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The Major Determinants in Normal

and Pathological Gait 102


Charalambos P. Charalambous

102.1 Author determinants may make effective compensation impossible


with the energy cost of locomotion increasing by threefold.
Saunders JB, Inman VT, Eberhart HD

102.5 Summary
102.2 Reference
In this classic article Saunders et al. describe the displace-
J Bone Joint Surg Am. 1953;35(3):543558. ment of the centre of gravity through the gait cycle, in both
the vertical and horizontal planes. They bring on the notion
than smooth and low amplitude displacement of the centre of
102.3 Institution gravity is important in minimising energy expenditure during
locomotion. They describe six primary determinants of
Department of Anatomy and orthopaedic surgery, School of human locomotion (pelvic rotation, pelvic tilt, lateral pelvic
medicine and the College of Engineering, University of displacement, knee flexion in the stance phase, and foot and
California, San Francisco knee mechanics) which work together to limit excessive dis-
placement of the centre of gravity and hence conserve energy.
Saunders et al. suggest that gait disorders can be analysed in
102.4 Abstract terms of changes in these primary determinants and therapeu-
tic interventions can be applied to correct these. The authors
Human locomotion is such a complex process consisting of also examine the compensatory changes occurring in the
multiple simultaneous individual three dimensional motions remaining gait determinants, when one of them fails. Such
that its analysis is difficult without a unifying principle. Such compensatory changes ensure that the centre of gravity main-
a unifying principle is the concept that locomotion is essen- tains its normal displacement pattern.
tially the travel of the centre of gravity through space along
a pathway that requires the least energy expenditure. This
allows qualitative analysis of gait in terms of the essential 102.6 Citation Count
determinants of gait. The six major determinants are pelvic
rotation, pelvic tilt, knee and hip flexion, knee and ankle 467
interaction, and lateral pelvic displacement. Changes in these
determinants may help understand and assess pathologi-
cal gaits. Pathological gaits may represent a try to preserve 102.7 Related References
energy consumption by exaggerating motion at unaffected
levels. Compensation is reasonably effective, with loss of 1. Murray MP, Drought AB, Kory RC. Walking patterns of
the knee determinant being the most costly. Loss of two normal men. J Bone Joint Surg Am. 1964;46:33560.
2. Lamoreux LW. Kinematic measurements in the study
of human walking. Bull Prosthet Res. 1971;10(15):
C.P. Charalambous, BSc, MBChB, MSc, MD, FRCS (Tr&Orth)
384.
Department of Trauma and Orthopaedics,
Victoria Hospital, Blackpool, UK 3. Cavagna GA, Margaria R. Mechanics of walking. J Appl
e-mail: bcharalambos@hotmail.com Physiol. 1966;21(1):2718.

P.A. Banaszkiewicz, D.F. Kader (eds.), Classic Papers in Orthopaedics, 403


DOI 10.1007/978-1-4471-5451-8_102, Springer-Verlag London 2014
404 C.P. Charalambous

102.8 Key Message that pathological gait could be identified when these six
determinants of gait were compromised. Any pathology that
The six major determinants of gait are pelvic rotation, pelvic increases the vertical distance between the high and low
tilt, stance phase knee flexion, knee and ankle mechanics, points increases the energy cost of ambulation
and lateral pelvic displacement. These, work in a synergistic 1. Pelvic rotation (in the horizontal plane)
way to ensure that during locomotion the centre of gravity This allows the swinging hip to move forwards faster than
translates through space along a smooth pathway requiring the stance hip. Pelvic rotation occurs anteriorly on the swing-
the least energy expenditure. Saunders et al. suggest that gait ing limb and posteriorly during mid-stance. It is maximal
disorders can be analysed in terms of changes in these pri- just before heel strike with a total motion of pelvic rotation
mary determinants and in terms of centre of gravity displace- of 5 to each side. Pelvic rotation also produces a longer
ment patterns and therapeutic interventions can be applied to stride length for the same amount of hip flexion of the
correct these. advancing leg and hip extension of the retreating leg. Thus,
it allows for longer steps without changing the COM dis-
placement significantly.
102.9 Why It Is Important 2. Pelvic tilt (in the frontal plane)
As the pelvis on the swing leg is lowered, the hip abduc-
Saunders paper is important because it links the various tors of the stance hip control pelvic tilt. During normal gait
components of pelvis and limb movements as coming the pelvis drops 5 on the side of the swinging leg. This pel-
together to influence energy expenditure in locomotion. vic dip decreases horizontal displacement of the COM dur-
They describe not only how motion occurs but why motion ing single limb support
occurs in this way. 3. Knee flexion
This decreases the vertical displacement of the COM.
This occurs during mid-stance, as knee flexes to approxi-
102.10 Strengths mately 15 occurs under the control of eccentric quadriceps
contraction and remains flexed until the foot is flat on the
Human locomotion is presented not only in the form of the ground.
isolated gait components but the way that such components 4,5. Knee and ankle motion
combine to allow a smooth centre of gravity propagation is This involves control of the knee-ankle-foot motion. This
analysed. synchronized movement results in eccentric control of plan-
tar flexion of the ankle and knee flexion, which occurs during
the first portion of the stance phase. These factors help to
102.11 Weaknesses avoid abrupt changes of the lowest portion of COM arc, pro-
ducing a smooth sinusoidal curve instead of an arched
The results of this paper are based on previous experimental pattern.
studies described by Saunders and detailed results of those 6. Lateral pelvic displacement
are not presented in this paper. Even though the methodol- This is the lateral sway or side to side oscillation that
ogy used in gathering data is briefly described, the main aim occurs with each step. This defines the motion of the COM in
of the paper is to bring together and describe the conclusion the horizontal plane.
of the authors in gait determinants of human locomotion. Pelvic rotation and tilt, knee flexion at mid-stance, foot
and ankle motion, and lateral pelvic displacement all affect
the displacement of the centre of gravity and hence the
102.12 Relevance energy efficiency of walking. Lateral pelvic displacement
reduces displacement of the centre of gravity in the horizon-
Sixty years ago, a group of researchers at the University of tal plane whereas the rest reduce displacement in the vertical
California proposed six kinematic mechanisms to explain plane.
how movements of the lower limb joints contributed to the Saunders et al. defined walking as the displacement of the
centre of gravity when humans walk at their preferred speed. centre of gravity through space in a way that requires the
These variables (described by Saunders as determinants of least energy expenditure. During each walking cycle, the
gait) influence the displacement of the centre of gravity in centre of gravity moves upwards and downwards twice, seen
such a way, and hence ensure efficient energy expenditure. as moving up and down of the head. It also displaces in a side
Saunders et al. began by assuming that gait was most effi- to side direction. Both the vertical and horizontal displace-
cient when vertical and horizontal (lateral) excursions of the ments follow a smooth sinusoidal pathway and are just less
bodys center of gravity were minimized. They suggested than 2 in. in magnitude. Any displacement of the centre of
102 The Major Determinants in Normal and Pathological Gait 405

Table 102.1 Determinants of gait


Determinant COM displacement Effect
First Pelvic rotation Decreased 4 from each side from a Energy conservation saves the COM
total of 8 drop at its lowest point 6/16 in.
About the vertical axis, alternating to Reduces the drop in COM during (elevates end or arc)
the right and to the left relative to line double limb support
of progression
Second Pelvic tilt Reduces the peak of COM during Energy conservation by shortening the
At horizontal axis at midstance single limb support pendulum of the leg(3/16 in.) at the
high part of arc(depresses summit arc)
Third Knee flexion in stance High point of COM further reduced by Energy conservation by decreasing
knee flexion in midstance rise of arc(7/16 in.) by walking over a
bent knee (depresses summit arc)
Fourth and Fifth Foot and ankle mechanism Combination of foot and ankle motion Flattens and slightly reverses arc of
with knee motion smoothes the COM translation(decreased 3/16 in.)
change in direction
Sixth Lateral displacement of pelvis Must bring COM above support point Lateral displacement of the pelvis is
to balance on one leg largely abolished by the presence of
the tibial-femoral angle. There is a
side-to-side sway of 1.7 in. radius
COM Centre of mass

gravity beyond its normal maximum limits or any abrupt 2. Welter ML, Do MC, Chastan N, Torny F, Bloch F, du Montcel ST,
irregular movement wastes energy. Agid Y. Control of vertical components of gait during initiation of
walking in normal adults and patients with progressive supranuclear
Saunders article is of vital importance as the gait deter-
palsy. Gait Posture. 2007;26(3):3939.
minants described form the basis of much of our understand- 3. Detrembleur C, Vanmarsenille JM, De Cuyper F, Dierick F.
ing of the kinematics of normal walking. Saunders provided Relationship between energy cost, gait speed, vertical displacement
a different way of looking at gait analysis where the various of centre of body mass and efficiency of pendulum-like mechanism
in unilateral amputee gait. Gait Posture. 2005;21(3):33340.
components of gait come together to ensure a smooth and
4. Dierick F, Domicent C, Detrembleur C. Relationship between
limited displacement of the centre of gravity and hence a antagonistic leg muscles co-contractions and body centre of gravity
more efficient way of conserving energy. mechanics in different level gait disorders. J Electromyogr Kinesiol.
Monitoring the displacement of the centre of gravity and 2002;12(1):5966.
5. Detrembleur C, van den Hecke A, Dierick F. Motion of the body
analysis of the gait determinants have been used in patho-
centre of gravity as a summary indicator of the mechanics of human
logical gait analysis in both neurological and orthopaedic pathological gait. Gait Posture. 2000;12(3):24350.
disorders. Interventions in such pathological gaits have been 6. Tesio L, Lanzi D, Detrembleur C. The 3-D motion of the centre of
assessed based on their corrective effects on the centre of gravity of the human body during level walking. I. Normal subjects
at low and intermediate walking speeds. Clin Biomech. 1998;
gravity and the resultant energy conservation they achieve
13(2):7782.
[19]. The principles of avoiding excessive centre of gravity 7. Tesio L, Lanzi D, Detrembleur C. The 3-D motion of the centre of
displacement, has also been used in athletic training to pro- gravity of the human body during level walking. II. Lower limb
vide energy efficient training (Table 102.1). amputees. Clin Biomech. 1998;13(2):8390.
8. Garca-Morales V, Gonzlez-Fernndez J, Prieto-Tedejo R, Velasco-
Palacios L, Cubo-Delgado E. Locomotion and gait disorders. Rev
Neurol. 2009;23(48 Suppl 1):718.
References 9. Cantor CR. Gait disorders. Clin Podiatr Med Surg. 1999;
16(1):14151.
1. Chastan N, Do MC, Bonneville F, Torny F, Bloch F, Westby GW,
Dormont D, Agid Y, Welter ML. Gait and balance disorders in
Parkinsons disease: impaired active braking of the fall of centre of
gravity. Mov Disord. 2009;24(2):18895.