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Thread: [Physical Exam] Stance and Gait

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    PharmD Year 1 TomHsiung's Avatar
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    Default [Physical Exam] Stance and Gait

    Disorders of gait reflect one of four possible problems: pain, immobile joints, muscle weakness, or abnormal limb control. Abnormal limb control, in turn, may result from spasticity, rigidity, diminished proprioception, cerebellar disease, or problems with cerebral control.

    When analyzing a patient's gait, the most important initial question to settle is whether the gait is symmetrical or asymmetrical. Pain, immobile joints, and muscle weakness are usually unilateral and thus cause asymmetrical abnormalities of gait. Rigidity, proprioceptive disorders, cerebellar diseases, and problem with central control all cause symmetrical abnormalities of gait. Spasticity may cause asymmetrical gait abnormalities or symmetrical ones.

    A.Painful Gait (Antalgic Giat)
    If bearing weight on a limb is painful, patients adopt an antalgic gait to minimize the pain. All antalgic gaits are characterized by a short contralateral step.

    1.Short Contralateral Step
    After bearing weight on the affected leg, patients with pain quickly step onto the sound leg. The short contralateral step produces an uneven cadence, one identical to that produced in anyone if a rock is in one shoe.

    2.Other Characteristic Features
    Depending on whether the pain is located in the foot, knee, or hip, each antalgic gait is distinctive, allowing diagnosis from a distance.

    a) Food Pain
    In patients with foot pain, the foot contacts the ground abnormally. For example, patients may bear weight during stance on the heel only or forefoot only or along the lateral edge of the foot.

    b) Knee Pain
    Patients with knee pain display a stiff knee that does not extend or flex fully during stride.

    c) Hip Pain (Coxalgic Gait)
    Patients with hip pain limit the amount of hip extension during late stance
    (when the normal hip extends 20 degrees). Even so, the most characteristic feature of the coxalgic gait is the so-called lateral lurch: When the patient is bearing weight on the painful limb, there is an excessive asymmetrical lateral shift of the upper body toward the weight-bearing side, causing the trunk to lean and ipsilateral arm to abduct.

    Lateral lurch reduces the pain of patients with hip disease because it minimizes the need to activate the ipsilateral hip abductor muscles. These muscles normally support the upper body during swing of the other leg, but, when activated, they can easily put 400 pounds of pressure on the femoral head, an intolerable force if there is hip disease. By leaning over the painful limb during stance, patients effectively balance their center of gravity over the painful limb and thus avoid activation of the hip abductors.

    B.Immobile Joints
    Most clinicians do not consider immobile joints as a cause of abnormal gait, but the condition is well known to physiatrists. A common example is plantar flexion contracture, a complication that may occur after prolonged periods of plaster immobilization or confinement to bed. Affected patients may place their weight on the forefoot during initial stance (instead of the heel), or during mid stance, they may lift the heel too early or lean the trunk forward. During swing phase, the abnormally flexed foot has difficulty clearing the floor, leading the patient to drag the foot or develop an unusual movement to clear it, such as contralateral trunk lean or contralateral vaulting.

    The clinical can easily identify immobile joints as the cause of abnormal gait by testing the range of motion of hips, knees, and ankles of both legs.

    C.Weakness of Specific Muscles
    Three muscle groups, when weak, cause specific gait abnormalities: 1) the hip extensor and abductor muscles, 2) the knee extensors, and 3) the foot and toe dorsiflexors. The gluteus maximus and quadriceps gaits were frequently observed historically as complications of poliomyelitis and diphtheria.

    1.Trendelenburg Gait and Sign (Abnormal Gluteus Medius and Minimus Gaits)

    a.Definition of Trendelenburg Gait
    The Trendelenburg gait occurs when the gluteus medius and minimus muscles do not function properly. These two muscles abduct the hip, an action that supports the opposite pelvis and prevents if from dropping excessively during the normal single-limb stance. During walking, a slight dip of the opposite pelvis is normal during stance phase on one limb. The finding of excessive drop of the opposite pelvis, however, is the abnormal Trendelenburg gait. When the abnormality is bilateral, the pelvis waddles like that of a duck.

    Like patients with the coxalgic gait, patients with Trendelenburg gait may lean their trunk over the abnormal leg during stance, but the lean lacks the dramatic lurch seen in coxalgic gait, and the opposing sways of the ipsilateral shoulder and opposite pelvis make it appear as if patients with the Trendelenburg gait have a hinge between the sacral and lumbar spine.

    b.Etiology of Trendelenburg Gait
    Causes of Trendelenburg gait include the following: 1) neuromuscular weakness of the hip abductors (although poliomyelitis and progressive muscular atrophy were important causes historically, this gait now occurs as a complication of hip arthroplasty using a lateral approach, which risks damage to the superior gluteal nerve or gluteus medius muscle) and 2) hip disease, especially congenital dislocation of the hip and coxa vara. In both of these disorders, the abnormal upward displacement of the greater trochanter shortens the fibers of the gluteus medius muscle and makes them more horizontal instead of vertical, thus abolishing their role as abductors.

    (More coming ... thanks for you patience)
    Last edited by TomHsiung; Sat 24th December '16 at 10:02pm.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

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