Gait Deviations Associated with Pelvis and Knee Pain Syndromes

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

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

Introduction

This article discusses gait deviations associated with pain syndromes in the pelvis and knee. 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 see this article. For an overview of gait deviations, please review this article. To review common gait terminology and definitions, please see this article.

Pain Syndromes and Gait Deviation

Gait deviations are likely related to the development of and / or associated with musculoskeletal pain syndromes. It is often the complaint of pain that will lead a patient to physiotherapy. It is the role of the physiotherapist to educate the patient on the aetiology of their pain while treating and correcting the noted gait deviation.

A gait deviation is an abnormality in the gait cycle that can effect the trunk, hip, knee, or ankle joint. Gait deviations can stem from increased age and / or certain pathologies. These pathologies can be musculoskeletal or neurological in nature. Gait deviations can have a tremendous impact on a patient's quality of life, morbidity, and mortality.

The most commonly noted gait deviations for pain syndromes include:

1. Decreased gait velocity (most frequent gait deviation for patients with neurological deficits)
2. Decreased vertical oscillation of centre of mass
3. Delayed heel off

Walking Speed, the Sixth Vital Sign

According to a 2009 paper by Fritz, walking speed (ie gait velocity) is "almost the perfect measure." Patient self-selected walking speed has been found to be a reliable, valid, sensitive and specific measure which correlates with functional ability, and balance confidence.

"Walking speed, like blood pressure, may be a general indicator that can predict future events and reflect various underlying physiological processes. While walking speed cannot stand alone as the only predictor of functional abilities, just at blood pressure is not the only sign of heart disease; walking speed can be used as a functional “vital sign” to help determine outcomes such as functional status, discharge location, and the need for rehabilitation."

Applications of walking speed as a clinical measure:

1. Has the potential to predict future health status and functional decline
2. Can be used to predict future hospitalisation, discharge location and patient mortality
3. Reflects both patient functional and physiological changes
4. Is a factor in determining potential for rehabilitation
5. Aids in prediction of falls and fear of falling
6. Walking speed progression has been linked to clinical meaningful changes in quality of life

According to Fritz et al 2009, the average walking speed for geriatric adults is 1-1.4 m/sec. The preferred average walking speed in healthy adults, aged up to 50 years, is 1.4 m/sec. This suggests that deviant gait velocity is measured at a pace slower than 1-1.4 m/sec.

The average stride length in healthy adults ranges between 150 and 170 cm. The average cadence in young adults ranges between 115 and 120 steps/min. Geriatric adults prefer a 40 % wider step width than younger adults. A 2017 study found that ageing is "associated with a decline in gait speed and step length whereas cadence remains relatively stable."

Please watch the following video for further discussion on walking speed and how to measure it in the clinic using the 10-metre walk test.

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. This 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 impact loading or 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 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
Increased vertical oscillation of centre of mass "Too much up and down motion"	Choose a fixed location such as the top of the head, sacrum, or belt line. Compare the highest point during swing phase to the lowest point during stance phase. When running: 6-8 cm or 2-3 inches is normal When walking: 9.5cm or 3.5 inches is normal	Bounding or bouncy gait Is considered deviant if decreasing the magnitude of the vertical oscillation of centre of mass decreases or eliminates pain symptoms	Increased float time in running A loud foot strike Extra vibration during treadmill running Early heel off
Decreased vertical oscillation of centre of mass	Same as above	Shuffling gait	Increased amount of time in double limb stance Slow gait velocity, less than one metre/second Increased cadence, greater than 120 steps/minute Delayed or late heel off Fall risk
Contralateral pelvic drop	During stance phase, a line drawn between the posterior superior iliac spines (PSIS) should deviate no more than four degrees inferiorly	During stance phase, the line between the PSISs will deviate inferiorly more than four degrees. Can be related to an anatomically long leg during stance phase	Lateral pelvic shift Absence of daylight between the thighs and knees Foot strike occurs across the midline of the body Oblique popliteal skin crease Excessive medial femoral internal rotation Excessive pronation
Contralateral pelvic elevation ie: hip or pelvic hiking	During stance phase, a line drawn between the posterior superior iliac spines (PSIS) should deviate no more than four degrees superiorly	During stance phase, the line between the PSISs will deviate superiorly more than four degrees. Commonly seen in patient with neurological impairments	Listing of trunk to the ipsilateral side Cicumduction of contralateral lower extremity during swing phase
Lack of knee separation "absence of daylight" between thighs or knees	Unless morbidly obese, when walking and viewed from front or behind, there should be a space or "daylight" between the knees and thighs.	When walking and viewed from front or behind, there is an absence of space or "daylight" between the knees or thighs. Anatomically short leg	Lateral pelvic drop Lateral pelvic shift Excessive medial femoral rotation Oblique popliteal skin crease Genu valgus Excessive pronation
Foot crossing the midline	When walking and viewed from front or behind, the opposite foot strike should be visible and not cross a vertical line which travels from the belly button to the ground. When walking, feet should remain on the ipsilateral side of the line When running, feet should be on the line	When walking and viewed from behind, the opposite foot strike is not visible because the foot crosses the vertical line. Can be compensation for an anatomically short leg	Asymmetry of arm swing Asymmetry of trunk rotation
Popliteal skin crease Excessive femoral medial rotation	When viewed from behind during stance phase, the skin crease on the back of the knee should be horizontal	When viewed from behind, the skin crease will be oblique from superior-lateral to inferior-medial (inferring there is excessive movement of the femur into medial rotation). Possibly due to an anatomically long leg	Pelvic drop Lateral shift of the pelvis No daylight between the knees Genu valgus In-toe gait Heel whip Excessive pronation
Varus thrust	During stance phase, when viewed from front or behind, there should be little to no lateral/medial deviation or translation of the knee	During stance phase, when viewed from front or behind, there is a high-velocity small-amplitude lateral deviation of the knee with a rapid return to neutral alignment	Excessive lateral lean of the trunk Unequal stance time Asymmetrical arm swing

Pain Syndromes Associated with Gait Deviations

Gait Deviation	Associated Pain and Pain Syndromes
Increased vertical oscillation of centre of mass "Too much up and down motion"	Back pain Knee pain Medial tibial stress syndrome Achilles pain in runners Plantar heel pain syndrome
Decreased vertical oscillation of centre of mass	Fall risk Back pain
Contralateral pelvic drop	Back pain Hip labral injuries Gluteal tendinopathy Piriformis syndrome Anterior and / or lateral knee pain Patellofemoral arthralgia Iliotibial band syndrome Medial tibial stress syndrome Ankle pain Achilles tendon pain Plantar heel pain
Contralateral pelvic elevation	Back pain Hip pain Knee pain Leg length discrepancy
Lack of knee separation "Absence of daylight" between thighs or knees	Gluteal tendinopathy Lateral knee pain IT band syndrome Knee osteoarthritis Medial tibial stress syndrome Posterior tibial tendon pain Achilles pain Plantar heel pain syndrome
Foot crossing the midline	Gluteal tendinopathy Hip osteoarthritis Anterior and or lateral knee pain Patellofemoral arthritis Medial tibial stress syndrome Achilles pain Plantar heel pain syndrome
Popliteal skin crease Excessive femoral medial rotation	Gluteal tendinopathy Piriformis syndrome Trochanteric buristis Anterior and lateral knee pain Patellofemoral arthralgia Achilles pain Metatarsalgia
Varus thrust	Knee osteoarthritis Ligamentous instability Lateral knee pain Iliotibial band syndrome

Resources

Recommended videos of gait deviations:

• Gait Deviations: Hip, Pelvis, Trunk

• Gait Deviations: Knee Joint

Recommended Journal Articles:

• Fritz S, Lusardi M. White paper:“walking speed: the sixth vital sign”. Journal of geriatric physical therapy. 2009 Jan 1;32(2):2-5.
• Tesio, L., & Rota, V. (2019). The Motion of Body Center of Mass During Walking: A Review Oriented to Clinical Applications. Front Neurol, 10, 999.

Clinical Resources:

• Directions for the 10-metre Walk Test