Gait Evaluation -| What’s Important?
TECHNIQUE
John K. Hyland
DC, DACBR, DABCO, CSCS
Evaluation of a patient's walking motion or an athlete's running style can give a doctor of chiropractic very important information. Many chronic or recurring pelvic, sacroiliac, spinal, and lower extremity complaints are associated with gait imbalances and awkward walking movements. Chiropractic treatment is much more effective and efficient when underlying locomotor problems are considered and when they are appropriately addressed.
Let's review some of the factors involved in gait evaluation, and then I'll share with you some simple procedures that I have found to be very efficient for screening patients for gait-related musculoskeletal problems.
^When there is a significant decrease in musculoskeletal efficiency, motion problems occur and symptoms develop. ï Ï
Human Gait
Walking and running (human locomotion) are normally very efficient methods of movement. When there is a significant decrease in musculoskeletal efficiency, motion problems occur and symptoms develop. These often begin as overuse, repetitive motion, or microtrauma injuries, and (if not addressed) frequently go on to become degenerative and joint breakdown problems. These lower extremity problems often transmit stress and torque into the pelvis and spine, causing the patient to seek out chiropractic care.
Gait Defined
Recall that there are two major phases of gait—when the leg is weight-bearing (in contact with the ground or floor) and when the leg is freely swinging. Very few musculoskeletal problems are caused by the swing phase; it is during the stance phase, when the leg is weight-bearing and supporting the spine and pelvis, that most problems occur. Therefore, evaluation of the various sub-phases of the Stance phase is important for our purposes. Stance is usually divided into three major subphases: contact, mid-stance, and toe-off. Incorrect or excessive movements during any of these sub-phases will transmit abnormal biomechanical forces to the knees, pelvis, and spine, and eventually, problems will develop. Therefore, we will want to evaluate the efficiency of our patients' gait during the stance sub-phases.
Evaluation Methods
Experimentally, many procedures have been used to evaluate the stance phases of gait. The most commonly used procedures aie variations of: Visual assessment, pressure transducers, physiological factors, secondary effects, and biomechanical function analysis. Let's look briefly at each and see what's useful:
Visual assessment - can be performed with either the naked eye1 or with high-speed video cameras2 3. This usually requires observation from various angles while the subject walks or runs in a hallway or on a treadmill.
Pressure transducers - are commonly placed inside the shoes4, attached to the feet, or are integrated into the walking surface5. Several high-tech devices have been designed to measure and record the changes in pressure at various anatomical points of the foot during the weight-bearing portion of walking and running.
Physiological factors - include oxygen uptake2 * * * 6, maximum heart rate7, and various other measurable parameters that are indicative of the relative efficiency of walking
and/or running styles. Secondary effects - include the wear patterns of the soles and heels of shoes8 as well the development of callosities and thickening of the skin. These observable signs frequently develop in response to
abnormal gait forces. Biomechanical function analysis - looks at the alignment of the structural components of the feet and ankles and may be done in either non-weight-bearing9 or in a functional
("closed chain")
position10. What’s Reasonable? Obviously, a busy doctor of chiropractic doesn't have the time or office space required to perform a comprehensive gait analysis on every patient. The solution is to perform
a simple and brief screening evaluation on all patients. This lower extremity screen will raise red flags to identify patients who need further analysis or more in-depth evaluation. In my experience, there aie five easy and important signs to look for, and now there is also a good objective measurement that can be performed when several red
flags aie present. 1. Watch every patient walk. I'm always surprised by how many
doctors of chiropractic never see their patients walking! The new patient is already present in the examination room when the doctor arrives, and during treatment the patients ai e waiting in treatment rooms (often already on the adjustment table). By observing a few normal paces, several abnormal gait indications can be detected. By far the most common fault (and one that is often implicated in spinal problems) is foot flare, or excessive toeing out during walking. This can be identified by looking at the alignment of the foot with the lower leg as your patient walks. An angle greater than 10° to 15° is a red flag for excessive rotational torque stresses to the knees, sacroiliac joints, and spine. Also be on the lookout for rarer problems like toeing in, limping, lurching, and also foot drop (which may indicate a
major neurological problem). 2. Look at the shoes. Somewhere
during your evaluation of every patient, you have an opportunity to look
at the shoes. Use this to check to see if there ai e any
excessive or abnormal weai’ patterns present on the shoes. At least
check the heels since they are particularly important. A red flag
is any asymmetrical, excessive, or lateral (rather
than posterior) wearing down of the heel since this is good evidence
from the software. " " A digital foot scan can add insight (within seconds) as to what’s causing your patient’s pain. Images on the screen compare the patient’s foot to an “ideal” foot, revealing their level of arch deterioration, if
of poor support of the pelvis and spine by the lower extremity, with
abnormal biomechanical forces. 3. Examine knee to foot alignment. If your patient's knee joints are not in line with their feet, it is very likely that adjustments to the pelvis will last little more than the time it takes the patient to walk out your front door! The quick way to check this is to look at the lower legs from the front. Mentally drop a straight line down from the mid-point of each kneecap to the foot. If this imaginary plumb line does not strike the foot over the first two metatarsals, a red flag should be raised
in your mind. 4. Is the Achilles tendon straight? When you see a patient's heel cord bowing inward (medially), you have a red flag that indicates probable instability of the calcaneus. When the heel bone is not aligned with the Achilles tendon, the patient frequently is an overpronator, and this biomechanical fault is often an important part of the
patient's back symptoms. 5. Check
the medial arches. A quick palpation of the medial arches of the feet while your patient is standing will tell you volumes about their biomechanical efficiency (or lack thereof!). If you cannot get your finger under the medial longitudinal arch, you have a red flag. If y ou can push a finger under the arch, take a moment to push upwards into the plantar fascia. With just a brief palpation, you will be able to tell if the connective tissue that supports
the arch is intact or is under excessive strain. Ifpushing up into the bottom of the foot causes pain, it is very likely that your patient has plantar fasciitis, hopefully still at a stage where conservative biomechanical treatment will
be rapidly helpful. In order for the pelvis to be level, the patient must have a level foundation, and that starts with the feet. This is why I recommend that every exam include a foot/gait exam as
described above. For those with a digital foot scanner, assessing every patient is a good idea. A digital foot scan can add insight (within seconds) as to what’s causing your patient’s pain. Images on the screen compare the patient’s foot to an “ideal” foot, revealing their level of arch deterioration, if any. With the leading brand, scans ai e accurate to a quarter of the width of a strand of human hair. Foot imbalances that may be imperceptible to the naked eye are revealed, while subsequent educational screens provide detailed graphs and images that make it easy for doctors to explain results to patients. Within moments, a doctor can determine if a patient is a candidate for custom orthotics, and if so, submit the patient’s scan directly
The best devices will generate a comprehensive report on the patient’s foot health for further consideration.
You may want to go into a brief description of the gait abnormalities, but I've found that I lose most patients quickly with detailed biomechanical descriptions. Your most important job at this point is to ensure the “light bulb moment” happens with your patient—that he or she understands that their foot imbalances may be at the root of their pain.
With the red flag screening procedure and a digital foot scan, I can perform a useful evaluation in a quick and efficient manner. The small amount of time required is rewarded when I identify a patient who would have been a problem case but who will now respond rapidly to chiropractic care.
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A 1980 graduate of Logan College of Chiropractic, Dr. John Hyland practiced for more than 20 years Colorado. In addition to his specialty board certifications in chiropractic orthopedics (DABCO) and radiology (DACBR), Dr. Hyland is nationally certified as a strength and conditioning specialist (CSCS) and a health education specialist (CHES). He has consulted chiropractors in the concepts and procedures of spinal rehabilitation and wellness exercise.
