Co-author: Steven Schmoldt, ACE-CPT, I.M.S
As fitness professionals, we teach our clients to exercise with good form so they can accomplish their health and fitness goals. We help them improve their mechanics so that they can perform sports with greater efficiency. We even provide them with postural and ergonomic suggestions so they can perform their jobs with fewer problems. However, the thing our clients do every single day that directly leads to many of their chronic pain and overuse injuries rarely receives any attention from us: walking.
Walking is the one activity virtually all of our clients have in common regardless of age, gender, occupation, sport, or motor skill level and is often the very thing that is driving their chronic foot, knee, low back, and even shoulder and neck problems.
Part I of this article discusses the basics of the human gait cycle, highlights a few of the more common problems that occur during the gait cycle, and introduces the principles of corrective movement. This information will form the basis for the corrective movement strategy that will be presented in Part II, which you can use with your personal training clients to improve the efficiency of their gait and halt, or even reverse, many of their chronic movement issues.
Fundamentals of Gait
To appreciate both how and why things go wrong with walking, as well as how to initiate an effective corrective approach, it is important to understand the basics of the gait cycle. The goal is not to discuss every single nuance of each individual moment of the gait cycle. Rather, it is to point out some of the more important phases of the cycle, particularly the points where clients will have the most likelihood for breakdowns and/or experience compensations.
The Gait Cycle
One gait cycle (see Images 1 & 2) is the sequence from when the right heel strikes the ground to the next time the right heel strikes the ground. Each gait cycle is comprised of a stance phase, where the referenced foot or both feet are in contact with the ground, and a swing phase, where the referenced foot is either moving toward or off the ground. Stance phase, or the period the referenced foot is in contact with the ground, is 60% of the gait cycle while swing phase, the period when one foot is coming off or off the ground, makes up the remaining 40% of the cycle (Osar, 2005). This article will primarily focus on the stance phase, as this is the phase that creates the most challenges and subsequently leads to the greatest number of compensations for clients.
Image 1. Stance phase of the gait cycle (Osar, 2005)
Image 2. Swing phase of the gait cycle (Osar, 2005)
Each gait cycle consists of eight distinct phases: initial contact, loading response, mid-stance, terminal stance, pre-swing, initial swing, mid swing, and terminal swing.
The loading response of the stance phase begins the instant the heel of the forward foot contacts the ground. At this point there is double leg support because the contralateral foot (trail leg) is still in contact with the ground.
Mid-stance begins as the center of gravity (COG) moves directly over the referenced foot and represents the only point in the gait cycle where the COG is directly over the base of support. This can be a very volatile phase for clients who struggle with transitioning weight from one leg to the other as well as controlling their COG while supported on one leg. During this phase the client must control both frontal plane forces (because the contralateral limb is off the ground) and rotary forces (from the contralateral limb swing and the counter rotation of the trunk).
During terminal stance, the body is advancing over the referenced foot and the heel starts to rise from the ground. Proper ankle rocker is required to prevent early heel rise or excessive transverse plane motion (abduction) through the foot (Allen et al., 2007).
Pre-swing occurs as the heel is moving off the ground and just before the toes of the referenced foot leave the ground. The contralateral limb is now starting its heel contact phase so there is once again double leg support.
Because of the eccentric control required to decelerate the advancing center of gravity as well as to deal with ground reaction forces, loading response and mid-stance tend to be the phases of the gait cycle where clients will demonstrate the most issues. Common dysfunctions during these phases include poor eccentric control of the foot lowering to the ground, poor deceleration of ankle dorsiflexion as the tibia is moving forward of the foot, and poor eccentric control of the lower extremity during mid-stance where the client must stabilize their center of gravity in unilateral stance. Common movement impairments during mid-stance include loss of frontal plane stability (positive Trendelenburg’s) and/or impaired control of pronation (increased transverse plane motion at one or multiple segments of the lower kinetic chain).
The assessment that follows will look at several of these components as they relate to the mid- and terminal-stance phases of the gait cycle.
While it takes many years to train one’s eyes to be tuned in to each of the nuances of each phase of the gait cycle, there are several gait components that the fitness professional can look at to determine with a relatively high level of predictability how well the client can handle loading and mid-stance phases.
The four gait assessments include:
- single leg support
- single leg squat
- ankle dorsiflexion
- breathing and rib cage mobility
These four tests will assess individual's ability to support and loads the lower extremity, to progress through the ankle (ankle rocker), and to breathe and stabilize the core (Osar, 2010).
Please Note: There are several hands-on components to the assessment and you should always work within your scope of practice as a fitness professional. It is important to refer out to an appropriate health care professional for more significant conditions that require medical attention, including, but not limited to, neurological symptoms, muscle atrophy, and/or labored breathing.
Single Leg Support
The single leg stance test and weight shift are two of the simplest ways to test a client’s ability to stabilize the center of gravity in mid-stance.
Have the client stand with both feet together, then raise one leg to approximately 90º of hip and knee flexion (see Image 3). Ask the client to shift weight from leg to leg. Note how much shifting it takes to transition from leg to leg and any compensation happening through the kinetic chain.
- Single leg support – The client should be able to support the trunk over the stance leg with the pelvis remaining level. It is considered a positive Trendelenburg’s test if the client cannot maintain a neutral pelvis, and a compensated Trendelenburg’s if the client shifts the trunk over the support leg. Either situation requires further evaluation for instability in the trunk, hip, or lower extremity.
- Weight shift – There should be limited shifting of the client's body while moving from one leg to the other. Excessive swaying to one side indicates instability that should be further evaluated.
- Foot response – The client should maintain a foot tripod, meaning his/her weight should be supported on digit number 1 (big toe), across the metatarsal heads, digit number 5 (small toe), and calcaneus. There should be minimal ankle sway as the center of gravity is supported over the stance leg. Excessive toe gripping, ankle sway, and hip (butt) gripping are signs of instability that should be further evaluated (Osar, 2010).
Single Leg Squat
The single leg squat test efficiently assesses how well a client stabilizes and decelerates his/her center of gravity. If the client failed the single leg stance and weight shift test earlier, there is no reason to test the single leg squat because the client has already proven he/she can’t stabilize while on one leg. A double leg squat can substitute for those clients that have knee pain, poor balance, are older, and/or sedentary individuals and run the risk of causing further problems by overloading the lower extremity.
The client stands on one leg and performs a single leg squat (see Images 4 & 5) with the knee bent to 30°. This allows you to evaluate the client’s ability to:
- maintain the thoracopelvic canister (see Image 4) – the client should be able to keep the trunk aligned over the pelvis with no loss of control within the thoracopelvic canister;
- maintain the foot tripod and alignment of the hip, knee and ankle – the client should be able to maintain alignment of the hip, knee, and foot with the knee moving approximately through the mid-axis of the foot;
- achieve a minimum of 10º of ankle dorsiflexion without foot or knee compensation (see Image 4) – the client should achieve proper 10º of ankle dorsiflexion without loss of the foot tripod or excessive internal rotation/abduction of the knee;
- decelerate and ascend under control – the client should descend into and ascent out of the squat position with no loss of lower extremity or trunk alignment.
Ankle Dorsiflexion and Hip Extension
A minimum of 10º of ankle dorsiflexion (ankle rocker) and 10º of hip extension are required for uncompensated gait (Michaud, 2007). A loss of ankle dorsiflexion can result in failure in either or both single leg support and the single leg squat. Assess ankle dorsiflexion by having the individual lie supine with a straight leg, then invert and dorsiflex the ankle. Passive ankle motion should also be tested by grasping the client’s foot, maximally inverting it to take out play within the metatarsals, and dorsiflexing the ankle (see Image 6). Hip extension is evaluated by having the client lie prone with both legs straight and lift one leg off the table at a time (see Image 7). If you are unable to do a manual assessment, you can simply observe the client performing both open chain as well as closed chain ankle dorsiflexion during the squat pattern being sure the client is able to achieve 10º ankle dorsiflexion in both positions. Additionally, the client should be able to achieve 10º of pure hip extension without compensatory anterior rotation of the pelvis or hyperextension of the low back.
|Image 6. Ankle dorsiflexion
||Image 7. Hip extension
Rib Cage Mobility and Respiratory Patterns
One important key to an efficient gait pattern is the ability to stabilize the trunk over the pelvis and simultaneously perform diaphragmatic breathing. This requires both proper alignment and mobility of the trunk as well as the ability of the deep stabilization system to remain active while maintaining diaphragmatic breathing.
The client lies with legs out straight and arms at sides (see Image 8). Note where the rib cage is positioned relative to the pelvis and where the client is primarily breathing, paying attention to the rate, depth, and ease of breath. If within your scope of practice, you can then perform a rib cage mobility assessment by gently rocking the client’s thorax side-to-side and noting the ease at which it moves (see Image 9), observing for:
- alignment — the inferior aspect of the rib cage should face towards the pelvis. An upward positioned rib cage is considered to be dysfunctional;
- the client’s primary respiratory pattern — the rib cage should move lateral and posterior and the diaphragm should move inferior with inspiration and superior with expiration. There should be minimal movement of the neck or chest during quiet respiration. Lack of rib cage movement either laterally or posteriorly represents a dysfunctional breathing strategy;
- mobility of the thorax — the thorax should be mobile and supple at rest. Excessive restriction, stiffness, and/or abdominal or back "gripping" represent a dysfunctional stabilization strategy and must be released to allow for optimal respiratory patterns and trunk motion during gait (Lee, 2008).
Any faulty patterns discovered during these assessments will need to be corrected prior to initiating fundamental movement patterns or the client will simply fall back into habitual patterns. We'll present a corrective movement strategy and progressions to address these issues in Part II.
Gait is one of the fundamental movement patterns and is a common cause of repetitive movement dysfunction. Unfortunately for our clients, gait rarely receives the attention it deserves in traditional personal training and rehabilitation programs. This article discussed several of the key components of the gait cycle as well as introduced two of the common causes for movement dysfunction as they relate to the gait cycle. Part II of this article will present the fitness professional with corrective movement strategies and progressions for improving the biggest challenges that clients have during the gait cycle—primarily deceleration and stabilization during the loading response and mid-stance phases.
- Allen, S., Waerlop, I. & Lardner, R. (2007). The Basics of Gait. Dynamic Chiropractic. Vol. 25, Issue 23. Downloaded May 25, 2011. Retrieved from http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=52419.
- Lee, L.J. (2008). Discover the Sports Pelvis: The Role of the Pelvis in Recurrent Groin, Knee, and Hamstring Pain and Injury. The Mid-Atlantic Physical Therapy Associates, Course Handouts: Fairfax, VA.
- Michaud, T. (1997). Foot Orthoses. Thomas Michaud. Self-published: Newton, MA.
- Osar, E. (2005). Form and Function. 2nd ed. Self-published: Chicago, IL.
- Osar, E. (2010). The Integrated Movement Specialist™. Course Handouts: Chicago, IL.