REIDER PART 1 17
Charter 1_Terms and Technigues 5
Gait
One of the most valuable components of the muscu-loskeletal examination is observation of the motion of the body segment in question while it is functioning dynamically. The most basie function of the lower cxtremities is ambulation; therefore, a vital part of the evaluation of any lower extrcmity disorder is to observe how the problem affects the patient s gaity or habitual pattern of ambulation.
The examiner must make a conscious effort to include the examination of gait in the office evaluation of musculoskeletal problems. Although traditionally the examiner might have observed the patients gait as the patient was walking into the examination room, nowa-days the clinician is morę likely to walk into an examina-tion room after the patient is already there. This means that the examiner often does not see the patient walk unless he or she makes a conscious effort to include this observation in the examination.
The materiał presented in each Gait section is by no means a description of laboratory gait analysis. Instead, these sections highlight details that can be detected by inspection and have a specific diagnostic significance. For example, the examiner’s attention may be directed to anomalous motion of the affected body part during ambulation or the way a particular orthopaedic abnor-mality may influence the overall gait pattern.
To understand or detect these abnormalities, a detailed knowledge of the science of gait analysis is not necessary. Most clinicians possess an intuitive under-standing of normal gait patterns. In order to observe and describe abnormalities of gait, however, it is helpful to be familiar with the terms used to describe the normal phases of a gait cycle. A complete gait cycle is considcrcd to be the series of events that occur between the time one foot contacts the ground and the time the same foot returns to the same position.
Although ambulation is a continuous process, a gait cycle is arbitrarily said to begin when one foot strikes the ground (Fig. 1-4). Because first contact normally is madę with the heel, this point in the gait cycle is describcd as heel strike. As the individual continues to move forward, the forefoot makes contact with the ground. The point at which both the forefoot and the heel are in contact with the ground is called foot fiat. At the same time, the opposite foot is pushing off the ground and beginning to swing forward. The point at which the swinging limb passes the weight-bearing limb is the point of midstance for the weight-bearing limb. This is an extremely helpful point in the gait cycle to look for abnormalities, because the limb that is in midstance is temporarily bearing all the weight of the individual’s body. As the opposite limb continues to move forward, weight is transferred from the standing limb to the swinging limb, and the standing limb begins to push off.
The process of push-off provides much of the propulsive energy used for ambulation. It is sometimes divided into heel-off, the point at which the heel leaves the ground, and the toe-off, the point at which the forefoot leaves the ground. The portion of the gait cycle just described, from heel strike to toe-off, is known as the stance phase of gait. Most abnormalities are evident during this gait phase because the involved limb is bearing weight and thus under stress. After toe-off, the limb passes through the swing phase of gait as it is advanced forward toward the next heel strike. During this time, the opposite limb is progressing through the same components of stance phase just described. When the First heel strikes the ground again, one entire gait cycle has been completcd. Each lower limb spends about 60% of the gait cycle in stance phase because there is a portion of the cycle during which both feet are in contact with the ground. The portion of the cycle during which both lower limbs are weight-bearing is called double leg stance, whereas the portions during which only one limb is weight-bearing is called single leg stance.
In the upper extremity, there is no such standardized way of evaluating the dynamie function of the limb. Much of this information is therefore obtained during the active rangę of motion (ROM) examination. At times, however, it may be helpful for the clinician to ask the patient to perform certain tasks, particularly in the cvaluation of the hand.
Rangę of Motion
The Rangę of Motion section of each chapter teaches the reader how to obscrve and quantitate the amount of motion possible in each joint. Traditionally, joint motion is assessed within three planes of movement, each described with a pair of terms: flexion/extension, abduction/adduction, and external rotation/internal rotation.
Each pair of terms describes movement that takes place in one of the bodys Cardinal planes when the body is in the anatomie position (Fig. 1-5). Flexion and exten-sion, for example, describe motion that occurs in the sagittal piane. These movements could also be described as occurring around a transverse axis. This description is sometimes only approximate. For example, as already noted, the flexion axis of the ankle is externally rotated compared with the true sagittal piane.
The exact meaning of the terms flexion and extension varies depending on the naturę of the joints in question. In the elbows, knees, and digits, flexion means move-ments that tend to bend the joint, and extension means movements that tend to straighten it. In the shoulder and hip, flexion refers to movements that bring the involved limb anterior to the coronal piane, whereas extension refers to movements that bring the limb posterior to the same piane (Fig. 1-6A and B). In the wrist, these terms
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