The Gait Cycle, Abnormal gait and

Examination of the Lower Limb

Dr. Mcharo
 Gait
• Gait simply means normal walking
• Consists of 4 phases
• Walking refers to the repetition of the 4 phases
• 4 phases:
1) Heel-strike phase
2) Stance phase
3) Toes-off phase
4) Swing phase
• If there is a problem with gait, one must
determine which phase is affected
• Abnormal gait simply means limping
• Limping has many causes
• Patients who are brought on stretchers and
wheelchairs, or come with the help of a
walking aid (crutches, stick) indicate problems
with gait
 Abnormal Gait – Heel strike phase
• Any pathology on the heel will affect the heel-strike phase
and the heel will not touch the ground.
• The problem may be congenital or acquired.
• Patients will be walking on their toes.
• Patients with congenital Tallipes Equino-varus deformity, have
club feet and are unable to make the heel touch the ground
• Patients with Congenital Equinus deformity present with
horse feet and cannot walk properly.
• An ulcer or any trauma to the heel also affects the heel-strike
phase.
 Abnormal Gait – Stance phase
• Patients may present with shortening limp due to
congenital shortening of one of the limbs.
• Patients have a swinging gait
• Must observe whether the shortening is in the
femur or in the tibia and to what extent it is
• Patients with pain in the joints of the lower limb
i.e. Knee joint, hip joint or ankle joint present
with Antalgic gait i.e. The stance phase is very
short.
 Abnormal Gait – Toes-off phase
• Patients with Pathology on the base of the
toes or the tarsal-metatarsal joint will not
have the toes-off phase
 Abnormal Gait – Swing phase
• Patient with problems involving the abductors of the
hip have an abnormal swing phase
• Sciatic nerve palsy also causes abnormal swing phase
• E.g. Patients with Palsy of the common Peroneal
nerve is unable to dorsiflex the foot and presents
with a High stepping gait.
• Patients with problems of the abductors of the hip
present with Trendelenburg gait (swinging on one
side) and are Trendelenburg test positive.
• If both hips are affected, patients have a
waddling gait.
 Examination of the Lower Limb
• The lower limb extends from the hip joint to
the toe
• Examination of a limb involves the
examination of the bones and the joints of the
limb.
• Strip the patient to his underpants
• Observe how the patient walks to you
• Examine for any obvious shortening of either
of the limbs while the patient is standing.
• Do the Trendelenburg test to check for any
abnormalities involving the abductors of the
hip joint
• Ask the patient to stand on his/her toes to
observe for any abnormalities
• Thereafter, ask the patient to lie on supine position
• Inspection & palpation of the Musculoskeletal system
• Inspection  observe for any obvious deformities,
and the axis of the lower limb.
• Normal axes are 7-8º vulgus.
• Abnormal axis – straight, knock knees, bow-legs,
rickets.
• Examine the feet
• Check for any atrophy of the muscles of the thigh i.e.
Compare the circumference of the muscles on both
limbs.
• Measure the distance from the centre of the
hip joint to the toe on both limbs i.e. From the
anterior superior iliac spine to the medial
malleolus.
• Palpation  tests
• Palpate for any swellings, deformities and
fractures.
• Examination of the joints
 Examination of the hip joint
• Ball and socket joint of synovial variety
• Articulation between the head of the femur
and the acetabulum.
• Stabilizing factors of the hip joint 
Ligamentum teres, extra capsular ligaments,
ilio-femoral ligaments, ischio-femoral
ligaments.
• Blood supply: branches of the femoral artery
• Check if the Range of Movements (ROM) are
normal i.e. Flexion, extension, abduction,
adduction, internal rotation and external
rotation.
• F/E: 135 – 0 – 0
• IR/ER: 35 – 0 – 35
• ABD/ADD: 35 – 0 – 35
• Flexion contracture: 135-45-0
• Patient can flex normally but is unable to
extend fully.
 Examination of the Knee joint
• Articulation between the femur and tibia –
tibial-femoral joint
• Stabilized by the medial and lateral collateral
ligaments.
• Anterior and posterior cruciate ligaments
 Inspection
• Is there a swelling?
• Is the swelling uniform?
• Is there any hypervascularization?
• Is the skin normal?
• Is there ulceration?
• Is there atrophy of the muscles?
• Is there effusion/fluid collection in the knee
joint? How much?
• Fluctuation test / patella tap test – used to
detect the amount of fluid in the knee joint.
• Check the temperature of the knee joint for
any inflammation.
• Patella-grinding test – to check for the
smoothness of the surface of the patella and
any tenderness.
 Range of movements
• Knee joint is a hinge joint
• F/E: 135-0-0
• Hyperextension: 135 – 0 – 5-10
 Special tests for the Knee joint
• Varus and Valgus stress tests for the lateral collateral
and medial collateral ligaments respectively.
• Lachmann test for the anterior and posterior
cruciate ligaments.
• Drawer’s test – test the movement of the tibia
anteriorly and posteriory
• Appley’s grinding/distraction test
– Grinding test – for the meniscus
– Distraction – for the ligaments
 Examination of the Meniscus
• Commonest – Mc Murray test
• Rye’s test