Evaluation of Gait and Station – The First Step in Functional Evaluation

George K. Petruska DC, DACRB

Abstract

Often many health care providers perform orthopedic and neurological testing without functional assessment. In depth assessment of chronic conditions is paramount to forming an accurate diagnosis. Complete assessment is equally important in designing an effective treatment plan. Accurate assessment and an effective treatment plan enhance the chances of a favorable outcome. 

Key Words

Functional assessment, gait, station, rehab prescription

Introduction

The evaluation of gait and station, which is a component of the musculo-skeletal exam, can reveal significant structural defects that will help you correctly identify the etiology or root cause of a patient’s chronic symptoms.  Further, your ability to identify these defects through objective assessment will provide some of the information necessary to develop an appropriate rehabilitation prescription and to justify the necessity of care.

Your structural analysis, especially in chronic cases, should begin with a visual assessment of the lower quarter.  Your assessment should begin with visualization of the posterior body.

Pelvis Assessment:

The first signs of most postural and muscular imbalance usually develop in the patient's static pelvic positioning. Anterior tilting of the pelvis suggests shortening of the hip flexors (iliopsoas, rectus femoris and tensor fascia lata) and/or the lumbar spinal extensors. Posterior tilting of the pelvis suggests tightness of the hamstrings. Lateral pelvic shifts suggests unilateral shortening of the hip adductors, but may also be associated with lumbar motion segment pathology, weakness of the lateral pelvic stabilizers or leg length inequality. Pelvic obliquity secondary to functional shortening of one leg is common. The muscles, which are most commonly related to leg shortening, are the hip adductors, the iliopsoas and the quadratus lumborum. A shortened latissimus dorsi may also elevate the pelvis from the trunk and result in a short leg. The piriformis, when tight, lengthens the leg. Primary pelvic obliquity due to structural leg length inequality is rarely observed in practice as the body usually shifts the pelvis laterally in order to level the sacrum and hips.

Buttocks Assessment

A generalized visual assessment of the glutei musculature should reveal muscles that are well rounded, symmetrical and a horizontal gluteal line. Flattening of the upper, outer quadrant of the buttock or a loosely hanging appearance of the muscle suggests weakness of the gluteus maximus or inhibition due to tightness of the hip flexors or sacroiliac joint dysfunction.

In the case of sacroiliac joint dysfunction, a typical pattern of changes in muscle activation occurs. There is arthrogenic inhibition of the gluteus maximus on the side of the blocked joint and of the gluteus medius on the contralateral side. In addition, painful spasms of the iliacus, piriformis and rectos abdominis are common.

Lower Extremity

In assessing the hamstrings, focus on the area about two-thirds down the posterior thigh and compare the muscle bulk bilaterally as well as to the gluteal muscles. Increased bulk of the hamstrings suggests hyperactivity compensatory to a weak or inhibited gluteus maximus on the same side, as the muscles are synergists for hip hyperextension.

The contour of the inner thigh normally forms a very shallow, S-shaped curve as you activate the hip adductors to tension. A distinct increase in muscle bulk in the upper one-third of the inner thigh suggests tightness of the short, or one joint, hip adductors.

The inner thigh, where the fibers of the one and two joint hip adductors cross look for a visible depression.  Where this abnormal finding is evident, this is known as an `adductor notch' and results from long standing tightness of the short hip adductors. A more distal position of an adductor notch suggests poorer function of that hip joint.

Thigh adductor tightness may be associated with leg length deficiency, lateral shift of the pelvis or hip joint pathology such as arthrosis.

Observe closely the size, shape and symmetry of the calf muscles and, for each leg, notice any difference in tone between the gastrocnemius and the soleus.

Increased bulk in the inner, lower one-third of the calf suggests soleus hypertophy. This creates a cylindrical shape to the lower leg, which contrasts, with the normal inverted bottleneck shape. Soleus hypertrophy is of paramount importance as it may be the only, hidden cause of low back pain and is also suggestive of ankle or foot dysfunction that should be investigated further.

Lower Back Assessment:

Observing initially the general postural attitude, quality of the lumbar lordosis, symmetry of body landmarks and muscular contours. Compare the quality of the spinal extensors in the lumbar and thoracolumbar region bilaterally. Ideally the sides are symmetrical and the muscle is slightly thicker and broader in the lumbar region.

Predominance of the thoracolumbar musculature suggests overactivation in gait, poor stabilization of the lumbar spine and is associated with a weak gluteus maximus.

Hip hyperextension, the most important movement for a normal gait pattern, should range from 5 to 15 degrees. Normal hip hyperextension takes place in relation to a pelvis stabilized by activity of the abdominal and lumbar extensors. When it is limited due to hip flexor tightness, the patient tilts the pelvis anteriorly, replaces extension of the hip with extension of the low back and activates the thoracolumbar extensors as a point of fixation. This impaired stabilization of the lumbar spine is a poor sign for the lower back.

The next step is to perform a visual assessment of the anterior body.

Abdomen:

Postural analysis of the anterior body begins with evaluation of the abdominal wall, whose role in stabilization and protection of the spine is crucial. Compare the upper quadrants of the abdomen to the lower and the rectus abdominis to the obliques. Ideally the abdominal wall should be flat. Increased tonus of the upper quadrants relative to the lower may be associated with a faulty paradoxical respiratory pattern. A groove lateral to the rectus suggests predominance of the obliques over the recti with poor stabilization of the spine in the anteroposterior direction. A bulging, hypotonic waistline reflects poor function of the whole abdominal wall and poor protection of the low back during both normal, physiological and sudden, unexpected movements.

Lower Extremity Assessment

The quality of the anterior thigh musculature may provide further insight into the patient's lumbopelvic posture and reflect the status of the lower extremity joints. The tensor fascia lata is a slender muscle and is normally not visualized, the contour of the lateral thigh should be flat in males and rounded in females. Compare bilaterally the contour of the anterior tibialis and observe the posture of the patella, ankle, foot and toes. Normally there should be no movement of the patella or toes, nor should there be tendon play on the dorsum of the foot in standing.

A groove on the lateral thigh in males or a flattened lateral thigh in females suggests shortening of the tensor or iliotibial band and may be accompanied by a superolateral shift of the patella. Where such a groove is apparent, this is commonly known as tibial band syndrome.

Superior deviation of the patella alone suggests shortening of the rectus femoris. Tightness of either the rectus femoris or tensor fascia lata may result in an attitude of hip flexion and anterior pelvic tilt as previously described.

An `unquiet patella' displays short, jittery up and down movements due to rectus femoris hyperactivity, which is compensatory to altered proprioception from the knee. Knee joint pathology involving, for example, the medial meniscus or cruciate ligaments is most often responsible for such proprioceptive changes.

Hypotrophy of the vastus medialis may also result from altered proprioception from the knee. Unilateral hypertrophy of the vastus may be due to repetitive forced lie extension or may be a sign that the patient overextends and overstresses the knee during gait.

Anterior tibialis precedes weakness of the toe extensors as a very early sign of L5 nerve root lesion.

Regular movements of the dorsi flexor tendons may reflect imbalance between the dorsi flexors and plantar flexors, impaired proprioception from the knee, ankle or foot, but may also be observed in S1 root syndromes. Presence of this sign may be helpful in differentiating root lesions from pseudo syndromes such as piriformis syndrome or tensor fascia lata syndrome.

Treatment

Where these conditions are identified, active care should begin as soon as possible. The sooner the health care provider can transition a patient from passive care to active rehabilitation, the greater the chance for a favorable outcome.

Initially, it may be necessary to initiate care with Post Isometric Relaxation (PIR).  This technique should be performed to the involved (shortened) structures identified in the functional assessment. This phase of treatment will lay the groundwork for an effective joint stabilization rehabilitation program (Active Care – Stage II). The goals of PIR should be to increase physiologic end range, relax tight muscles and activate inhibited muscles. Once these goals have been achieved, the “Flex Building” muscle energy technique, which involves isokinetic resistance to patient comfort throughout the full range of motion in both directions, should be performed if possible. The Flex Building technique increases range of motion beyond the impeded end range, increase muscles tone in “weak” muscles, stretches “tight” muscles and activates inhibited muscles hence resolving “Tightness Weakness” syndromes as described by Janda.  A contraindication to this technique would be pain or increase of symptoms at one or more discreet points in the range of motion. If this occurs, Proprioceptive Neuromuscular Facilitation (PNF) should be performed prior to utilization of the Flex Building technique and transition of the patient to Active Care – Stage II. Ultimately, your goal is to prepare the patient to transition to a comprehensive conditioning program focused to functional restoration. The transition to Active Stage II can occur when basic flexibility is restored. The transition to Active Stage III can occur when identified muscle imbalances and joint stability are improved.

The rehabilitation prescription throughout the various phases of care should include proprioception and flexibility training, stability training, endurance training, aerobic conditioning and strength training using balance board protocols, otis ring protocols, body blade protocols, gym ball protocols and thera-bands. Rehabilitation should always be directed at restoring the patient’s capacity to perform some work, recreational or daily activity and should be terminated when the patient’s functional progress plateaus. The patient should then be released from treatment with instruction. While maintenance care and continuation of rehabilitation in a home-based program is indicated, it is often not reimbursable.

Conclusion

Restoration of function is the key component to development of an effective outcome-based treatment program.  Being able to develop an outcome-based treatment program is the key to receiving appropriate reimbursement. To demonstrate appropriate functional outcomes, you must first document functional deficit.  In many cases, orthopedic and neurologic assessments fail to reveal the source of the patient’s symptoms or functional limitations. In these circumstances, functional assessment will lead to accurate diagnosis and development of a treatment program designed to improve the patient’s functional abilities. 

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