foot pattern. So if you have diminished vertical oscillation of centre of mass, you're described as a terrestrial runner, if you have a bouncy gait you're described as an aerial runner. And in terms of the arm movement, if more of your movement is at the shoulder versus the elbow, the shoulder tends to be somebody that stays close to the ground and the elbow, excessive elbow movement tends to be a aerial runner. And then the position of the pelvis at initial contact is low and retroverted if you're a terrestrial runner and it's high and anteverted if you're an aerial runner. And then the position of the foot at ground contact, if you're a terrestrial runner, it's more a long stride farther from the centre of mass, and if you're an aerial runner, it's closer to your centre of mass under your body. And then the foot strike for the terrestrial runner tends to have an increased angle of foot relative to the ground, whereas the aerial runner tends to be a mid-foot or forefoot striker. This patterning has been used to study whether one pattern is more economic or has better performance and can run faster. And so far as I can tell, there's no advantage to one or the other, but I think it would be interesting to use this patterning or sub-classifying to determine if there's a particular type of injury associated with being a terrestrial runner versus an aerial runner.
• Susanne Jauhiainen et al. in 2020, they looked at a hierarchical cluster analysis to determine whether injured runners exhibit similar patterns. So they were trying to look at injured runners and group sub-classify or cluster their running pattern. They found five running patterns as opposed to two. The first subgroup they showed a movement of a valgus thrust, no daylight between the knees, too long a step, and increased up and down motion. Another group showed decreased knee flexion, decreased step length, increased cadence, decreased up and down motion. They described it as a stiff gait. A third group was a bouncy gait. They showed no daylight between the knees, decreased cadence, increased up and down. A fourth group showed an increased angle of foot relative to the ground, increased toe out, increased pronation, and too long a stride. And then the fifth group showed increased pronation or prolonged pronation and toe in. So how did it relate to injuries? The sub-grouping of running patterns did not match up with the type of injury. Those five groups didn't predict what kinds of injuries they would have. The homogeneous, the five groups sub-grouping patterns existed independent of the injury location. This research challenges the hypothesis that a specific gait deviation leads to a specific musculoskeletal pain and challenges the Kinesiopathologic model. However, they concluded it's important to consider these homogeneous or sub-grouping when planning injury prevention or rehab strategies, applying the concept of treating the patient in front of you. Look at that. And this is an example when aggregate data evidence or clinical trials is often not helpful for the patient that's sitting in front of us.
• Bart Dingenen and colleagues in 2020, they made a sub-classification of recreational runners with a running-related injury based on their kinematics or their gait deviations. And they did it with markers on 2D slow-motion video analysis. So they're trying to sub-classify and help with responsiveness to intervention. They retrospectively looked at 53 injured runners to identify deviations. They found different sub-groups demonstrate the same running-related injury can be represented by different gait patterns. However, they found two homogeneous subgroups based on the patterns of gait deviations with similar pain syndromes. The sub-classification based on gait deviations may help us in our clinical reasoning process. This group found that runners with a gait deviation of too long a step or stride, there was a correlation with shin injuries. And the runners that had excessive contralateral pelvic drop, the hippy dippy gait, there was a correlation with hip and knee injury. Their procedure was a 2D slow-motion analysis using markers and looked at the runners, but when you dig into the method, they only looked at kinematics or deviations that occurred in the first and second period of stance. They did not pay attention to the third period of stance. I would suggest if we use their method and looked at the third period of stance, we may find that individuals that have gait deviations in terminal stance or in forefoot rocker may have more foot problems, plantar heel pain syndrome, big toe problems, sesamoiditis. So a gait deviation of either an early heel off or a late heel off during that third period of stance may be a sub-classification that should be considered.

So in summary of the review of literature, the three gait deviations that I think stand out are too long a step or stride, contralateral pelvic drop, and excessive pronation, I think assume a little bit more importance.

Four Patterns or Sub-classifications of Gait Deviations

So is there a better way to sub-classify or cluster gait deviations? From my experience in observing gait deviations, I've seen four patterns or sub-classifications. The first would be what I would call increased impact loading, second would be a geriatric type of gait, a third would be a hippy dippy catwalk gait, and a fourth would be an OA gait or an osteoarthritic gait.

increased impact loading.

The following gait deviations occur or gait deviations with secondary signs would be too long a step or stride, slow cadence, increased up and down motion or vertical oscillation of centre of mass, they're going to be loud, clompers and stompers. They may have increased knee extension, increased hip extension, increased angle of foot relative to the ground at foot strike, foot crossing the midline, an early heel off in terminal stance, increased dorsiflexion of the first MTP in terminal stance. And the one in this clustering that I think assumes more importance is too long a step or stride, primarily because it's fairly easy to identify and we have a lot more tools in our kit to alter it or intervene.

So this gentleman has, we've seen before, has impact loading. He does not have a long step. He has the chronic recurring bilateral plantar heel pain syndrome, and he has the increased vertical oscillation of centre of mass and the up and down motion and the early heel off.

So if we see something, if we see too long a step or stride, what do we do? See a gait deviation, we need to do something. We need to generate a working hypothesis of why the treatment we're choosing will work. When you choose, when you raise a hypothesis, you have assumptions. You raise questions. So if we see too long a step or stride, we need to do something. Here's a potential hypothesis. If too long a step or stride is the more important gait deviation related to impact loading and musculoskeletal pain syndromes, then using verbal cues to alter too long a step or stride will decrease pain. This raises questions. What are good verbal cues to alter too long a step or stride? Is there a difference between a verbal cue, a prompt, and a feedback? These are questions we're going to address in future modules.

geriatric gait

and the important deviation there is slow velocity, less than a metre or 1.4 metres per second when walking. They have a slow cadence, less than a hundred steps per minute, they may have prolonged heel contact or delayed heel off, decreased up and down, decreased vertical oscillation, decreased hip extension, increased forward lean, diminished arm swing. And the two deviations in this classification that I think assume more importance and we can intervene with are slow velocity and a delayed heel off. So if I see these, if I see there's a slow velocity, I need to generate a working hypothesis rationale for my treatment. So if the slow velocity walking is a risk factor for falls and occurs with musculoskeletal pain syndromes, then cueing the client to walk faster will alter that risk factor or decrease their pain. This raises questions. What are the side effects of an intervention? What are the unintended consequences of asking this client to walk faster? If a verbal cue is given to increase ankle plantarflexion in terminal stance, cueing the patient to walk with spring in their step, will the increased ankle plantarflexion, will that increase their velocity? Will altering one gait deviation affect the other? These are questions we're going to address in the future modules.

hippy dippy gait, catwalk gait, excessive contralateral pelvic drop.

the secondary signs or gait deviations that cluster with this are a lateral deviation of centre of mass, popliteal skin crease, an excessive internal rotation at the hip, medial rotation, no daylight between the knees, foot crossing the midline, increased toe out, increased pronation, they may have a heel whip, medial or lateral. The gait deviation that I think assumes a lot of importance because of the literature and experience is a contralateral pelvic drop.

This was the retired model that we saw earlier, and she shows excessive bilateral contralateral pelvic drop, no daylight between the knees, foot crossing the midline, can have gluteal tendinopathy, knee pain, and so forth. So if you see the gait deviation, do something. So the hypothesis is if we do remedial strengthening exercises and we progress those remedial strengthening exercises to gait training, then the resolution of the problem will be more effective and efficient. So, what I'm saying here is as opposed to just giving the patient glute med strengthening, if I add gait training to cue her to not do those gait deviations, can I get it done quicker and be more effective and long lasting? So this raises questions. How do you modify remedial exercise to account for a length-associated muscle weakness? Or a stretch weakness? I would argue that we need to pay attention to the glute med weakness at the shortest length of that muscle, because it's more likely a length-associated muscle weakness. Same may be true for a delayed heel off. It may be that the achilles is too long and calf muscle is too long. We need to address the exercises. So we exercise in the shortest length. But how do we transition from remedial exercises, strengthening exercises to gait training? That's what we're going to discuss in future modules in terms of intervention, how to transition exercise into gait training.

OA gait or the osteoarthritic gait.

Individuals are going to have increased toe out, knee OA, hip OA, gonna have a trunk lean, you're going to have a lateral shift of centre of mass, may have valgus or a varus thrust, they're going to be slow and have decreased step length. The one gait deviation that is, I pay more attention to here, tends to be increased toe out.

Remember, this is our gentlemen with bad right knee osteoarthritis, valgus deformity that's fixed a valgus thrust on the right. He has a lateral shift of centre of mass and you'll notice on the right he has increased toe out. So I need to figure out what to do with that, which of those do I address.

So see something, do something. So if a gait deviation is increased toe out and it continues after the joint is replaced, a total knee joint is replaced, then verbal cueing and feedback to toe in will alter that habitual gait deviation and prevent other injuries. This raises questions. How can I apply motor learning principles, tactics, mechanisms of teaching part versus whole or whole-part-whole to alter gait deviations to decrease toe out. How can I use the dance step to nowhere, right? That's a question. And when the patient is status post total knee replacement, continues to toe out and I provide them feedback to decrease the magnitude of the toe out and he complains of increased knee pain, that's a side effect. Do I have him work through that side effect or do I alter the treatment and go another direction? These are questions we're going to address in future modules.

Prioritising Gait Deviations for Interventions

So my bias, in my opinion, to answer the question of gait deviations, which to address first, is the more important gait deviations related to musculoskeletal pain syndromes are slow velocity, too long a step or stride, contralateral pelvic drop, delayed heel off or increased toe out. Historically, excessive pronation was considered important. Over the years, my bias is it's not so important. It's during that second rocker phase, when you have the whole foot on the ground. For pain syndromes, using pattern recognition during periods of stance can provide a better sub-classification.

So is there a gait deviation that's more important? In some ways, there's an easy answer to that. I choose the gait deviation that the patient expressed concern about during the initial review of the smartphone of their gait. When they say, what is that? It's important to them. I'm going to pay more attention to that. I choose a gait deviation that's more likely related to the patient's specific functional goals. I choose a gait deviation correlated with the patient's history or impairment. If their history was they fractured their ankle during their growth period, the gait deviations that I see there, I got to problem solve because they have to compensate for that. And when faced with multiple gait deviations, choose one and test it with the working hypothesis. Does it eliminate the pain? Does it decrease the pain? Does it increase the pain? Or does it cause secondary side effects? There's a saying "done is better than perfect". Choose one, evaluate the results. All assumptions deserve to be tested.

Summary

So in summary, multiple gait deviations, the way we walk and run is likely related to the development of musculoskeletal pain syndromes. There is conflicting evidence whether gait deviations, or clusters of gait deviations are more significant, one's more significant than another. Currently, there is no definitive answer, excuse me, definitive evidence suggesting one gait deviation occurs more frequently than the other. And so until additional research is available, an analysis of gait deviations needs to be on an individual clinical level. Development of working hypotheses between the healthcare provider and the client needs to be done on an individual basis with clinical reasoning.

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