Gait Deviations Associated with Lower Leg and Foot Pain Syndromes

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

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

Introduction

This article discusses gait deviations associated with pain syndromes in the lower leg and foot. While this information focuses on certain regions of the body, remember that the human body functions within a kinetic chain. No one movement is ever completely isolated and without effect on another.

For a review of the gait cycle, please read this article. For an overview of gait deviations, please review this article. To review common gait terminology and definitions, please see this article.

Anatomy Review

The ankle is the part of the lower limb, encompassing the distal portion of the leg and proximal portions of the foot. The ankle encompasses the ankle joint, an articulation between the tibia and fibula of the leg and the talus of the foot.

The foot is the part of the lower limb distal to the ankle joint. It is covered on its dorsal surface by loosely adherent skin. On its plantar surface, it is covered by thick hairless skin that is tough and strongly adherent to the underlying plantar aponeurosis. The foot contains 26 small bones that are designed for weight bearing and force distribution. The bony alignment creates three arches the provide efficient weight distribution while avoiding compression of plantar neuro-vascular structures. The three arches (medial and lateral longitudinal and the transverse arch) together create an architectural vault, which is one of the strongest load-bearing structures known to mankind.

Please read the linked article for a more in-depth anatomical review of the Foot and ankle.

Ground Reaction Forces

Example of a vertical ground reaction force.

Ground reaction force is a summation of all the forces transmitted from the ground up into the body. Ground reaction force is influenced from all directions: vertical, anterior-posterior, and medial-lateral. These forces are typically measured and recorded using a three-dimensional force plate.

Example of an anterior-posterior ground reaction force

During walking, the vertical ground reaction force is the largest component of the total ground reaction force. It creates forces greater than a person's total body weight per step. The graphed curve of the vertical ground reaction force consists of two peaks: the passive (weight acceptance as the heel strikes the ground) peak and the active (push off) peak. The passive peak is caused by the foot pushing against the ground, whereas the active peak is caused by the active force applied by the foot as it pushes away from the ground. The anterior-posterior ground reaction force includes braking peak and propulsion peak. The unique patterns of these peaks illustrate the load forces at the joints and muscles of the lower extremity. These forces felt throughout the limb can influence the development or exacerbation of musculoskeletal overuse or stress injuries.

When interpreting a ground reaction curve, the steeper the curve the more significant the impact forces. The curve on the anterior-posterior curve (the breaking forces) will be negative. In general, the greater the forces, the greater risk for stress or overuse injuries.

Please view the following video for a quick yet detailed overview of ground reaction forces during the human gait cycle. This video provides an excellent visualisation of how ground reaction forces shift in different directions as the person moves through space.

Gait Deviations

Gait Deviation	Expected Movement Pattern	Deviant Movement Pattern	Secondary Signs Associated with Deviant Movement
Late heel off ie: prolonged heel contact	The heel of the trailing foot lifts off the ground just prior to the contact of the leading foot.	The heel of the trailing foot stays on the ground beyond the moment of the leading foot heel strike. Can occur due to an anatomically longer leg	Hyperextension of the knee during terminal stance Hyperflexion of the knee during terminal stance A decrease in the up and down motion of centre of mass The appearance of a "geriatric gait"
Early heel off ie: premature heel rise	(Same as above)	The heel of the trailing foot leaves the ground prior to the leading foot heel strike. Bouncy gait Toe walker Can occur due to an anatomically short leg	Hyperextension of the knee during terminal stance Hyperflexion of the knee during terminal stance An increase in the up and down motion of centre of mass Loud heel strike
Stride length too long	During walking when viewed from the side, the linear distance from the foot strike to the person's centre of mass is relatively short.	During walking when viewed from the side, the linear distance from the foot strike to the person's centre of mass is too long.	Increased angle of foot relative to the ground Loud foot strike Visible vibration of treadmill during treadmill walking Calf muscle or lower leg appear to "shimmy" Increased knee extension or hyperextension, particularly at heel strike Increased hip extension in terminal stance Foot may cross the midline Slow walking cadence, less than 120 steps/min; slow running cadence, less than 180 steps/min
Toe out	During walking when viewed from the front or behind, the foot is 5-10 degrees out from the line of progression. It is common to see two of the lateral toes when viewed from behind.	Greater than 10 degrees of toe out relative to the line of progression. When viewed from behind during ambulation, more than two of the lateral toes are visible. There is an asymmetry in the degree of toe out between the person's lower extremities. Will occur with hallux limitus or first MTP joint osteoartirits Can occur due to an anatomically short leg	Laterally oriented patella Popliteal skin crease is oblique from superomedial to anterolateral When viewed from behind, the lateral malleolus is visible but the medial malleolus is not
Toe in	During walking when viewed from behind, should not be able to view the big toe.	The big toe is visible during walking when viewed from behind. Or when there is an asymmetry in the degree of toe in between the person's lower extremities. Will occur with hallux limitus or first MTP joint osteoartirits Can occur due to an anatomically longer leg	Popliteal skin crease is oblique from superolateral to inferomedial Medially oriented patella When viewed from behind, medial malleolus is visible but the lateral malleolus is not
Loud foot strike	It is expected for foot strike to emit a sound. The sound is representative of the ground reaction force.	If the sound of the foot strike is asymmetrical between the lower extremities, or between the non-painful and the painful side.	Loud single or double sounds with the same foot strike Slow cadence with a long stride length Increased angle of foot relative to the ground (increased PF) with a prolonged heel only period during stance The heel stays on the ground longer in early stance phase
Heel whip	This is the one gait deviation that occurs between the transition from stance to swing phase. During walking when viewed from behind, it is expected to see a 5-10 degree rotation of the heel and foot in the transverse plane as the foot comes off the ground.	If the heel whip angle of rotation is greater than 10 degrees. Also deviant is when the heel whip is greater on one side compared to the other side. Can occur due to an anatomically long leg Likely related to muscle imbalances at the hip	Oblique popliteal skin crease No daylight between the knees The foot crossing the midline of the body Signs of excessive wear on shoe bottom under the metatarsal heads where shear or twisting force occurs
Excessive pronation	A bisected calcaneus or shoe heel counter is perpendicular relative to the ground. When viewed from behind: Can view two or fewer of the lateral toes The navicular bone is not visible	When viewed from behind: Heel of the shoe is lifted off the ground Bisection of the calcaneous or shoe heel counter is tilted medial relative to the ground Can view more than two of the lateral toes If the navicular bone is plantarflexed and ABDucted	Contralateral pelvic drop No daylight between the knees Knee valgus thrust Knee valgus alignment Oblique popliteal skin crease
Absent windlass effect ie: increased dorsiflexion of the first MTP joint	During forefoot contact/terminal stance, there is normally 35-65 degrees of first MTP joint dorsiflexion. When viewed from the side, the proximal first metatarsal bone displaces dorsally or the longitudinal arch rises (the windlass effect)	During forefoot contact/terminal stance, there is greater than 65 degrees of first MTP joint dorsiflexion. When viewed from the side, if there is the failure of the proximal first metatarsal bone to displace dorsally or the longitudinal arch rises (absent windlass effect)	Excessive pronation Heel whip Increased hip extension Knee extension in terminal stance
Decreased dorsiflexion of the first MTP joint	During forefoot contact/terminal stance when viewed from the side, there is normally 35-65 degrees of first MTP joint dorsiflexion.	During forefoot contact/terminal stance, there is less than 35 degrees of first MTP joint dorsiflexion.	Absent windlass effect

What is the Windlass effect (Windlass mechanism)?

According to a 2004 study published in the Journal of Athletic Training:

• A “windlass” is the tightening of a rope or cable.
• The plantar fascia "simulates a cable" attached between the calcaneus and the metatarsophalangeal (MTP) joints.
• Dorsiflexion during the propulsion phase of gait tightens the plantar fascia around the head of the metatarsal. This tightening of the fascia shortens the distance between the calcaneus and metatarsals to elevate the medial longitudinal arch. This shortening of the plantar fascia is the hallmark of the windlass mechanism principle.
• From heel strike to weight acceptance: foot pronation increases the distance between the calcaneus and metatarsals. This lengthening applies tension stress to the plantar fascia.
• From midstance through the propulsive phase (i.e. the period from the end of midstance when the heel lifts to toe off): foot supination occurs causing the foot becomes a rigid lever arm using the windlass mechanism to propel gait. As with pronation, forces generated during supination also apply tension to the plantar fascia.

Pain Syndromes Associated with Gait Deviations

Gait Deviation	Associated Pain and Pain Syndromes
Late heel off ie: prolonged heel contact	Anterior groin pain Hip pain Acetabular labral injuries Anterior knee pain Patellofemoral arthralgia Anterior ankle pain Ankle impingement Achilles pain (Achilles is relatively long due to tendon lengthening procedure or a tendon rupture) Plantar heel pain syndrome
Early heel off ie: premature heel rise	Anterior knee pain Patellofemoral arthralgia Achilles pain (Achilles is relatively short) Ankle pain Plantar heel pain syndrome Metatarsalgia Forefoot pain
Stride length too long	Back pain Anterior groin pain Acetabular labral injury Anterior and or lateral knee pain IT band syndrome Patellofemoral arthralgia Medial tibial stress syndrome Stress fractures Achilles pain Plantar heel pain syndrome
Toe out	Hip osteoarthritis Knee osteoarthritis Gait pattern can become habitual post total joint replacements Patellofemoral arthralgia Medial tibial stress syndrome Tibial stress fracture Achilles pain Plantar heel pain syndrome Metatarsalgia
Toe in	Anterior knee pain Patellofemoral arthralgia Medial tibial stress syndrome Posterior tibial tendinopathy Plantar heel pain Metatarsalgia pain Hallux valgus pain
Loud foot strike	IT band syndrome Medial tibial stress syndrome Stress fracture Plantar heel pain syndrome
Heel whip	Gluetal tendinopathy Anterior and or lateral knee pain Patellofemoral arthralgia IT band syndrome Medial tibial stress syndrome Tibial stress fracture Metatarsalgia Hallux valgus
Excessive pronation	Gluteal tendinopathy Patellofemoral arthralgia Medial tibial stress syndrome Posterior tibial tendinopathy Plantar heel pain syndrome Hallux valgus
Absent windlass effect	Plantar heel pain syndrome Sesamoiditis Hallux valgus Metatarsalgia
Decreased dorsiflexion of the first MTP joint	Plantar heel pain syndrome Hallux limitus First MTP joint osteoarthritis Osseous chondroma of the great toe Benign chondroma Hallux valgus Sesamoiditis Metatarsalgia

Resources

Recommended video of gait deviations:

Recommended Journal Articles:

• Steffen TM, Hacker TA, Mollinger L. Age-and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Physical therapy. 2002 Feb 1;82(2):128-37.
• Naylor BH, Seidman D, Scuderi GR. Bridging the Gap: The Influence of Foot and Ankle Pathomechanics in Total Knee Arthroplasty. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2021 Jul 15;29(14):e693-701.