Trendelenburg Gait: Difference between revisions

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'''<u>''Search Strategy:<br>''</u>'''<u></u>Search engines: Web of Knowledge, PUBmed &amp; Science Direct<br>Keywords: Trendelenburg gait, Trendelenburg, disordered gait, Trendelenburg test<br>Limits: link to full free text
<br><u>'''''Definition/ Description:<br>'''''</u>The trendelenburg gait or gluteus medius gait is an abnormal gait who is observed in patients that have weak hip abductor muscles. This condition makes it difficult to support the body's weight on the affected side. The abductor muscles themselves are normal but they have a mechanical disadvantage. During the stance phase of gait, the hip abductors function ineffectively and the pelvis tilts away from the affected side. In an attempt to lessen this effect, the child compensates by leaning over the affected hip. This brings the center of gravity over the hip and reduces the degree of pelvic drop.&nbsp;<ref>[1] Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> <ref>[2] Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18(2):222-227.</ref> Level of evidence: A2  
<br><u>'''''Definition/ Description:<br>'''''</u>The trendelenburg gait or gluteus medius gait is an abnormal gait who is observed in patients that have weak hip abductor muscles. This condition makes it difficult to support the body's weight on the affected side. The abductor muscles themselves are normal but they have a mechanical disadvantage. During the stance phase of gait, the hip abductors function ineffectively and the pelvis tilts away from the affected side. In an attempt to lessen this effect, the child compensates by leaning over the affected hip. This brings the center of gravity over the hip and reduces the degree of pelvic drop.&nbsp;<ref>[1] Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> <ref>[2] Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18(2):222-227.</ref> Level of evidence: A2  


<br><u>'''''Clinically Relevant Anatomy:<br>'''''</u>The gait cycle is divided into two main phases, a stance and a swing phase, each consisting of numerous sub phases. The human gait cycle has six determinants that function independently, to generate the normally fluid, continuous movements of ambulation. <ref>[3] Pease W, Bowyer B, Kadyan V. Human walking. In: DeLisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR, eds. Physical Medicine and Rehabilitation: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins; 2005:156-167.</ref>&nbsp;<ref>[4] Whittle M. Normal gait. In: Whittle MW. Gait Analysis: An Introduction. 3rd ed. Philadelphia, PA: Butterworth-Heinemann; 2002:42-86.</ref>&nbsp;<ref>[5] Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J Bone Joint Surg Am. 1953;35(3):543-558.</ref>  
<br><u>'''''Clinically Relevant Anatomy:<br>'''''</u>The gait cycle is divided into two main phases, a stance and a swing phase, each consisting of numerous sub phases. The human gait cycle has six determinants that function independently, to generate the normally fluid, continuous movements of ambulation. <ref>[3] Pease W, Bowyer B, Kadyan V. Human walking. In: DeLisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR, eds. Physical Medicine and Rehabilitation: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins; 2005:156-167.</ref>&nbsp;<ref>[4] Whittle M. Normal gait. In: Whittle MW. Gait Analysis: An Introduction. 3rd ed. Philadelphia, PA: Butterworth-Heinemann; 2002:42-86.</ref>&nbsp;<ref>[5] Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J Bone Joint Surg Am. 1953;35(3):543-558.</ref>  


<br><u>'''''Epidemiology/ Etiology:<br>'''''</u>Trendelenburg gait occurs when the patient has to deal with weakness of the abductors of the hip (Musculus gluteus medius). <ref>[1] Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref>&nbsp;Patients who have e significant shorter height and greater body mass index sustained the trendelenburg gait.<ref>[6] Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.</ref>&nbsp;Level of evidence: B<u><br></u>  
<br><u>'''''Epidemiology/ Etiology:<br>'''''</u>Trendelenburg gait occurs when the patient has to deal with weakness of the abductors of the hip (Musculus gluteus medius). <ref>[1] Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref>&nbsp;Patients who have e significant shorter height and greater body mass index sustained the trendelenburg gait.<ref>[6] Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.</ref>&nbsp;Level of evidence: B<u><br></u>  
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<br><u>'''''Examination:'''''<br></u>The modified McKay criteria is useful to assess whether a patient has Trendelenburg gait or not. This criteria measure pain symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement. Level of evidence: A2<br>  
<br><u>'''''Examination:'''''<br></u>The modified McKay criteria is useful to assess whether a patient has Trendelenburg gait or not. This criteria measure pain symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement. Level of evidence: A2<br>  


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<br><u>'''''Medical Management:<br>'''''</u>Currently, no treatment modalities exist for patients with compensated Trendelenburg gait. What we can do is try to deal with the causes who develop Trendelenburg gait. Open reduction and Salter innominate osteotomy (SIO) without preoperative traction is effective in the management of development dysplasia of the hip in children younger than 6 years.&nbsp;<ref>[13] Bohm P, Brzuske A. Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am 2002;84:178–86.</ref>&nbsp;Level of evidence: A2  
<br><u>'''''Medical Management:<br>'''''</u>Currently, no treatment modalities exist for patients with compensated Trendelenburg gait. What we can do is try to deal with the causes who develop Trendelenburg gait. Open reduction and Salter innominate osteotomy (SIO) without preoperative traction is effective in the management of development dysplasia of the hip in children younger than 6 years.&nbsp;<ref>[13] Bohm P, Brzuske A. Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am 2002;84:178–86.</ref>&nbsp;Level of evidence: A2  


Pelvic support osteotomies cause a significant improvement in terms like posture, gait and walking tolerance to patients who have to deal with untreated congenital dislocations.<ref>[14] Lance PM (1936) Osteotomies sous-trochanterienne dans le traitement des luxations congenitales inveterees de la hanche. Masson &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Cie, Paris.</ref>&nbsp;<ref>[15] Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595.</ref>&nbsp;Level of evidence: B<br>  
Pelvic support osteotomies cause a significant improvement in terms like posture, gait and walking tolerance to patients who have to deal with untreated congenital dislocations.<ref>[14] Lance PM (1936) Osteotomies sous-trochanterienne dans le traitement des luxations congenitales inveterees de la hanche. Masson &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Cie, Paris.</ref>&nbsp;<ref>[15] Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595.</ref>&nbsp;Level of evidence: B<br>  


Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters with people who have to deal with somatic dysfunctions, this can be measured due to a GaitMat II system. Further research is needed to tell more about the relationship between somatic dysfunctions and gait deviations.&nbsp;<ref>[19] Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults [published online ahead of print October 25, 2005]. Neuroepidemiology. 2006;26:52-60.</ref> Level of evidence: C<br>  
Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters with people who have to deal with somatic dysfunctions, this can be measured due to a GaitMat II system. Further research is needed to tell more about the relationship between somatic dysfunctions and gait deviations.&nbsp;<ref>[19] Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults [published online ahead of print October 25, 2005]. Neuroepidemiology. 2006;26:52-60.</ref> Level of evidence: C<br>  

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Definition/ Description:
The trendelenburg gait or gluteus medius gait is an abnormal gait who is observed in patients that have weak hip abductor muscles. This condition makes it difficult to support the body's weight on the affected side. The abductor muscles themselves are normal but they have a mechanical disadvantage. During the stance phase of gait, the hip abductors function ineffectively and the pelvis tilts away from the affected side. In an attempt to lessen this effect, the child compensates by leaning over the affected hip. This brings the center of gravity over the hip and reduces the degree of pelvic drop. [1] [2] Level of evidence: A2


Clinically Relevant Anatomy:
The gait cycle is divided into two main phases, a stance and a swing phase, each consisting of numerous sub phases. The human gait cycle has six determinants that function independently, to generate the normally fluid, continuous movements of ambulation. [3] [4] [5]


Epidemiology/ Etiology:
Trendelenburg gait occurs when the patient has to deal with weakness of the abductors of the hip (Musculus gluteus medius). [6] Patients who have e significant shorter height and greater body mass index sustained the trendelenburg gait.[7] Level of evidence: B


Differential Diagnosis:

This disturbance in the gait cycle is frequently observed in children with the development of congenital dislocation of the hip (CDH), dysplasia of the hip (DDH) and congenital coxa vara. Coxa vara can also occur from other disorders like Legg-Calvé-Perthes disease or slipped capital femoral epiphysis (SCFE). These are 2 of the most common causes of pain in the hip or limp.[8] [9] [10] The trendelenburg gait mostly occurs when we have to deal with a neuronal injury. A lesion of the superior gluteal nerve (SGN) is the main nerve stimulating the hip abductors.[11] [12] This nerve is the supplies the gluteus medius, gluteus minimus and tensor fascia lata.[13]

Diagnostic Procedures:
When pain in the hip is diagnosed, the surgeon will base the diagnose on data obtained from clinical and X-ray assessment. These 2 factors will provide an answers to: (A) the level of the proximal osteotomy, (B) the amount of valgus, extension and derotation at the proximal osteotomy, (C) the level of the distal osteotomy, and (D) the amount of varus and lengthening at the distal osteotomy.[14] [15] [16] Level of evidence: B


Examination:
The modified McKay criteria is useful to assess whether a patient has Trendelenburg gait or not. This criteria measure pain symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement. Level of evidence: A2

Grade Criteria
Excellent Stable, painless hip; no limp; negative
Trendelenburg sign; full range of movement
Good Stable, painless hip; slight limp; slight
decrease in range of movement
Fair Stable, painless hip; limp; positive
Trendelenburg sign; and limited range of
movement, or a combination of these
Poor Unstable or painful hip or both; positive
Trendelenburg sign


Medical Management:
Currently, no treatment modalities exist for patients with compensated Trendelenburg gait. What we can do is try to deal with the causes who develop Trendelenburg gait. Open reduction and Salter innominate osteotomy (SIO) without preoperative traction is effective in the management of development dysplasia of the hip in children younger than 6 years. [17] Level of evidence: A2

Pelvic support osteotomies cause a significant improvement in terms like posture, gait and walking tolerance to patients who have to deal with untreated congenital dislocations.[18] [19] Level of evidence: B

Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters with people who have to deal with somatic dysfunctions, this can be measured due to a GaitMat II system. Further research is needed to tell more about the relationship between somatic dysfunctions and gait deviations. [20] Level of evidence: C

There is a significant difference in the incidence of a positive Trendelenburg gait between surgical approaches, using trochanteric osteotomy or not. This shows the effectiveness of distal trochanteric transfer.[21] Level of evidence: A2


Physical Therapy Management:
Trendelenburg gait is an abnormal gait caused by weakness of the hipabductors. Therefore the mean purpose of your physical therapy is to strengthen the abductors of the hip. The exercise most appropriate for Trendelenburg gait is by laying the patient on the other side than the affected side en bring the leg towards the ceiling. To make the exercise heavier, we can use a weight around the leg we move upwards or a teraband. Other exercises in the revalidation of Trendelenburg gait are functional closed-chain exercises, lateral step-ups and functional balance exercises. It is also important to strengthen the rest of the leg on the affected side. Level of evidence: D

The use of an Electromyogram (EMG) reduces the Trendelenburg gait by an average of 29 degrees. The average stride length has increased from 0,32 ± 0,3m to 0,45 ± 0,2m and the speed of gait has increased from 1,6 ± 0,4 kmh−1 to 3,1 ± 0,5 kmh−1. [22] Levels of evidence: B


References:

  1. ↑ [1] Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
  2. ↑ [2] Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18(2):222-227.
  3. ↑ [3] Pease W, Bowyer B, Kadyan V. Human walking. In: DeLisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR, eds. Physical Medicine and Rehabilitation: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins; 2005:156-167.
  4. ↑ [4] Whittle M. Normal gait. In: Whittle MW. Gait Analysis: An Introduction. 3rd ed. Philadelphia, PA: Butterworth-Heinemann; 2002:42-86.
  5. ↑ [5] Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J Bone Joint Surg Am. 1953;35(3):543-558.
  6. ↑ [1] Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
  7. ↑ [6] Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.
  8. ↑ [1] Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
  9. ↑ [7] Kelsey JL. Epidemiology of slipped capital femoral epiphysis: a review of the literature. Pediatrics 1973.
  10. ↑ [8] Yochum TR, Rowe LI. Essentials of skeletal radiology. Baltimore: Williams and Wilkins, 1987; 465-68.; 51: 1042-50.
  11. ↑ [6] Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.
  12. ↑ [9] Jacobs LG, Buxton RA. The course of the superior gluteal nerve in the lateral approach to the hip. J Bone Joint Surg [Am] 1989;71:1239-43.
  13. ↑ [10] Bülbül M, Ayanoğlu S, Öztürk K, İmren Y, Esenyel C, Yeşiltepe R, et al. How reliable is the safe zone of Hardinge approach for superior gluteal nerve? Trakya Univ Tıp Fak Derg 2009;26:134-6.
  14. ↑ [16] Saleh M, Milne A (1994) Weight-bearing parallel-beam scanography for the measurement of leg length and joint alignment. J Bone Joint Surg Br 76(1):156–157.
  15. ↑ [17] Paley D (2002) Normal lower limb alignment and joint orientation. In: Paley D (ed) Principles of deformity correction. Springer, Berlin, pp 1–18.
  16. ↑ [18] Gage JR (1991) Gait analysis in cerebral palsy, 1st edn. Clinics in developmental medicine, vol 121. Mac Keith Press, London.
  17. ↑ [13] Bohm P, Brzuske A. Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am 2002;84:178–86.
  18. ↑ [14] Lance PM (1936) Osteotomies sous-trochanterienne dans le traitement des luxations congenitales inveterees de la hanche. Masson &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Cie, Paris.
  19. ↑ [15] Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595.
  20. ↑ [19] Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults [published online ahead of print October 25, 2005]. Neuroepidemiology. 2006;26:52-60.
  21. ↑ [21] Fernandez DL, Isler B, Müller ME. Chiari’s osteotomy: a note on technique. Clin Orthop 1984;185:53-8.
  22. ↑ [20] J. S. Petrofsky. Microprocessor-based gait analysis system to retrain Trendelenburg gait. Medical and Biological Engineering and Computing , Volume 39, Number 1, 140-143, DOI: 10.1007/BF02345278.


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