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Gluteal gait is an abnormal gait caused by neurological problems. If the superior gluteal nerve or obturator nerves are injured, they fail to control the gluteus minimus and medius muscles properly, thus producing an inability to tilt the pelvis upward while swinging the leg forward to walk. To compensate for this loss, the leg swings out laterally so that the foot can move forward, producing a shuffling or waddling gait.
Injury to the superior gluteal nerve results in a characteristic motor loss, resulting in a disabling gluteus medius limp, to compensate for weakened abduction of the thigh by the gluteus medius and minimus, and/or a gluteal gait, a compensatory list of the body to the weakened gluteal side.
As a result of this compensation, the center of gravity is placed over the supporting lower limb. Medial rotation of the thigh is also severely impaired. When a person is asked to stand on one leg, the gluteus medius and minimus normally contract as soon as the contralateral foot leaves the floor, preventing tipping of the pelvis to the unsupported side. When a person with paralysis of the superior gluteal nerve is asked to stand on one leg, the pelvis descends on the unsupported side, indicating that the gluteus medius on the contralateral side is weak or non-functional. This observation is referred to clinically as a positive Trendelenburg's sign.
When the pelvis descends on the unsupported side, the lower limb becomes, in effect, too long and does not clear the ground when the foot is brought forward in the swing phase of walking. To compensate, the individual leans away from the unsupported side, raising the pelvis to allow adequate room for the foot to clear the ground as it swings forward.
This gait pattern is reminiscent of a marionette. Hypertonia in the legs, hips and pelvis means these areas become flexed to various degrees, giving the appearance of crouching, while tight adductors produce extreme adduction, presented by knees and thighs hitting, or sometimes even crossing, in a scissors-like movement while the opposing muscles, the abductors, become comparatively weak from lack of use. Most common in patients with spastic cerebral palsy, the individual is often also forced to walk on tiptoe unless the plantarflexor muscles are released by an orthaepedic surgical procedure.
These features are most typical with the scissors gait and usually result in some form and to some degree regardless of the mildness or severity of the spastic CP condition:
- rigidity and excessive adduction of the leg in swing
- plantar flexion of the ankle
- flexion at the knee
- adduction and internal rotation at the hip
- progressive contractures of all spastic muscles
- complicated assisting movements of the upper limbs when walking.
Foot drop is characterized by steppage gait. While walking, people suffering the condition drag their toes along the ground or bend their knees to lift their foot higher than usual to avoid the dragging. This serves to raise the foot high enough to prevent the toe from dragging and prevents the slapping. To accommodate the toe drop, the patient may use a characteristic tiptoe walk on the opposite leg, raising the thigh excessively, as if walking upstairs, while letting the toe drop. Other gaits such as a wide outward leg swing (to avoid lifting the thigh excessively or to turn corners in the opposite direction of the affected limb) may also indicate foot drop.
Patients with painful disorders of sensation (dysesthesia) of the soles of the feet may have a similar gait but do not have foot drop. Because of the extreme pain evoked by even the slightest pressure on the feet, the patient walks as if walking barefoot on hot sand.
Idiopathic toe walking can be described as bilateral toe walking with no orthopedic or neurological cause past the age of two. In this condition, children are able to voluntarily walk with the normal heel-toe pattern, but prefer to walk with the toe-toe pattern. In order for it to be considered idiopathic, the child's medical history should be clear of any neurological, orthopedic, or neuro-psychiatric conditions including other gait abnormalities.
Two classifications of idiopathic toe walking have been established. The Alvarez's classification identifies the severity of the dysfunction based upon kinematics and ankle rockers. The Pomarino classification identifies the toe walking according to the individual's specific characteristics and characterizes them into three types based on the signs presented.
Diagnosis includes a spin test, walking, heel walking, dorsiflexion range of motion, and lumbar lordosis. Some treatment options include serial casting and surgery for ankle motion.
Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the common fibular nerve including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. Foot drop is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion). Foot drop may be temporary or permanent, depending on the extent of muscle weakness or paralysis and it can occur in one or both feet. In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along the ground.
Foot drop can be caused by nerve damage alone or by muscle or spinal cord trauma, abnormal anatomy, toxins, or disease. Toxins include organophosphate compounds which have been used as pesticides and as chemical agents in warfare. The poison can lead to further damage to the body such as a neurodegenerative disorder called organophosphorus induced delayed polyneuropathy. This disorder causes loss of function of the motor and sensory neural pathways. In this case, foot drop could be the result of paralysis due to neurological dysfunction. Diseases that can cause foot drop include trauma to the posterolateral neck of fibula, stroke, amyotrophic lateral sclerosis, muscular dystrophy, poliomyelitis, Charcot Marie Tooth disease, multiple sclerosis, cerebral palsy, hereditary spastic paraplegia, Guillain–Barré syndrome, and Friedreich's ataxia. It may also occur as a result of hip replacement surgery or knee ligament reconstruction surgery.
The Trendelenburg gait pattern (or gluteus medius lurch) is an abnormal gait (as with walking) caused by weakness of the abductor muscles of the lower limb, gluteus medius and gluteus minimus. People with a lesion of superior gluteal nerve have weakness of abducting the thigh at the hip.
This type of gait may also be seen in L5 radiculopathy and after poliomyelitis, but is then usually seen in combination with foot drop.
During the stance phase, the weakened abductor muscles allow the pelvis to tilt down on the opposite side. To compensate, the trunk lurches to the weakened side to attempt to maintain a level pelvis throughout the gait cycle. The pelvis sags on the opposite side of the lesioned superior gluteal nerve.
This gait is precipitated by strain to the gluteus maximus and gluteus minimus. Sufferers frequently complain that an overly strenuous session at the gym, particularly with glute-isolating equipment, result in this awkward gait, or worse.
This gait may be caused by cleidocranial dysostosis.
Biofeedback and physical therapy have been used in treatment.
When the hip abductor muscles (gluteus medius and minimus) are weak, the stabilizing effect of these muscles during gait is lost.
When standing on the right leg, if the left hip drops, it's a positive right Trendelenburg sign (the contralateral side drops because the ipsilateral hip abductors do not stabilize the pelvis to prevent the droop).
"When the patient walks, if he swings his body to the right to compensate for left hip drop, he will present with a compensated Trendelenburg gait; the patient exhibits an excessive lateral lean in which the thorax is thrust laterally to keep the center of gravity over the stance leg."
Trendelenburg's sign is found in people with weak or paralyzed abductor muscles of the hip, namely gluteus medius and gluteus minimus. It is named after the German surgeon Friedrich Trendelenburg.
The gluteus medius is very important during the stance phase of the gait cycle to maintain both hips at the same level. Moreover, one leg stance accounts for about 60% of the gait cycle. Furthermore, during the stance phase of the gait cycle, there is approximately three times the body weight transmitted to the hip joint. The hip abductors' action accounts for two thirds of that body weight. The Trendelenburg sign is said to be positive if, when standing on one leg, the pelvis drops on the side opposite to the stance leg to reduce the load by decreasing the lever arm. By reducing the lever arm, this decreases the work load on the hip abductors. The muscle weakness is present on the side of the stance leg. A Trendelenburg sign can occur when there is presence of a muscular dysfunction (weakness of the gluteus medius or minimus) or when someone is experiencing pain. The body is not able to maintain the center of gravity on the side of the stance leg. Normally, the body shifts the weight to the stance leg, allowing the shift of the center of gravity and consequently stabilizing or balancing the body. However, in this scenario, when the patient/person lifts the opposing leg, the shift is not created and the patient/person cannot maintain balance leading to instability.
Toe walking refers to a condition where a person walks on their toes without putting much weight on the heel or any other part of the foot. Toe walking in toddlers is common. These children usually adopt a normal walking pattern as they grow older. If a child continues to walk on their toes past the age of three, they should be evaluated by a doctor.
Toe walking can be caused by different factors. One type of toe walking is also called "habitual" or "idiopathic" toe walking, where the cause is unknown. Other causes include a congenital short Achilles tendon, muscle spasticity (especially as associated with cerebral palsy) and paralytic muscle disease such as Duchenne muscular dystrophy. A congenital shortening of the Achilles tendon can be hereditary, can take place over time as the result of abnormal foot structure which shortens the tendon, or can shorten over time if its full length is not being used. Toe walking is sometimes caused by a bone block located at the ankle which prevents the antagonist movement, dorsiflexion. This cause is often associated with trauma or arthritis. It may also be one way of accommodating a separate condition, foot drop. Persistent toe walking in children has been identified as a potential early sign of autism.
Toe walking has been found to be more prevalent in males than females when tested with very large numbers of children. This study looked for family history of toe walking and the connection to children demonstrating ITW. 64.2% of the subjects with ITW were males showing a relationship between ITW and males. Of 348 subjects with positive family history of toe walking, about 60% had family history on the paternal side showing it may be genetically related to paternal genes. In 30-42% of idiopathic toe walkers, a family link has been observed.
Gait abnormality is a deviation from normal walking (gait). Watching a patient walk is the most important part of the neurological examination. Normal gait requires that many systems, including strength, sensation and coordination, function in an integrated fashion. Many common problems in the nervous system and musculoskeletal system will show up in the way a person walks.
Persons suffering from peripheral neuropathy experience numbness and tingling in their hands and feet. This can cause ambulation impairment, such as trouble climbing stairs or maintaining balance. Gait abnormality is also common in persons with nervous system problems such as cauda equina syndrome, multiple sclerosis, Parkinson's disease, Alzheimer's disease, myasthenia gravis, normal pressure hydrocephalus, and Charcot–Marie–Tooth disease. Research has shown that neurological gait abnormalities are associated with an increased risk of falls in older adults.
Orthopedic corrective treatments may also manifest into gait abnormality, such as lower extremity amputation, post-fracture, and arthroplasty (joint replacement). Difficulty in ambulation that results from chemotherapy is generally temporary in nature, though recovery times of six months to a year are common. Likewise, difficulty in walking due to arthritis or joint pains (antalgic gait) sometimes resolves spontaneously once the pain is gone. Hemiplegic persons have circumduction gait and those with cerebral palsy often have scissoring gait.
Scissor gait is a form of gait abnormality primarily associated with spastic cerebral palsy. That condition and others like it are associated with an upper motor neuron lesion.
Tandem gait is a gait (method of walking or running) where the toes of the back foot touch the heel of the front foot at each step. Neurologists sometimes ask patients to walk in a straight line using tandem gait as a test to help diagnose ataxia, especially truncal ataxia, because sufferers of these disorders will have an unsteady gait. However, the results are not definitive, because many disorders or problems can cause unsteady gait (such as vision difficulties and problems with the motor neurons or associative cortex). Therefore, inability to walk correctly in tandem gait does not prove the presence of ataxia.
Profoundly affected tandem gait with no other perceptible deficits is a defining feature of posterior vermal split syndrome.
Suspects may also be asked to perform a tandem gait walk during the "walk and turn" part of a field sobriety test.
Steppage gait (High stepping, Neuropathic gait) is a form of gait abnormality characterised by foot drop due to loss of dorsiflexion. The foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking.
It can be caused by damage to the deep peroneal nerve.
Myopathic gait (or waddling gait) is a form of gait abnormality.
The "waddling" is due to the weakness of the proximal muscles of the pelvic girdle.
The patient uses circumduction to compensate for gluteal weakness.
Conditions associated with a myopathic gait include pregnancy, congenital hip dysplasia, muscular dystrophies and spinal muscular atrophy
The tibia or lower leg slightly or severely twists inward when walking or standing.
The cause of in-toeing can be differentiated based on the location of the disalignment. The variants are:
- Curved foot (metatarsus adductus)
- Twisted shin (tibial torsion)
- Twisted thighbone (femoral anteversion)
Jumper's knee (patellar tendinopathy, patellar tendinosis, patellar tendinitis) commonly occurs in athletes who are involved in jumping sports such as basketball and volleyball. Patients report anterior knee pain, often with an aching quality. The symptom onset is insidious. Rarely is a discrete injury described. Usually, involvement is infrapatellar at or near the infrapatellar pole, but it may also be suprapatellar.
Depending on the duration of symptoms, jumper's knee can be classified into 1 of 4 stages, as follows:
Stage 1 – Pain only after activity, without functional impairment
Stage 2 – Pain during and after activity, although the patient is still able to perform satisfactorily in his or her sport
Stage 3 – Prolonged pain during and after activity, with increasing difficulty in performing at a satisfactory level
Stage 4 – Complete tendon tear requiring surgical repair
It begins as inflammation in the patellar tendon where it attaches to the patella and may progress by tearing or degenerating the tendon. Patients present with an ache over the patella tendon. Most patients are between 10 and 16 years old. Magnetic resonance imaging can reveal edema (increased T2 signal intensity) in the proximal aspect of the patellar tendon.
The congenital absence of the gluteal muscle was described in 1976, as occurring in a brother and sister with absence of gluteal muscles and with spina bifida occulta. It was thought to be caused by an autosomal recessive gene.
Edgar "et al." (2012) reported the case of a 15-year-old white male with congenital absence of the "gluteus maximus" muscles associated with spina bifida occulta, learning disability, optic nerve hypoplasia, scoliosis, and central nervous system hamartomas.
If gluteal muscles were absent the following actions would not be possible. The "gluteus maximus" extends the thigh at the hip in actions like stair climbing, running or walking. It also abducts the thigh, elevates the trunk and also prevents the trunk of a person from moving forward or backward when the rest of the body is in movement. The "gluteal maximus" also aids in stabilizing the femur and the tibia. The "gluteas minimus" and "medius" are also part of the gluteal muscles. If these muscles were missing, the leg would not be able to abduct or medial rotate the thigh. The body would also not be able to shift weight from one side to the other when one foot is on the ground but not another. Considering this a rare congenital disease with other complications, walking would also not be possible in the list of additional symptoms above.
An antalgic gait is a gait that develops as a way to avoid pain while walking ("" = "" + "", "against pain"). It is a form of gait abnormality where the stance phase of gait is abnormally shortened relative to the swing phase. It can be a good indication of pain with weight-bearing.
Patellar tendinitis (patellar tendinopathy, also known as jumper's knee), is a relatively common cause of pain in the inferior patellar region in athletes. It is common with frequent jumping and studies have shown it may be associated with stiff ankle movement and ankle sprains.
Yoga foot drop is a kind of drop foot, a gait abnormality. It is caused by a prolonged sitting on heels, a common yoga position of vajrasana. The name was suggested by Joseph Chusid, MD, in 1971, who reported a case of foot drop in a student who complained about increasing difficulty to walk, run, or climb stairs. The cause was thought to be injury to the common peroneal nerve, which is compressed and thereby deprived of blood flow while kneeling.
Yoga foot drop is a potential adverse effect of yoga, allegedly unmentioned by yoga teachers and books.
Lameness is most commonly caused by pain, but may also be the result of neuromuscular disease or mechanical restriction. Lameness itself is a clinical sign, and not a diagnosis.
Neurologic lameness may be the result of infection, trauma, toxicities, or congenital disease. Neurological evaluation of a lame horse may be warranted if the cause of the lameness is not obvious. Signs more commonly associated with a neurologic cause include unilateral muscle atrophy, paresis, paralysis, or dysmetria. Neurologic causes of lameness include:
- Cervical vertebral stenotic myopathy (Wobbler disease): compression of the spinal cord in the cervical (neck) region results in lameness, ataxia, and change in gait, especially in the hind legs, and neck stiffness or pain.
- Stringhalt: caused by damage to the long digital extensor muscle, or from eating the weed Hypochaeris radicata; it produces a gait characterized by rapid, spasmodic hyperflexion of the hind limbs.
- Shivers: a rare neuromuscular disorder characterized by muscle tremors, difficulty picking up the hind feet when asked to lift for farriery work, hyperflexion or hyperextension of the hind limbs, and abduction of the hind limbs. Normal athletic function is often maintained, at least initially.
- Cerebellar abiotrophy: a rare genetic disorder that occurs in Arabian horses, producing ataxia, a base-wide stance, proprioceptive deficits, and high-stepping gait.
- Damage to individual nerves will affect the muscles they innervate and subsequently alter gait. Radial nerve paralysis will cause a dropped elbow and make it difficult to extend the affected limb. Suprascapular nerve damage will lead to atrophy of the main muscles of the shoulder (sweeny). Femoral nerve paralysis causes hyperflexion of the stifles, hocks, and fetlocks and the horse usually walks on the toe of the hind foot.
- Infectious causes affecting the nervous system may be bacterial, viral, protozoal, or rickettsial. Those that commonly alter gait include tetanus, botulism, Lyme disease, equine protozoal myeloencephalitis (EPM), rabies, West Nile virus, equine encephalitis virus, and equine herpesvirus 1.
- Neoplasic (cancerous) changes in the brain or around the spinal cord may also cause alterations in gait.
Pathology is insertional tendinopathy of the medius and tendons and enlargement of the associated bursa.
Gluteals remain inactive in a seated position. Movements that require muscles become more difficult; stress is put on the spine.
The person's feet seem attached to the floor as if by a magnet. In magnetic gait, each step is initiated in a "wresting" motion carrying feet upward and forward. Magnetic gait can be visualized in terms of a powerful magnet being forcefully pulled from a
steel plate.