See it in a whole new light
Gait cycle used to be a gigantic pain for me. Like everyone else training to become a chiropractor, I was exposed to it very early in my curriculum. And I recall quite vividly being extremely bored with the concept. What was the point?
Today, after two decades of treating patients, I have come to see the gait cycle in a whole new light. I now use it as a tool to help me diagnose issues with the feet, ankles, knees, hips, and lower back. Part of the art of our craft is the ability to recognize patterns and presentations quickly that are hallmark signs of common occurrences to establish comprehensive yet efficient evaluation, examination, and treatment protocols.
Whenever I examine a patient, I do a few things when it comes to applying these techniques to the gait cycle.
Simplifying the gait cycle
Gait cycle mechanics can be very complicated. I think this is why it was so daunting all those years ago. Entire books are dedicated to dissecting the gait cycle to the nth degree. For our purposes, let’s break down this complex topic to what’s clinically relevant for us in daily practice.
To put it simply, gait cycle is the way someone walks around. To the casual observer, there might be very little to notice. The trained eye, however, can make distinct observations about the health of a patient’s gait cycle.
Recall that we have three arches under each foot: the medial longitudinal, lateral longitudinal, and transverse (metatarsal) arches. The way these arches are supported by the plantar fascia determines in large part whether the gait cycle is healthy or unhealthy.
Gait cycle is divided into the stance (60 percent) and the swing phase (40 percent). Most of this discussion focuses on the stance phase because the weight-bearing that occurs here reveals many of the deficiencies or problems that translate into pain in the lower extremities and spine.
The stance phase has three parts: heel strike, mid stance (foot flat) and toe-off. Let’s look at what happens during each one.
This part of the stance phase is when a person first puts their foot on the ground. For most humans, the heel (or calcaneus) is the first part of the foot that strikes. During this phase, the calcaneus bone touches the ground and inverts. The foot supinates and the ground force begins its transfer from the heel to the ankle. The force also begins its journey up the axial kinematic chain through the leg.
On average, a human’s foot strikes the ground with approximately five Gs of force, assuming they have healthy arch support, and their foot absorbs 30 percent of the ground shock, as it should normally.
When patients complain of heel pain when they walk or stand, this is a helpful part of the gait cycle to observe. You can do so by looking at the angle or position of their calcaneus as it hits the ground. This can help you understand whether there might be a heel spur, Achilles tendon issue, calf issues, or the ever-famous plantar fasciitis pain.
This is my favorite phase because this is where we can see the most drastic effects of foot and ankle issues. The mid stance is when we see most of the foot touching the ground. As the foot starts to bear more weight, it begins to pronate at the subtalar joint. Concurrently, we see the tibia and femur bones internally or medially rotating. These motions allow the foot to conform to the surface on which it’s standing. In essence, this stage of the gait cycle permits the foot to grip the ground for maximum traction or contact.
If the patient’s foot is pronating excessively and the three arches collapse and overstretch the plantar fascia, the patient will appear to have very flat feet. Not only will the feet flatten out and the arches fall toward the ground, but also the tibia and femur bones will over-rotate, potentially creating medial ankle or knee and lateral hip stress. This also is where we see other signs of excessive foot pronation, such as foot flare, knock knees and medially bowing Achilles tendons.
The final portion of the stance phase has the foot moving from the pronated position back to supination. At this point in the gait cycle, the toes will dorsiflex at the metatarsal phalangeal joints. If the plantar fascia is working normally, it actually will tighten and start bringing non-weight-bearing shape back to the arches. The tibia and femur bones will return to external rotation.
The forefoot (ball of the foot) really becomes the focus in the toe-off phase. Stress from weight-bearing puts pressure on the metatarsal or transverse arch and can cause it to fall over time. When the transverse arch collapse is coupled with the collapse of the lateral and medial longitudinal arches, the foot goes through physical changes. This is where you observe bunions, corns, callouses, hammer toes, and hallux valgus.
Putting it all together
So what does this all mean? It doesn’t take much time to watch someone walk and, with an understanding of what to look for throughout the phases of the gait cycle, you can quickly diagnose problems. Whether the patient is deficient in one phase or multiple phases, picking out the excessive pronation or supination and stress to the lower extremities becomes quite easy.
I realize some of you may not think of the feet and the walking cycle as being important. In fact, you may even think it’s boring, but hopefully what I have presented here will encourage you to take the next step toward understanding your patients’ pain—and that’s the first step toward treating their pain.
KEVIN M. WONG, DC, is an expert on foot analysis, walking and standing postures, and orthotics. He discusses spinal and extremity adjusting at speaking engagements. He can be contacted through orindachiropractic.com.