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

Dr Damien Howell performed a literature review related to running injuries, gait deviations, and pain syndromes. He used the gathered data to attempt to answer the following clinical questions:

Which gait deviations are clinically important for musculoskeletal pain syndromes?

There is a need to develop and refine diagnostic labels, classifications and sub-classifications related to rehabilitation movement expertise. Proper sub-classification should improve patient's outcomes by allowing clinicians to more quickly and accurately find the correct rehabilitation diagnosis which will lead to more efficient treatment and interventions.

Christopher Bramah et al 2018 performed a retrospective study to see if there are pathological gait deviations associated with common soft tissue running injuries. They compared 72 injured runners against 36 controls. The injuries included patellofemoral arthralgia, iliotibial (IT) band syndrome, medial tibial stress syndrome and Achilles pain. The injured runners with soft tissue injuries demonstrated the following gait deviations: (1) contralateral pelvic drop, (2) forward lean of the trunk at mid-stance, (3) increased knee extension and ankle dorsiflexion at initial contact (an increased angle of foot relative to the ground), and (4) too long a step or stride length.

In 2021, Christopher Bramah and colleagues performed another retrospective looking at gait deviations of runners with a history of recurring calf muscle strain. They retrospectively included 15 runners with a history of calf injury against 15 controls. The runners with calf injury demonstrated: (1) contralateral pelvic drop, (2) increased anterior pelvic tilt, (3) too long a step or stride length, and (4) increased stance time.

Seyed Mousavi et al 2019, performed a systematic meta-analysis on kinematic risk factors for lower limb tendinopathies in runners. 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 syndrome, 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 is commonly seen in rehabilitation, for example: hemiplegic gait or Parkinsonian gait. However, there is a limited amount of clustering or sub-classifying gait patterns as related to musculoskeletal pain syndromes.

There are clustering and sub-classifying occurring for global running form. Cyrille Gindre et al 2016 describes the Volodalen method, which provides a method for classifying running patterns into two categories: aerial and terrestrial using five movement patterns. The movement patterns are: (1) vertical oscillation of centre of mass (COM), (2) arms movement, (3) pelvic position at ground contact, (4) foot position at ground contact, and (5) foot strike pattern.

	Aerial runner	Terrestrial runner
Vertical oscillation of COM	Pronounced	Low
Arms movement	By elbows	By shoulders
Pelvic position at ground contact	High and anteverted	Low and retroverted
Foot position at ground contact	Below COM	In front of COM
Foot strike pattern	Mid-foot or forefoot	Rear-foot, increased angle of foot relative to the ground

This patterning has been used to study whether one pattern is more economic or has better performance and can run faster. However, there is no advantage to one running pattern over the other.

Please watch the following optional short video for a quick overview of the Volodan method.

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

There is conflicting evidence whether specific gait deviations, or clusters of gait deviations, are more significant than another. Currently, there is no definitive evidence suggesting one gait deviation occurs more frequently than another. Until additional research is available, gait analysis is an important tool for the rehabilitation clinician and should be performed with each patient to create an individualised therapy plan of care. The development of a working hypotheses needs to be done on an individual basis with clinical reasoning.

One potential way to sub-classify or cluster gait deviations is by commonly observed deviation patterns seen in clinical practice. This would include: (1)increased impact loading, (2) "geriatric" gait, (3) excessive contralateral pelvic drop, and (4) osteoarthritic (OA) gait.

Increased Impact Loading

The following gait deviations can occur together or as secondary signs of increased impact loading:

1. Too long step length
2. Slow cadence
3. Increased vertical oscillation of COM
4. Loud foot strike
5. Knee hyperextension in stance
6. Increased hip extension in terminal stance
7. Increased angle of foot relative to ground at foot strike
8. Foot crossing the mid-line of body
9. Early heel off in terminal stance
10. Increased dorsiflexion 1st MTPJ in terminal stance

The deviation which assumes the most clinical importance is too long a step or stride length. This deviation is simple to identify and there are many therapeutic intervention options.

Geriatric Gait

The following gait deviations can occur together or as secondary signs of geriatric gait:

1. Slow velocity, less than 1- 1.4 m/sec
2. Slow cadence, less than 100 steps/min
3. Prolonged heel contact or delayed heel off
4. Decreased vertical oscillation of COM
5. Decreased hip extension
6. Increased forward lean
7. Decreased arm swing

The deviations which assume the most clinical importance are slow velocity and delayed heel off.

Excessive Contralateral Pelvic Drop

The following gait deviations can occur together or as secondary signs of excessive contralateral pelvic drop:

1. Contralateral pelvic drop
2. Lateral deviation of center of mass
3. Popliteal skin crease, i,e. increased medial femoral rotation
4. No daylight between the knees
5. Foot crossing midline
6. Increased toe-out
7. Increased pronation
8. Heel whip, can be medial or lateral

The deviation which assumes the most clinical importance is contralateral pelvic drop. These patients can also present with: gluteal tendinopathy and knee pain.

OA Gait

The following gait deviations can occur together or as secondary signs of OA gait:

1. Increased toe-out
2. Increased trunk lean
3. Lateral shift of COM
4. Varus or valgus thrust of the knee
5. Slow velocity
6. Decreased step or stride length

The deviation which assumes the most clinical importance is increased toe-out. Oftentimes patients with knee or hip osteoarthritis develop gait deviations which continue due to "habit" after undergoing total joint replacements. Patients who undergo post-operative rehabilitation report improved joint pain and stiffness but commonly demonstrate incomplete recovery of gait function.

Prioritising Gait Deviations for Interventions

The more important gait deviations related to musculoskeletal pain syndromes are:  

1. Slow velocity
2. Too long step or stride length
3. Contralateral pelvic drop
4. Delayed heel off
5. Increased toe-out

Other useful considerations when prioritising gait deviation interventions:

• Historically, excessive pronation is considered important
• Pattern recognition for pain syndromes noted during stance phase can provide better sub-classification
• Focus on the deviation the patient is most concerned about. Utilize gait recordings to help patients see and understand the deviations.
• Choose the deviation most likely related to patient specific goals
• Choose the deviation which correlates with patient history and impairment(s)
• When faced with multiple gait deviations: focus on the treatment of one deviation, then assess how the treatment affects the patient's pain or if it alters any secondary signs of associated gait deviations

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