Common Deviations

Ankle and Foot: Stance Phase Portion of Phase Deviation

Initial Contact
Foot Slap -

Description
At heel strike, forefoot slaps the ground Toes contact ground instead of heel Tip-toe posture may be maintained through-out phase, or heel may contact ground Entire foot contacts ground at heel strike Tibia does not advance to neutral from 10 PF -

Sagittal Plane Analysis Possible Causes Analysis

Flaccid of weak DF or reciprocal inhibition of DF Atrophy of DF Leg length discrepancy Contracted heel cord PF contraction Spasticity of PF Flaccidity of DF Painful heel Excessive fixed DF Flaccid or weak DF Neonatal/proprioceptive walking No eccentric contracture of PF Could be due to flaccidity/weakness in PF Surgical overrelease, rupture, or contracture of Achilles tendon Spasticity of PF Inability of PF to control tibial advance Knee flexion or hip flexion contractures Could be due to plantar grasp reflex that is only partially integrated Could be due to positive supporting reflex Spastic toe flexors Mechanical fixation of ankle and foot Flaccidity or inhibition of PF, inverters, and toe flexors Rigidity/co-contraction of PF and DF Pain in forefoot Look for low muscle tone at ankle Look for steppage gait (excessive hip and knee flexion) in swing phase Compare leg lengths and look for hip and/or knee flexion contractures Analyze muscle tone and timing of activity in PF Check for pain in heel Check ROM at ankle Check for hyperextension at knee and persistence of immature gait pattern Check for spastic of weak quads Hyperextension at knee Hip hyperextension Backward- or forwardleaning trunk Check for weakness in PF or rupture of Achilles Check for spasticity in PF, quads, hip flexors, and hip ADD Look at ankle muscles, knee and hip flexors, ROM, and position of trunk Check plantar grasp reflex, positive supporting reflexes, and ROM of toes

Toes First

Foot Flat

Mid-stance

Excessive positional PF

Heel lift in midstance Excessive positional DF

Toe Clawing

Heel does not contact ground in mid-stance Tibia advances too rapidly over foot, creating greater than normal amount of DF Toes flex and grab floor

Push-Off
(heel off to toe off)

No roll off

Insufficient transfer of weight from lateral heel to medial forefoot

Check ROM at ankle and foot Check muscle function and tone at ankle Look at dissociation between posterior foot and forefoot

Ankle and Foot: Swing Phase Portion of Phase Deviation

Swing
Toe Drag -

Description
Insufficient DF (and toe extension) so that forefoot and -

Sagittal Plane Analysis Possible Causes Analysis

Flaccidity or weakness of DF and toe extensors Spasticity of PF Check for ankle, hip, and knee ROM Check for strength and

Varus

toes do not clear floor Foot is excessively inverted

Inadequate knee or hip flexion Spasticity of invertors Flaccidity or weakness of DF and invertors Extensor pattern

muscle tone at hip, knee, and ankle Check for muscle tone of invertors and PF Check strength of DF and evertors Check for extensor pattern of lower extremity

Knee: Stance Phase Portion of Phase Deviation

Initial Contact
Excessive knee flexion -

Description
Knee flexes or buckles rather than extends as foot contacts ground A greater than normal extension at the knee -

Sagittal Plane Analysis Possible Causes Analysis

Painful knee Spasticity of knee flexors or weak/flaccid quads Short leg on contralateral side Flaccid/weak quads and soleus compensated for by pull of glut maximus Spasticity of quads Accommodation to a fixed ankle PF deformity Same as above Check for pain at knee Tone of knee flexors Strength of knee extensors Leg lengths Anterior pelvic tilt Check for strength and muscle tone of knee and ankle flexors ROM at ankle

Foot Flat

Knee hyperextension (genu recurvatum)

Mid-stance

Knee hyperextension (genu recurvatum)

Push-Off

Excessive knee flexion

During single limb support, tibia remains in back of ankle mortice as BW moves over foot Ankle is PF Knee flexes to more than 40 during push-off

Same as above

Limited knee flexion

Normal amount of knee flexion (40) does not occur

Center of gravity is unusually far forward of pelvis Could be due to rigid trunk, knee/hip flexion contractures Flexion withdrawal reflex Dominance of flexion synergy in middle recovery from CVA Spastic/over-active quads and/or PF

Look at trunk posture, knee and hip ROM, and flexor synergy

Look at tone in hip, knee and ankle muscles

Knee: Swing Phase Portion of Phase Deviation

Acceleration to mid-swing
Excessive knee flexion -

Description
Knee flexes more than 65 -

Sagittal Plane Analysis Possible Causes Analysis

Diminished pre-swing knee flexion Flexor withdrawal reflex Dysmetria Pain in knee Diminished knee ROM Extensor spasticity Circumduction at hip Look at muscle tone in hip, knee and ankle Test for reflexes and dysmetria Assess for pain in knee Knee ROM Test muscle tone at hip and knee

Limited knee flexion

Knee does not flex to 65

Hip: Stance Phase Portion of Phase Deviation

Heel strike to foot flat
Excessive flexion -

Description
Flexion exceeding 30 -

Sagittal Plane Analysis Possible Causes Analysis

Hip and/or knee flexion contractures Knee flexion caused by weak soleus and quads Hypertonicity of hip flexors Weakness of hip flexors Limited hip ROM flexion Glut maximus weakness Hip flexion contracture Spasticity in hip flexors Spasticity of hip IR Weakness of hip ER Excessive forward rotation of opposite pelvis Excessive backward rotation of the opposite pelvis Contracture of glut medius Trunk lateral lean over ipsilateral hip Spasticity of hip flexors and hip ADD such as seen in spastic diplegia Pelvic drop to contralateral side Check hip and knee ROM Strength of soleus and quads Check tone of hip flexors Check strength of hip flexors and extensors Analyze hip ROM Check hip ROM Tone of hip muscles Check tone of hip IR Strength of hip ER Measure ROM at both hip joints Assess ROM at both hip joints Check for hip ABD pattern Assess tone of hip flexors and hip ADD Test muscle strength of hip ABD

Limited hip flexion

Hip flexion does not attain 30

Flat foot to midstance

Limited hip extension Internal rotation (IR)

Hip does not attain a neutral position An internally rotated position of the extremity An externally rotated position of the extremity An abducted position of lower extremity An adducted position of lower extremity

External rotation (ER) Abduction (ABD)

Adduction (ADD)

Hip: Swing Phase Portion of Phase Deviation

Swing
Circumduction -

Description
A lateral circular movement of entire lower extremity consisting of ABD, ER, ADD, and IR Shortening of swing leg by action of the quadratus lumborum Flexion greater than 20-30 -

Sagittal Plane Analysis Possible Causes Analysis

Compensation for weak hip flexors Compensation for inability to shorten leg so it can clear the floor Compensation for lack of knee flexion and/or ankle DF Compensation for extensor spasticity of swing leg Attempt to shorten extremity in presence of foot drop Flexor pattern Check strength of hip flexors, knee flexors, and ankle DF Check ROM in hip flexion, knee flexion, and ankle DF Check for extensor pattern Check strength and ROM at knee, hip and ankle Check muscle tone at knee and ankle Check strength and ROM at ankle and foot Check for flexor pattern

Hip hiking

Excessive hip flexion

Trunk: Stance phase Portion of Phase Deviation

Stance
Lateral trunk lean -

Description
A lean of trunk over the stance extremity (Gluteus medius gait/Trendelenberg gait) -

Sagittal Plane Analysis Possible Causes Analysis

Weak or paralyzed glut medius on stance side cannot prevent a drop of pelvis on swing side, so a trunk lean over the stance leg helps compensate for weak muscle Lateral trunk lean over the affected hip may also be used to reduce force on hip if patient has a painful hip Weakness or paralysis of glut maximus on the stance leg An anteriorly rotated pelvis Compensation for quad weakness Forward lean eliminates the flexion moment at the knee Hip and knee flexion contractures Posteriorly rotated pelvis Check strength of glut medius Assess for pain in the hip

Backward trunk lean

Forward trunk lean -

Backward leaning of the trunk, resulting in hyperextension at the hip (Gluteus maximus gait) A forward leaning of the trunk, resulting in hip flexion

Check for strength of hip extensors Check pelvic position

Check for strength of quads

A forward flexion of the upper trunk

Check pelvic position