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

The way we walk and run is likely related to the development of musculoskeletal pain syndromes. Some gait deviations can occur independent of other gait deviations, while others occur together. This leads the rehabilitation professional to wonder if some gait deviations are more clinically important than others when dealing with musculoskeletal pain syndromes or if it is possible to cluster or sub-classify gait deviations in order to improve clinician analysis and patient outcomes.

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 a patient's outcomes by allowing clinicians to more quickly and accurately find the correct rehabilitation diagnosis, thus leading to more efficient treatment and interventions.

Bramah et al. 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, Bramah and colleagues performed another retrospective study 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.

Mousavi et al. 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. While pronation occurred with Achilles problems and plantar heel pain syndrome, it was not statistically significant.

Does clustering or sub-classifying gait deviations improve the analysis and responsiveness of interventions?

Clustering or sub-classifying gait patterns based on neurologic diagnosis is commonly seen in rehabilitation (e.g. hemiplegic gait or Parkinsonian gait). However, there is a limited amount of clustering or sub-classifying gait patterns in relation to musculoskeletal pain syndromes.

There are clustering and sub-classifying patterns for global running form. Gindre et al. describes the Volodalen Method, which provides a method for classifying running patterns into two categories: aerial and terrestrial using five movement patterns. These are: (1) vertical oscillation of centre of mass (COM), (2) arm 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
Arm 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 economical than the other or if one results in better performance / faster running. It does not appear that either pattern is more advantageous than the other.

You might find it useful to watch the following short video for a quick overview of the Volodan method.

Jauhiainen et al. looked at a hierarchical cluster analysis to determine whether injured runners exhibit similar patterns. They identified five running patterns:

1. First subgroup: (1) movement of a valgus thrust, (2) no daylight between the knees, (3) too long a step or stride length, and (4) increased vertical oscillation of COM.
2. Second subgroup: (1) decreased knee flexion, (2) decreased step or stride length, (3) increased cadence, (4) decreased vertical oscillation of COM. They described it as a "stiff gait."
3. Third subgroup: (1) no daylight between the knees, (2) decreased cadence, (3) increased vertical oscillation of COM. They described it as a "bouncy gait."
4. Fourth subgroup: (1) increased angle of foot relative to the ground, (2) increased toe-out, (3) increased pronation, and (4) too long a step or stride length.
5. Fifth subgroup: (1) increased pronation or prolonged pronation, and (2) toe-in.

The sub-grouping of running patterns did not match up with the type of injury or predict potential injuries. The five 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. However, the authors concluded it is important to consider these sub-groupings when planning injury prevention or rehabilitation strategies.

Dingenen et al. created a sub-classification system of recreational runners using running-related injuries based on their gait deviations. Data was compiled using 2D slow-motion video analysis. They retrospectively looked at 53 injured runners to identify deviations and found that different sub-groups with the same running-related injury can be represented by different gait patterns. The authors found two homogeneous subgroups based on the patterns of gait deviations with similar pain syndromes: (1) runners with too long a step or stride length had a correlation with shin injuries, and (2) runners with excessive contralateral pelvic drop had a correlation with hip and knee injury.

This study utilised 2D slow-motion analysis, but they only looked at gait deviations which occurred in the first and second period of stance. Dr Howell suggests that if Dingenen et al.'s method was used to look at the third period of stance, it might indicate that individuals who have gait deviations in terminal stance may have more foot problems (i.e. plantar heel pain syndrome, big toe problems, sesamoiditis). Thus, a gait deviation of either an early heel off or a late heel off during the third period of stance may be a useful sub-classification to consider.

In summary of the review of literature, gait deviations that tend to stand out as clinically important include: (1) too long a step or stride, (2) contralateral pelvic drop, and (3) excessive pronation.

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 should be considered an important tool for the rehabilitation clinician. It 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 of 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 centre 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 OA 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 - utilise 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

Resources

Clinical Resources:

• Learn more about the Volodalen Method (website in French)

Optional Recommended Reading:

• Bramah C, Preece SJ, Gill N, Herrington L. Is there a pathological gait associated with common soft tissue running injuries?. The American journal of sports medicine. 2018 Oct;46(12):3023-31.
• Jauhiainen S, Pohl AJ, Äyrämö S, Kauppi JP, Ferber R. A hierarchical cluster analysis to determine whether injured runners exhibit similar kinematic gait patterns. Scandinavian Journal of Medicine & Science in Sports. 2020 Apr;30(4):732-40.
• Mousavi SH, Hijmans JM, Rajabi R, Diercks R, Zwerver J, van der Worp H. Kinematic risk factors for lower limb tendinopathy in distance runners: A systematic review and meta-analysis. Gait & posture. 2019 Mar 1;69:13-24.