ORIGINAL ARTICLE
Gait Findings in the Adolescent Subject With a Stiff Hip
Andi B. Gordon, MPT, Mark L. McMulkin, PhD, Bryan Tompkins, MD,
Paul Caskey, MD, and Glen O. Baird, MD
Background: Adolescent subjects with severe unilateral hip dis-
ease are often stiff and painful yet have limited surgical options.
Although hip fusion has been used successfully to minimize
pain, acquired gait compensations after arthrodesis are factors
felt to lead to knee and back pain over time. However, these gait
compensations may already be present in a person with a stiff
hip. The purpose of this study was to describe the quantitative
gait findings of the adolescent subject with a unilateral stiff hip
and to determine whether these findings are similar to those of
subjects presenting after arthrodesis.
Methods: This study was a retrospective review of 6 subjects seen
in a motion analysis laboratory between 2005 and 2009 (age 13
to 17 y). All adolescents had been referred to the motion analysis
laboratory for a routine clinical gait study. Subjects were se-
lected for this study based on kinematic sagittal plane hip mo-
tion found to be <25 degrees (mean 16.2 degrees). Diagnoses
included: Legg-Calvé-Perthes (3) and hip avascular necrosis (3).
Results: Compared with laboratory-based normative data, the
following findings were significant: increased arc of trunk and
pelvic motion (sagittal, coronal); involved side—decreased arc
of hip and knee motion (sagittal), decreased peak hip abduction
in swing; contralateral side—increased arc of hip and knee
motion (sagittal); and increased peak hip abduction in swing.
Conclusions: Gait compensations in multiple planes and joints
were identified in adolescent subjects with a unilateral stiff hip.
These compensations are necessary for these subjects to generate
forward progression in gait and are similar to deviations found
after hip arthrodesis. Subjects with a stiff hip may already be at
risk to develop pain and/or arthrosis in adjacent motion seg-
ments due to these obligatory gait characteristics. Hip fusion
may not increase these risks (in this patient population) since the
compensations are already present and requisite, but may pro-
vide an opportunity to decrease pain and improve function.
Level of Evidence: Level IV, Case Series.
(J Pediatr Orthop 2013;33:139–144)
C hildhood diseases such as Legg-Calvé-Perthes, slip-
ped capital femoral epiphysis, infection, and trauma
can lead to early degeneration of the hip joint. A subset of
From the Walter E. and Agnes M. Griffin Motion Analysis Laboratory,
Shriners Hospitals for Children, Spokane, WA.
None of the authors received financial support for this study.
The authors declare no conflict of interest.
Reprints: Andi B. Gordon, MPT, Walter E. and Agnes M. Griffin Motion
Analysis Laboratory, Shriners Hospitals for Children, 911 West 5th
Ave., Spokane, WA 99204. E-mail: abgordon@shrinenet.org.
Copyright r 2013 by Lippincott Williams & Wilkins
J Pediatr Orthop  Volume 33, Number 2, March 2013
these subjects with severe disease or injury can go on to
have function-limiting symptoms in the adolescent years.
These subjects with degeneration often present with a stiff
and painful unilateral hip. This problem can be difficult to
address and has limited surgical options to correct or
alleviate the symptoms. Total hip arthroplasty is often
reserved for the older, less active subject as the lifespan of
arthroplasty remains a limiting factor for the adolescent
and young adult. Another surgical alternative, hip fusion,
has been found to successfully minimize pain in the in-
volved hip even at long-term follow-up.1,2 However, ac-
cessory motions in other joints after hip arthrodesis have
been well documented3,4 and are considered to be factors
that contribute to pain in the knee and back over time.3,5
An adolescent with a stiff hip is likely to present
with gait patterns similar to those who present after hip
arthrodesis. If these gait patterns are present before hip
arthrodesis, then the intended benefits of the surgical in-
tervention such as pain relief and postponement of ar-
throplasty may be worthwhile. The subject with a painful
stiff hip and marked degeneration would have the op-
portunity to have reduced hip pain through fusion with
no greater risk than is already present for developing pain
in adjacent joints with the additional opportunity for
improving function. Following a literature review, no
prior studies were found that quantitatively evaluated the
adolescent subject with a stiff hip before arthrodesis. The
purpose of this study was to describe the quantitative gait
findings of the adolescent subject who presents with a
unilateral stiff hip and to determine if these subjects have
similar gait compensations to those who have been fused
with a hip arthrodesis.
METHODS
A retrospective review of the Motion Analysis
Laboratory (MAL) database at our children’s hospital
(between 2002 and 2009) was conducted after approval by
the local Institutional Review Board. Six subjects were
identified from our MAL patient database and selected
for this study based on kinematic sagittal plane hip mo-
tion found to be <25 degrees (mean 16.2 degrees)
(Fig. 1). Absolute position of the hip varied markedly
(peak hip extension range from 1 to 30 degrees). All
subjects were between 13 and 17 years of age. Diagnoses
included Legg-Calvé-Perthes (3 subjects), avascular ne-
crosis due to osteomyelitis (2 subjects), and avascular
necrosis due to trauma (1 subject). All subjects had been
referred to the MAL for a routine clinical gait study that
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Gordon et al J Pediatr Orthop  Volume 33, Number 2, March 2013

1 had no intervention. For kinematic and kinetic data,

both the involved side and the uninvolved sides were
compared with our normative database and analyzed
with unpaired t tests. The Gait Deviation Index, an
overall index of gait pathology determined from kine-
matic variables over the entire gait cycle,6 was calculated
for both involved and uninvolved sides and compared
with the mean value for our normative laboratory data
which is 100 with an SD of 10. Significance was set at
P < 0.05.

FIGURE 1. Individual hip sagittal plane kinematics for 6 sub-
jects with a unilateral stiff hip (typical—shaded ± 1 SD).
included: video documentation, 3 dimensional (3-D)
computerized kinematic and kinetic data, and physical
examination.
Instrumented 3-D gait kinematic data were col-
lected using standard protocols with an 8-camera VICON
612 system (Oxford Metrics Group, Oxford, UK). All
subjects walked at their self-selected speed for 3-D data
collection. Kinetic data were generated with AMTI force
plates (Watertown, MA) using inverse dynamics for in-
ternal moment and power data. Generalized hip pain
in the involved hip was described by 4 of the 6 subjects
with an additional subject reporting involved-side hip
pain with range of motion only. After the MAL study, 2
subjects went on to receive a hip arthrodesis. For the
remaining 4 subjects, 1 had valgus osteotomy, 2 had hip
arthrogram, steroid injection, and percutaneous hip ad-
ductor release (1 having valgus osteotomy after this), and
RESULTS
Subjects had significantly increased trunk arc of
motion in the sagittal and frontal planes (Table 1). There
were also significantly increased pelvic arc of motion in
the sagittal plane and increased mean pelvic obliquity.
For the involved side, subjects had significantly decreased
arc of hip and knee motion in the sagittal plane (Table 1,
Fig. 2). For the involved side, there were reduced peak hip
extension, reduced peak knee flexion, and decreased peak
dorsiflexion. In the coronal plane, there was decreased
peak hip abduction in swing (absolute position of ad-
duction). On the contralateral limb, subjects had sig-
nificantly increased arc of hip and knee motion in the
sagittal plane. For the contralateral side, there were in-
creased peak hip extension, increased peak knee flexion,
and increased peak dorsiflexion (Table 1, Fig. 2). In the
coronal plane, there was increased peak hip abduction in
swing. The Gait Deviation Index6 was >3 SD from typ-
ical (63.5) for the involved side and >2 SD from typical
(72.7) on the contralateral side.
Stance phase time and cadence were significantly
different compared with laboratory-based normative da-
ta. For the involved side, stance phase time (percent of
total gait cycle) was significantly lower than normative
data, 56.8% compared with 59.3% (P < 0.01). The

TABLE 1. Kinematic Gait Findings for 6 Subjects With a Unilateral Stiff Hip Compared With Laboratory-based Normative Values
Involved Side Contralateral Side Laboratory Controls
Arc of trunk motion
Sagittal plane 111* 3.31
Frontal plane 7.71* 3.61
Arc pelvic motion
Sagittal plane 13.91* 3.01
Mean pelvic obliquity 9.81* (elevated) 9.51* (downward) 0.11
Arc of hip motion
Sagittal plane 16.21* 62.61* 43.31
Peak hip extension 13.41* (flexed) 13.51* (extended) 5.11
Peak hip abduction
Swing 10.81* (adducted) 161* (abducted) 8.41
Arc of knee motion
Sagittal plane 41.91* 68.41* 55.11
Peak knee flexion
Swing 44.91* 65.61* 59.01
Peak ankle dorsiflexion
Stance 4.91* 15.51* 12.81
Gait Deviation Index 63.5* 72.7* 100
*Significant difference, P < 0.05.

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J Pediatr Orthop  Volume 33, Number 2, March 2013 Gait for Adolescents With Stiff Hip

FIGURE 2. Mean frontal and sagittal plane kinematics for 6 subjects with a unilateral stiff hip. Solid line—involved hip side,
dashed line—uninvolved hip side, shaded—typical ± 1 SD.

contralateral side had significantly increased stance phase
timing (64.2%) compared with normative data (P < 0.01).
Overall cadence was significantly lower for the subjects
with a stiff hip, 114 steps/min, compared with normative
cadence, 128 steps/min (P < 0.05).
Kinetics on the involved side demonstrated sig-
nificantly less pronounced hip peak flexor and extensor
moments, reduced peak hip power generation, and
reduced ankle plantar flexion moment and power in
late stance compared with laboratory normative data

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Gordon et al
TABLE 2. Kinetic Gait Findings for 6 Subjects With a Unilateral Stiff Hip Compared With Laboratory-based Normative Values
Involved Side
Peak hip extensor moment—stance (N m/kg)
Peak hip flexor moment—stance (N m/kg)
Peak hip power generation (W/kg)
Peak ankle plantarflexor moment—late stance (N m/kg)
Peak ankle power generation—late stance (W/kg)
*Significant difference, P < 0.05.
(Table 2). The contralateral side demonstrated sig-
nificantly more pronounced peak flexor and extensor
moments at the hip.
Physical examination demonstrated limited hip ab-
duction for all subjects with the involved hip not able to
attain hip abduction to neutral for 5 subjects and past
neutral to 5 degrees for 1 subject (mean 10 degrees).
Two subjects were measured to have hip flexion con-
tractures of the involved limb. In both cases, the absolute
position of hip flexion on kinematics was more flexed
than the other 4 subjects. The presence of a hip flexion
contracture did not relate to overall hip flexion/extension
arc of motion in gait. Anthropometric measures taken for
data collection revealed a mean leg-length discrepancy of
0.5 cm where the involved side was shorter for 3 subjects,
longer for 2 subjects, and equal for 1 subject.
DISCUSSION
The purpose of this study was to describe the
quantitative gait findings of the adolescent subject who
presents with a unilateral stiff hip. Gait compensations in
multiple planes and joints were identified in this pop-
ulation. Trunk and pelvis demonstrated increased arcs of
motion which are felt to be compensations that assist with
the generation of forward progression in the absence of
available hip flexion range and power. Hip power and
ankle power were reduced for the involved limb compared
with normal. In addition, the involved limb demonstrated
overall decreased arcs of motion in the sagittal plane hip
and knee. The contralateral limb demonstrated increased
motion at the hip and knee in the sagittal plane.
Anthropometric measures resulted in a wide and
bidirectional range of leg-length discrepancies which was
not expected given the significant and unidirectional ob-
liquity of the pelvis. Although it was anticipated that the
involved side would be universally shorter, this was not
the case. Nevertheless, the kinematic findings suggest that
the limbs functionally behaved similarly (involved limb
shorter) across subjects despite the variable anthro-
pometric leg-length values measured. This kinematic
presentation is felt to be the result of the sagittal and
coronal plane deviations. Pelvic obliquity (with the in-
volved side elevated) was felt to be due to limited hip
abduction motion for all 6 subjects. In the presence of a
hip adduction contracture of the involved limb, the pelvis
tilts upward in the coronal plane for the feet to remain
beneath the body. This upward tilting of the pelvis
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Contralateral Side Laboratory Controls
0.59* 1.30* 0.95
0.40* 0.85* 0.66
0.18* 1.33 1.28
1.08* 1.46 1.29
2.25* 3.89 3.41
functionally shortens the limb and makes clearance dur-
ing swing easier given the sagittal plane restrictions in
range of motion of the stiff hip. The subsequent obliga-
tory downward obliquity of the pelvis on the contralateral
side functionally lengthens this limb. The significant in-
creased motions of the hip, knee, and ankle on this side
are felt to be compensations to assist with clearance of
this functionally long limb in swing.
Westhoff et al7 investigated 3D computerized gait
analysis of 33 children with unilateral Legg-Calvé-Perthes
disease and reported only frontal plane kinematics. Two
pattern types were identified within the study. The first
group (9% of their subjects) showed a pelvic drop of the
swinging limb only. The second more common pattern
was a trunk lean to the affected stance limb with the pelvis
neutral or elevated. This more frequent second pattern
was consistent with our 6 subjects who demonstrated in-
creased lateral trunk lean to involved side during stance
with elevated pelvis. No sagittal plane data were reported
and it is difficult to determine if the patients with similar
frontal plane kinematics actually had a stiff hip (or hip
adduction contracture). We are also unable to compare
how the other joints in the sagittal plane may have be-
haved to maintain forward momentum given their uni-
lateral joint disease. The lateral motion of the trunk to the
stance limb is likely to reduce the moment about the hip
in the frontal plane both to minimize joint loading (to
reduce pain) and to minimize the moment thereby re-
ducing the strength requirements of the hip abductors.
Karol et al3 reported on 9 subjects approximately 9
years after arthrodesis (surgery—mean age 13 y), inves-
tigating specifically for compensations at the knee and
lumbar spine to more clearly define the excessive motions
that may contribute to pain related to these adjacent re-
gions. Similar to our study, their significant findings in-
cluded reduced cadence, reduced dorsiflexion at the ankle
in the sagittal plane on the involved side, and increased
pelvic motion. They showed 12.8 degrees of increased
pelvic motion comparing closely to our increased range
of pelvic motion of 13.9 degrees with similar pattern of
greater anterior tilt during single limb stance of the in-
volved limb.
Thambyah et al4 also studied subjects who had
long-standing hip arthrodesis (surgery—mean age 38 y).
In this cohort (9 subjects), they reported significantly in-
creased pelvic arc of motion and reduced hip power
generation of the involved side similar to the present
study. With regards to the contralateral side, they report
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J Pediatr Orthop  Volume 33, Number 2, March 2013
the hip in the sagittal plane to have a pattern similar to
normal though no normative data was present making it
difficult to assess any differences to the present study.
Overall, they conclude that the gait compensations ob-
served (in the coronal plane) may be a subject’s method of
reducing joint loading (including the knee). None of the 9
subjects reported pain of the fused hip approximately 14
years after arthrodesis. We believe that in addition to the
coronal plane deviations reducing joint loading, devia-
tions may also be directly related to hip adduction con-
tracture and the subsequent positioning assists with
clearance. The sagittal plane deviations are necessary to
maintain forward momentum and may increase the pro-
pensity to degenerative changes in adjacent joints.
Gore et al8 studied 28 men with a mean age of 35
years who were on average 6 years after hip arthrodesis.
They found increased pelvic motion and increased motion
of the uninvolved hip in the sagittal plane similar to the
current study.
Wadsworth et al9 described the gait characteristics
of subjects with hip disease using electrogoniometric
methods in the early 1970s. Although their cohort was
older (mean age 61 y) and approximately half of their
population had bilateral involvement, their results dem-
onstrated a markedly reduced hip motion in the sagittal
plane that was of a magnitude similar to our study.
Kinematic data for other joints and planes were not re-
ported. Other studies with 3-D motion analysis data have
been conducted on the adult population without fusion
but with unilateral hip joint disease.10,11 Hurwitz et al10
reported on the kinematics and kinetics of subjects (mean
age 60 y) with unilateral hip osteoarthritis relating the gait
compensations to pain and range of motion limitations.
They also found limited sagittal plane hip motion and
significantly reduced hip extensor moments. Murray
et al11 who also studied adults (mean age 55 y) with uni-
lateral hip pain found decreased excursion of the involved
side hip motion and increased rocking of the pelvis which
was similar to other post-arthrodesis studies3,8 and to our
own. The single bump pattern at the pelvis is appreciated
in the present study and we believe that this rocking is
necessary for forward progression given the nearly absent
early swing hip power and decreased late stance peak
ankle power of the involved side. In addition, the rocking
of the pelvis functionally increases the contact of the in-
volved limb with the ground to increase step length.
Although well documented as an acceptable treat-
ment option12,13 for young people with a degenerative,
stiff and painful hip, arthrodesis continues to require
careful consideration as a treatment alternative in this
population. Gait compensations are felt to lead to pain in
adjacent joints with time. Pain in adjacent joints after hip
arthrodesis has been reported in 32% to 78% of pa-
tients.1–3,12,14–16 Kirkos et al5 found that despite reports
of pain in many subjects, this group remained generally
satisfied with their hip fusion. The researchers found de-
generative changes in adjacent joints of subjects; however,
it is difficult to determine if this higher incidence of de-
generative changes were significantly different than the
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Gait for Adolescents With Stiff Hip
general population. Thambyah et al4 in contrast found no
degenerative changes of the lumbar spine, knees, or
contralateral hip. Hip arthrodesis has been found to
provide both pain relief and good function1,12 allowing
fewer limitations on the adolescent’s activities compared
with arthroplasty. If a hip fusion is performed in these
adolescents, it should be done using techniques that pre-
serve the hip abductor mechanism. Conversion from fu-
sion to total hip arthroplasty may be performed later in
life and hip abductor function is of paramount im-
portance in functional outcomes of patients.17
In the present study, with a small sample size, sag-
ittal plane deviations of a stiff hip were significantly dif-
ferent than normal and compared with compensations of
those presenting post-arthrodesis. These similar charac-
teristics show that this group is functioning like they have
already had an arthrodesis even given their wide range of
absolute flexion magnitudes (kinematically). Patients with
a stiff hip may already be at risk to develop pain and/or
arthrosis in adjacent motion segments due to obligatory
gait characteristics. Therefore, hip arthrodesis may not
significantly increase the risks to these subjects while
providing a significant reduction in pain and improve-
ment in function. The potential subject’s habits, lifestyles,
and anticipated occupation should be considered care-
fully so that the position of the hip fusion can be opti-
mized (within the acceptable range) while minimizing the
limitations for a specific person.
In conclusion, subjects in this study who present
with a unilateral stiff hip demonstrated several deviations
from normal in multiple planes and joints that compared
with previously published work for subjects with a fused
hip. Since these compensations already seem to be pres-
ent, a hip fusion may be a viable option to reduce pain
and increase function.
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