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Kinematics and Kinetics of Gait: From Lab to Clinic

Article  in  Clinics in sports medicine · July 2010

DOI: 10.1016/j.csm.2010.03.013 · Source: PubMed

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 Author's personal copy

Kinematics and
K i n e t i c s o f G a i t : F rom
Lab to Clinic
Jay Dicharry, MPT

KEYWORDS
 Gait  Kinematics  Kinetics  Running

The ultimate goal of gait analysis is to understand the relationship between an

individual’s functional capabilities and limitations and gait pattern, with the purpose
of enhancing performance while preventing injury.1 The physiologic aspects of training
the running athlete are well-known. The biomechanical variables associated with
training are less understood by clinicians. This article reviews the components of
gait and helps clinicians apply these concepts to clinical analysis.
Human locomotion involves moving a center of mass (COM) across a given
distance. Gait can be monitored subjectively in the clinic, or can be quantified
objectively in a modern three-dimensional (3D) gait laboratory setting. The selected
method must be able to assess the desired parameters. The relatively young science
of biomechanical gait analysis, combined with the inherent variability of individual
runners, makes the comprehensive study of running gait challenging.2,3 A
clinical gait evaluation, however, used in conjunction with a thorough history, physical
examination, and functional screen is a powerful tool for shedding light on the
dysfunction causing an individual’s symptoms.

THE GAIT CYCLE

The gait cycle describes the time and space parameters that occur in the distinctly
different activities of walking and running.4 The lower body limbs experience both
stance and swing periods, but the timing and contact patterns of these stance and
swing phases differentiate the two tasks of walking and running. Stance phase begins
at contact with the ground. Swing phase initiates as that limb moves into toe-off. The
walking gait cycle has a period of double support (both feet in contact with the ground
at the same time) and a period of single-leg support. An individual is able to walk at
varied speeds while still maintaining these essential characteristics, and as evidenced
by the rapid pace of elite race-walkers. Gait is described as running when the gait
cycle exhibits single-leg support and double-leg float (flight) periods. Therefore,

The Center for Endurance Sport, Department of Physical Medicine and Rehabilitation, The
University of Virginia, 545 Ray C. Hunt Drive, Suite 240, Charlottesville, VA 22903, USA
E-mail address: [email protected]

Clin Sports Med 29 (2010) 347–364

doi:10.1016/j.csm.2010.03.013 sportsmed.theclinics.com
0278-5919/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
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walkers always have at least one limb in contact with the ground, and runners either
have one limb or no limbs in contact with the ground at respective periods of gait.
Gait cycles can be categorized. The walking gait is subdivided into eight distinct
phases: initial contact, loading response, midstance, terminal stance, preswing, initial
swing, midswing, and terminal swing (Fig. 1). Although these distinct periods offer
a method to categorize gait, they can be combined to reflect the three functional
components for each limb: (1) weight acceptance (initial contact, loading response),
(2) single limb support (midstance, terminal swing, preswing), and (3) limb advance-
ment (initial swing, midswing, terminal swing). The first two functional components
occur during the stance phases with the third occurring during swing. Running gait
cycles are broken down into the following phases: stance phase absorption, stance
phase generation, swing phase generation, swing phase reversal, and swing phase
absorption. The stance phase is typically emphasized in most clinical running obser-
vation and can be broken down into (1) initial contact to foot flat, (2) foot flat to heel-off,
and (3) heel-off to toe-off.
Definition of temporal–spatial gait parameters allows objective reports of both
walking and running; they define where, when, how long, and how rapidly the indi-
vidual is in contact with the ground. These parameters include stride time, step
time, stride length, step length, gait velocity, and cadence. Stride time is the time
from initial contact of one foot to initial contact of the same foot. Step time refers to
the period of initial contact of one foot to initial contact of the opposite foot. Stride
length is the distance covered between initial contact of one foot to initial contact of
the same foot, whereas step length reflects the distance form initial contact of one
limb to the initial contact of the opposite limb. Gait velocity is stride length divided
by stride time, usually expressed as meters per second or miles per hour. Cadence
refers to the number of steps taken in a unit of time, usually expressed as steps per

Fig. 1. The gait cycle. (A) Walking figure. IC, initial contact; ISW, initial swing; LR, loading
response; MST, midstance; MSW, midswing; PS, preswing; TST, terminal stance; TSW,
terminal swing. (B) Walking gait cycle. IC, initial contact; LR, loading response; IS, initial
swing; MS (first instance), midstance; MS (second instance), midswing; PS, preswing; TO,
toe off; TS (first instance), terminal stance; TS (second instance), terminal swing. (C). Running
figure. 1. Stance phase absorption. 2. Stance phase generation. 3. Swing phase generation.
4. Swing phase reversal. 5. Swing phase absorption. (D) Running gait cycle for running and
sprinting. Absorption, from SwR through IC to StR; generation, from StR through TO to SwR.
IC, initial contact; StR, stance phase reversal; SwR, swing phase reversal; TO, toe off. (From
Novacheck TF. The biomechanics of running. Gait Posture 1998;7:77–95; with permission.)
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Gait: Lab to Clinic 349

minute. These characteristics can be monitored with pressure mats, force platforms,
and 3D motion analysis camera systems. Foot switches (on/off devices to collect foot
contact timing) allow temporal data to be collected but ignore spatial data.
During the walking gait cycle, approximately 60% of time is spent in stance phase
and 40% in swing. Under average walking speeds, each double-limb support
comprises 10% of the gait cycle (total, 20%), whereas single-limb stance accounts
for the remaining 80% of stance phase. During slower walking speeds the double-
limb support phase increases, whereas faster walking speeds reflect shorter
double-limb support periods (Fig. 2).3,5 Running reverses the support characteristics
found in walking: less than 40% of the gait cycle is spent in stance and greater than
60% is spent in swing. As running speed increases, the time spent in stance
decreases and that spent in swing increases. To increase speed, an initial increase
occurs in step length, followed by increased cadence. Increased stride length is asso-
ciated with an increase in velocity and is limited by leg length and the athlete’s ability to
generate sufficient force to move the COM forward. Although cadence is trainable, its
direct impact on ground contact time, and thus ground reaction forces (GRFs) acting
on the runner, reflect that a preferred cadence might be a protective effect to stem
both impact forces and loading rates.6 Typical values for cadence vary from the low
70s to the mid-90s for all runners, including distance runners and sprinters. Fig. 2
illustrates the relationship of stance time to swing time throughout various speeds.3

KINEMATICS OF GAIT

The study of kinematics involves the use of 3D motion analysis systems that digitally
reconstruct the individual’s body as a multisegment system. After infrared markers are
placed at specific anatomic landmarks, their position is triangulated by cameras to
calibrate the individual into the system. Construction of the coordinates and orienta-
tion of the rigid body segments allow calculation of joint angles of the proximal and
distal segment, joint angular velocity, and joint acceleration. Measurements are
collected for each joint in all three cardinal planes of motion. Movement of the COM
of each body segment impacts the overall COM of the individual, which is critical
for balance and energy expenditure.1 During walking, the COM trajectory is at the
highest point in stance, when speed is minimum. During running, the COM reaches

Fig. 2. Variation in gait cycle parameters with speed. For each condition, the bar graph
begins at initial contact on the left and represents two complete gait cycles or strides.
Note that as speed increases, time spent in swing (clear) increases, stance time (shaded)
decreases, double float increases, and cycle time shortens. (From Novacheck TF. The biome-
chanics of running. Gait Posture 1998;7:77–95; with permission.)
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350 Dicharry

the highest point in the flight phase, when velocity is maximum.5 Although skin artifact
is inherent in this data collection process, modern 3D motion analysis systems
currently represent the most noninvasive tool for reliable kinematic data
collection.2,7–11
Running-joint kinematic patterns differ somewhat from those of walking. Differences
are more pronounced in the sagittal plane and somewhat muted in the coronal and
transverse planes. However, absolute peak values are not always the primary focus
of an analysis, because they are also greatly influenced by the athlete’s training level
and speed. The timing of the extremes of mobility (and force data presented in the
following section) is a more important descriptor because it better exemplifies
individual characteristics.3 Although 3D gait analysis produces graphs for each plane
of motion of each specific joint (Fig. 3), all body segments are coupled in a closed
kinetic chain during stance and an open kinetic chain in swing.

Sagittal Plane Kinematics

As the body transitions from walking to running to sprinting, the COM is lowered and
the body tilt in space shifted forward. The combined effect is to maximize the propul-
sion phase. Although Novacheck reported that pelvic orientation stays remarkably
similar to maintain economy,3 recent studies have shown changes in pelvic orientation
with running.
Using healthy adult subjects, Franz and colleagues12 recently showed that despite
an increased stride length in running, hip range of motion is unchanged from walking
to running. Instead, the compensations in sagittal plane involved an increase in
anterior pelvic tilt and thigh angle (thigh-in-space angle). Furthermore, they observed
a greater anterior pelvic tilt in subjects who displayed reduced utilized peak hip exten-
sion. Thus, this limitation of hip flexor mobility shifts pelvic orientation and may place
the lumbar spine in a compromised position for core muscle activation and have impli-
cations for low-back pain.13 Both Chumanov and colleagues14 and Thelen and
colleagues15 report that this altered pelvic orientation and relationship between the
hip flexors and extensors may also place additional strain on the hamstrings. Preser-
vation of pelvic alignment during running is a key variable to consider in these injury
populations.
In walking, the hip shows peak extension just before toe-off and peak flexion in mid-
to terminal swing. In running, the peak range of extension is similar to that of walking;
however, peak extension occurs at toe-off. Increased peak hip flexion is seen during
running to advance the limb in swing. Overall hip flexion/extension and abduction/
adduction mobility are increased in running (approximately 60 and 15 , respectively)
compared with walking (approximately 40 and 10 , respectively).
Unlike in walking, in running the hip must extend in the later part of swing so as to
place the foot in the correct orientation under the body. If this did not occur, foot
contact would be too far ahead of the COM and shift the GRFs posterior, thus causing
deceleration. Correct hip position at contact can be best visualized as riding on
a skateboard or scooter. Planting the stance leg close to the COM at contact tends
to preserve the GRF close to the COM and minimize the deceleration component.
Placing the foot excessively anterior will cause an abrupt braking force. This charac-
teristic is accentuated in sprinters in that the hip in a more extended position at contact
will continue to produce net acceleration with the COM ahead of the contact limb.
The knee exhibits similar patterns in walking and running, flexing once to absorb in
stance and once to clear the limb in swing. Although the patterns are the same, the
amount of knee flexion in swing increases greatly from approximately 60 in walking
to upwards of 90 in running. Some sprinters achieve 105 to 130 of knee flexion in
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Fig. 3. Sample plots of kinematics are shown for hip, knee, and pelvis in all three cardinal planes of movement. All data are plotted in percent (%) gait
Gait: Lab to Clinic

cycle. Data are from a sample of healthy runners collected at the University of Virginia Center for Endurance Sport Gait Laboratory.
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swing. In stance, the running knee is flexed approximately 25 at contact and
continues flexing to 45 peak in midstance. Less peak flexion in stance occurs in
sprinters because of the lower ground contact time.
In walking, the tibia is positioned so that the contact is made at the heel with the
ankle in plantar flexion. The position of the tibia is more vertical in running, requiring
more dorsiflexion of the ankle to achieve contact. Moving past initial contact, the
walking ankle initially plantar flexes to achieve foot flat, whereas the running ankle
moves into dorsiflexion as the limb is loaded. Because of shorter contact times,
sprinters tend to run more on the forefoot, and thus have less peak dorsiflexion at
the ankle in midstance. Moving into propulsion, sprinters have increased plantar
flexion at toe-off and decreased need for dorsiflexion to clear the limb in swing
because of increased mobility of the knee.
To summarize, net ankle mobility is higher in running (50 ) than walking (30 ). The
timing of peak ankle values occur earlier in the stance phase as running speed
increases.
Full dorsiflexion of the metatarsal joints (normally 85 ) is not needed for walking or
running; however, a limitation (<30 metatarsophalangeal [MTP] at the first ray) can
cause significant changes. A significant amount of leverage, and thus stability, is
provided from the first ray and its musculotendinous structures from late stance
through toe-off. An individual with restricted MTP extension cannot rollover through
the metatarsal heads at toe-off, causing the foot to supinate early and thus shifting
the base of support laterally on the foot away from the stable first ray. This process
introduces a ‘‘heel whip’’ into the gait cycle that forces rotational motion into the entire
kinetic chain.
A clinical examination performed with the ankle in a relaxed plantar flexed position
can reveal arthrokinematic restriction in mobility of the MTP joints. However, all of the
lower leg tissues are continuous in nature. Assessing MTP mobility with the ankle in
slight dorsifexion better replicates the position of the ankle at toe-off and offers the
unique ability to examine the combined effects of the calf musculature, Achilles,
and plantar fascia together. A limitation in one or all of these structures can limit
mobility of the MTP even when the joint itself might move freely. Identification and
treatment of the soft tissue structure at fault allows unimpeded progression of the
runner through the forefoot.

Coronal and Transverse Plane Kinematics

Motion in the mediolateral direction during walking and running is more subtle than in
the sagittal plane. Nonsagittal plane mobility in gait acts to moderate stability, force
attenuation, and economy in gait. Motions of pronation and supination are visualized
not as isolated events occurring only in the foot, but as an interconnected multiseg-
ment system that functions together. An alteration in one specific location can impact
the joints both above or below that segment. Table 1 summarizes the coupled
motions occurring in the lower quarter during the pronation and supination phases.
The hip adducts relative to the pelvis during the stance phase and is abducted rela-
tive to the pelvis during the swing phase.3 Thus, if the runner is on the right foot during
midstance, the right hip will be adducted, the contralateral side of the pelvis will be
lower, and the lumbar spine will be slightly side bent to the right side. This coupled
motion between the hip, pelvis and lumbar spine acts to minimize motion to the trunk
and head for balance and equilibrium.
Although some mobility here is beneficial, too much or too little may cause addi-
tional problems. Step width may influence this motion, because a crossover or
adducted gait may induce excessive pelvic drop on the contralateral side. Weak hip
 Table 1
The effects of pronation and supination on the kinetic chain

Pronation Supination
Sagittal Frontal Transverse Sagittal Frontal Transverse
Lumbosacral Extension Lat Flexion Same Side Protraction Extension Lat Flexion Opp Side Retraction
Pelvis Anterior rotation Translation and Forward rot same side Anterior rotation Translation opp side; Rear rot same side
elevation, same side depression same side
Hip Flexion Adduction Internal rotation Extension Abduction External rotation
Knee Flexion Abduction Internal rotation Extension Adduction External rotation
Ankle PF-DF Internal rotation DF-PF External rotation
STJ PF Eversion Adduction DF Inversion Abduction
MTJ DF Inversion Abduction PF Eversion Adduction
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Abbreviations: DF, dorsiflexion; Lat, lateral; MTJ, midtalar joint; Opp, opposite; PF, plantarflexion; rot, rotation; STJ, subtalar joint.
Data from Dugan SA, Bhat KP. Biomechanics and analysis of running gait. Phys Med Rehabil Clin N Am 2005;16(3):603–21; with permission.
Gait: Lab to Clinic
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abductors can cause increased hip adduction and pelvic drop (Trendelenberg). Weak
hip stability can also lead to a compensatory lateral trunk shift to move COM laterally
and limit pelvic drop. Altered hip stability recruitment patterns decrease running
economy and have been shown to be associated with injury, including patellofemoral
dysfunction.16,17 Too little motion, with little to no adduction between the hip and
pelvis, can also be problematic. Although commonly seen when sprinting all out,
this should not be a goal of typical gait. Additionally, too little motion may require
additional stabilization at the knee (high metabolic cost) or contribute to inadequate
shock transmission. For example, using a wide stance width with little coronal plane
mobility at the hip and pelvis can lead to decreased shock absorption. This positioning
could create a situation where additional forces could be transferred to the pelvis.
Problem-solving through this unique combination of gait attributes can show the
biomechanical flaws placing additional stress at the pelvis and thus contributing to
an injury such as osteitis pubis or sacral stress fractures. If the cause of this gait abnor-
mality is not corrected in the run technique, the abnormal loading pattern will persist
and conditions will become repeat or chronic.
Foot and ankle mechanics are a critical aspect of the evaluation. The foot and ankle
function as a mobile lever. Their ability to move into an open packed position (full
pronation) to absorb and dissipate shock is critical to achieve contact and avoid
excessive shock transmission up the kinematic chain. Likewise, the foot must be
able to resupinate at the correct time in push-off to maximize force transfer.
In a clinical setting, barefoot gait evaluation can yield a plethora of information about
the foot, but clinicians must be aware of the complex foot mechanics.18 In running, it is
typically taught that the foot moves from a supinated position at contact (in 6 –8
calcaneal inversion) into 6 to 8 eversion at midstance, and then immediately begins
to supinate into a more rigid state.1 This premise was based largely on using rearfoot
mobility to define the pronatory status of the foot. McPoil and Cornwall19 accordingly
note that rearfoot pronation peaks at 37.9% of stance phase of walking. Recent work
has shown that using the rearfoot to define the pronatory status of the foot may be less
specific than using a dynamic foot measurement with motion analysis. Peak
composite foot deformation does not occur until approximately 78% of stance in
walking and until 52% to 54% in running.20 Maximal deformation of the foot in the
gait cycle occurs at maximal GRF application.

KINETICS OF GAIT

Although kinematics can be visually evaluated in the laboratory and clinic, they do not
show why individuals move the way they do. Kinetics reflect the cause of movement,
and therefore the forces, power, and energy that affect the manner in which an
individual moves.21 GRFs measured with force plates imbedded in the ground or
treadmill refer to the forces that act on the body throughout the stance phase.22 Anal-
ysis of the GRFs acting on the COM is typically broken down into vertical, mediolat-
eral, and anteroposterior force plots (Fig. 4). The origin of force on the foot is
termed center of pressure (COP). Processing the COP, GRFs, and joint kinematics
together allows calculation of joint kinetics (joint moments). More specifically, joint
kinetics show how the external GRFs, inertia, and gravity interact with the internal
recruitment of muscles, tendons, ligaments, and bony structures that stabilize the
joint. Joint power indicates the velocity of the joint moment, or the rate of the work
exhibited by the muscles. Although monitoring kinetics is not possible outside a labo-
ratory setting, understanding these attributes helps clinicians appreciate why runners
move the way they do at various points in the gait cycle.
Fig. 4. Sample plot shows raw force data for individuals in the vertical, anteroposterior, and mediolateral components, respectively. All data are plotted
in percent stance, with percent body weight (BW) as the unit of measure. For the vertical ground reaction force (GRF), the first peak represents the
collision of shoe and lower leg with the ground. The magnitude of the impact varies greatly with contact style, cadence, and slope of the running
surface. The more prominent second represents active peak; this is the point in the gait cycle where external forces acting on the body are at their
peak, thus triggering maximum internal force generation of the musculotendinous structures to balance this response. Note that the active peak
Author's personal copy

on the vertical GRF always corresponds to the ‘‘0’’ point on the anteroposterior GRF as long as speed is at steady state. Data are from a sample of healthy
runners collected at the University of Virginia Center for Endurance Sport Gait Laboratory.
Gait: Lab to Clinic
355
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The vertical GRF has two distinct peaks for walking gait and one distinct peak for
running. With an average comfortable walking speed, the GRF spikes at initial contact
to form a small impact peak, and then increases through the absorption phase peak to
approximately 100% to 110% body weight, dips to approximately 80% COM in
double support, and finally increases back to approximately 100% to 110% in the
force generation phase. Thus, in walking, the typical peak vertical forces are similar
to those experienced in a single-leg stance. During running, vertical GRF spikes
sharply at contact to produce an impact peak, may slightly decrease (depending on
contact style), and then continues to an active peak of 2.2 to 2.6 times the body weight
in a typical distance runner.
The impact peak is formed through collision of the shoe, foot, and lower leg mass
with the ground. The active peak is influenced by the mass of the runner, landing
velocity, and leg stiffness.23 The presence of an impact peak, or its prominence,
can be moderated by alteration in contact style. Runners with a more pronounced
heel contact exhibit larger impact peaks, whereas sprinters or toe runners may have
no discernable impact peak. Cadence also has an effect, with increased turnover
exhibiting muted or even absent impact peaks, and decreased turnover accentuating
impact peaks.24 Cadence change has been shown to be a clinically significant compo-
nent of a plan to decrease the incidence of bone-strain–related injury.25 Gottschall and
Kram23 reported that impact force peaks were dramatically larger for downhill running
and smaller for uphill running.
Do increased impact forces lead to injury or impact performance? Hreljac26,27 is
widely cited as identifying impact peak force as the variable that distinguished injured
from uninjured runners. However, this concept has been sharply contested by Nigg,28
who states that impact forces help in pre-tension, or tuning the muscle contraction of
the leg before impact. Furthermore, some level of impact force is necessary for the
integrity of bone and cartilage.29 Nigg28 does speculate, however, that excessive
running without sufficient recovery may adversely affect the remodeling rate of
bone. Impact peak forces are comparatively small and experienced for a short time
during each gait cycle (<8% of each stance phase). Joint contact forces during the
impact peak are three to five times smaller than they are during the active force
peak, and are therefore within the normal operating ranges for joint function and
unlikely to contribute to the development of running injury.30
As depicted by the vertical GRF graphs (see Fig. 4), peak forces on the body are
sustained during midstance, not initial contact. The active force peak of the vertical
GRF reflects the number of motor units required to hold the body at a given point
and occurs at the lowest point of the COM in the stance phase.24,31–33 Decreased
active peak for the same speed means a decrease in motor unit activation and meta-
bolic demand to hold speed.32 The active peak of the GRF can be modified through
mass, velocity of the runner, and contact time.32,33 Unlike the impact peak, the active
peak is not altered with incline or decline as long as steady state velocity is
maintained.23
Midstance is the time in the gait cycle when GRFs are highest on the body, with
peak internal joint moments generating peak mechanical strain on tissues. The ability
of the runner to stabilize these forces is essential to tissue health. Dynamic screening
tests performed in single-leg stance offer a functional and running specific midstance
posture from which to evaluate stability. From a rehabilitation standpoint, challenging
a runner’s multiplane stability in single-leg stance replicates the position and phase in
gait at which it is most critical.
In addition to vertical GRF, the anteroposterior (or parallel forces) and mediolateral
GRFs are analyzed to describe the sagittal and frontal plane forces, respectively.
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Gait: Lab to Clinic 357

Assuming the runner is at steady state, the active peak corresponds to the ‘‘0’’ point
on the x axis. Any negative value will then decelerate the COM, with positive values
accelerating the COM. At steady state velocity, the time-integrated brake force equals
the propulsive force so that minimum mechanical efficiency is lost. Anteroposterior
GRF can be altered through contact style, cadence, or incline so that braking peak
increases for running downhill and decreases for running uphill. Likewise, propulsion
force increases in uphill running and decreases in downhill running.23 Excessively
elevated parallel braking forces can indicate that the individual’s COM is well behind
the foot at contact. This tendency can be remedied by encouraging a more neutral
postural alignment and foot strike closer to the COM.
Mediolateral GRF allows quantification of the path of the COM in the frontal plane.
Excessive deviation from medial to lateral (or lateral to medial) imparts excess coronal
plane forces that the runner is required to stabilize. Increased deviation in this plane is
often seen when the runner lacks adequate hip and core stability. This increased insta-
bility of COM combined with poor neuromuscular control can lead to a ‘‘downward
spiral’’ in the stance. Efforts should target identification of the biomechanical fault
and be combined with gait drills to minimize the peak deviation of COM in relation
to the stance foot.
Joint Kinetics
Quantitatively, motion laboratories use inverse dynamics to combine kinematics and
external GRF to produce joint moments and powers. The ability to conceptualize
the joint moment at each specific gait phase helps in applying a clinical and dynamic
evaluation to a gait analysis. The GRF has a given magnitude for a given gait phase.
Additionally, this vector has a point of origin or COP and direction in relation to
each joint. The location of this vector dictates what the external GRF is doing to the
joint, and what the runner is doing to counter this action. For example, during
midstance, the ankle joint is in dorsiflexion and the GRF is anterior to the ankle joint
line (Fig. 5). The GRF is imposing an external torque trying to dorsiflex the ankle, while
the runner activates the plantar flexors to generate an equal and opposite internal joint
torque to maintain position of the ankle at that particular point in time. At any instance
in stance, three factors influence the joint kinetics: (1) the magnitude of the GRF, (2) the
3D GRF location in relation to the joint, and (3) the origin of the COP (influenced by foot
contact style or compensatory foot function). Fig. 6 shows sample graphs of running
joint kinetics in healthy young adults.
The origin of COP is affected by contact style. Because rear-foot runners land on the
posterolateral border of the foot, the origin of COP initiates on the lateral aspect of the
foot and travels distal for two thirds of the stance phase before traveling medial across
the metatarsal heads and finally through the first and second rays.34 Midfoot strikers’
COP originates on the lateral midfoot, with an initial path posterior toward the base of
the foot as the rearfoot approximates the ground. After maximum foot contact, the
COP moves rapidly toward the medial forefoot. Forefoot strikers share this same
general pattern, except that the initial COP origin is even more distal on the foot.35
These described paths are typical values, but compensations can occur because of
foot mechanics. An individual who has poor forefoot stability may have an excessive
lateral to medial COP shift as he moves into propulsion phase, whereas the COP of an
individual with hallux rigidus will track more lateral and exit through the lateral forefoot.
Rise and fall of the COM occurs during walking and running; however, this action
yields different results in each task. In walking, kinetic and potential energy are out
of phase so that COM moves from its highest point in single-leg stance to its lowest
point in double-leg stance. This pendulum-like oscillation of the COM is maintained
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Fig. 5. External and internal factors that effect joint kinetics at the ankle.

by the interchange of potential and kinetic energy and, combined with a given amount
of muscle work, propels the body. During running, the body acts like a pogo stick in
that potential and kinetic energy are in phase. Potential and kinetic energy are highest
in the flight phase. Potential energy is lost as the body falls down to the ground. Kinetic
energy is lost as the foot achieves ground contact, but is stored in the musculotendi-
nous structures as elastic energy. After midstance, the tendon springs release approx-
imately 95% of their stored energy in combination with tensioning from the muscles to
generate the COM upward and thus raise potential and kinetic energy back to their
high point. This storage and rebound of the tendon units is an important component
of running gait, because they supply most of the work performed.3,36
Although the muscles act as tensioners to the tendons, they do not exhibit much of
a change in length. Rather, uniarticular muscles stabilize joints, whereas biarticular
muscles transfer energy to adjacent joints.37,38 The gluteus medius is an example of
a uniarticular muscle. The gluteus medius exhibits tension during the stance phase
to hold the pelvis stable, although it does not undergo a significant change in muscle
length. When looking at a biarticular example, the energy from one segment is trans-
ferred through the ‘‘energy strap’’ so that the energy of the femur extending over the
tibia can be transferred through the hamstrings to extend the hip in relation to the
pelvis.3
During walking, a great deal of mechanical work is dissipated at each contact point
because of collision of the foot with the ground.39,40 The contralateral trailing limb
restores this energy and the velocity of COM, but the difference must be made up
from active muscle work (significant muscle change in length) that is not seen in
running. In running, a major energy expense seems to be due to body weight support.
The overly flexed position of the knee (compared with walking) increases the joint
moment and the knee extensor demand.41,42 During running, the stiffness of the
stance leg spring may be altered as much as twofold to adapt either to cadence
changes outside the individual’s preferred frequency, or to the surface so that stability
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Fig. 6. Sample plots of joint kinetics and powers for the hip, knee, and ankle in all three cardinal planes of motion. All data are plotted in stance and
Gait: Lab to Clinic

represent a sample of healthy runners collected at the University of Virginia Center for Endurance Sport Gait Laboratory.
359
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360 Dicharry

and efficiency may be maintained across a wide variety of terrain.24 This compensa-
tion maintains COM in a somewhat consistent oscillatory path throughout a wide
range of real-world conditions, because excessive rise and fall or the excessive
minimizing of the COM has been associated with increased energy expenditure.24
Ankle, knee, and hip power patterns are similar to those in walking, except that the
amplitudes of power absorption and generation are related to the speed (greater
power for greater velocity). Ankle patterns are fairly similar to those in walking, with
the joint moment speed faster because of shorter contact time and a higher GRF.
Knee sagittal moments in running are higher than in walking. In running the knee is
more flexed throughout the stance phase, thus requiring more internal muscular
support to maintain stability through midstance. Hip sagittal plane moments are
similar to those in walking, except the amplitude is greater in running.
Arm movement has been discounted as a source of propulsion in distance running,
and said to produce only lift.43 Conversely, Novacheck and colleagues44 identifies the
arms as aiding a constant horizontal velocity through counterbalancing the rotation of
the lower extremity. The upper body is unique in that it shows gross stabilization
deficits in the lower body. An excessively wide arm swing can be a strategy to provide
additional lateral support when core/hip control is diminished. Excessive crossover of
the arms may indicate a lack of stability in the transverse plane. Although these cues
do not identify the exact cause of the imbalance, they reveal movement patterns that
may be the cause or, conversely, the compensation for the default.
Restricted hip flexors, lumbar spine extensors, thoracodorsal fascia, inadequate
core muscle support, chronic low back pain, posture dysfunction, or postural fatigue
during a run can move the runner into excessive lumbar spine extension. This
extended lumbar spine position can alter forces at the lower extremity, because the
COM tends to migrate forward with changes in trunk angle.45 Observation of the
runner ‘‘fresh’’ and also several miles into a run can reveal unique gait traits that affect
gross movement pattern dysfunction.
Additional tools can be used to obtain gait parameters: accelerometers allow
measure of loading rate of structure, dynamic electromyography allows examination
of the respective muscles responsible for internal joint moment, and monitoring
oxygen consumption allows data on the metabolic economy of gait to be collected.46
All gait technologies have their role; the key is to use the technology that can obtain the
parameters of interest.

Economy of Motion
Metabolic efficiency is often discussed in terms of physiologic training; however,
biomechanical constraints do have a role. Efficiency equals mechanical work/meta-
bolic work. Martin and Morgan47 identified four primary areas of study: body structure,
kinematics, kinetics, and biomechanical feedback/training. However, they were
unable to determine how to improve biomechanical economy. Individuals seem to
freely choose their most economic speed when walking, as shown by the inverted
U theory in Fig. 7. Between 1.1 and 1.4 m/s, a relatively flat energy curve range, is
observed. Slower speed is more metabolically costly for distance given, whereas
excessively fast walking speeds show the same trend. This fact provides evidence
that a freely chosen range of walking velocities are optimal. During running, no single
range of velocities seems as optimal, in that the faster velocity is offset by additional
distance covered. Regarding metabolic economy in running, little correlation exists
between the energy invested to cover a given distance and distance travelled. Mech-
anisms that do affect metabolic economy are believed to include stride length, stride
frequency, muscle shortening velocity, and mechanical power output. Kram and
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Gait: Lab to Clinic 361

Fig. 7. Metabolic economy of walking and running. Note the inverted U for walking and the
relatively flat curve for running energy consumption.

Taylor32 claim the two most important biomechanical constraints in running economy
are the total mechanical work done by the body to support the COM in stance, and the
inverse relationship with ground contact time (the lower the time of contact, the higher
the expenditure).
Current literature supports three critical aspects with respect to biomechanical
economy: (1) minimizing the active muscle mass recruited, (2) aligning the legs with
the net force vector, and (3) maximizing the effects of elastic recoil. Increased vertical
GRF reflects an increase in motor units to go from point A to point B at a given velocity.
Greater force equals greater metabolic cost. Decreased ground contact time mini-
mizes the change in vertical COM height, which in turn increases leg stiffness and
causes an increased peak GRF. Optimum ground contact time should be short
enough to minimize muscle work but long enough to allow for the release of elastic
recoil from the tendons.32,48 In this manner, the average force production from each
leg (the area under the curve) is maximized without increasing the peak force
produced. Furthermore, a change in the vertical component is accompanied through
a change in the horizontal component (if peak vertical GRF decreases, then acceler-
ation and braking forces also decrease).
Aligning the force vector closer to the leg decreases the external joint moment and
minimizes muscle cost.48 This function is achieved through running with straighter
limbs during the stance phase. Using straighter limbs to avoid excessive energy
loss with increased joint excursion from flight to stance-phase absorption can help
maximize the effects of elastic recoil.48 Additionally, individualized drills and neuro-
muscular activities that compliment runners’ structure will train them to use elastic
recoil in gait. Although sufficient data from multiple works reinforce these concepts,
many questions remain unanswered because of the multifactorial and complimentary
nature of gait attributes.49
Observational gait analysis, although not as specific as 3D analysis, can improve
a clinician’s ability to bridge the outcome of special tests of dynamic function in
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gait. The use of slow-motion video capture can vastly improve visualization of gait
form. Requirements include a high-quality video camera, a tripod, and video editing
software. Video software makes it possible to edit, slow, or freeze-frame footage for
specific analysis. Observational video analysis should comprise 30- to 45-second
long data collections from multiple angles: front upper body, front lower body, side
upper body, side lower body, rear full body, and posterior view from the knee down
for a closer look at the foot function. The most important thing is to be consistent
when looking at gait; each evaluation should be approached the same each time,
irrespective of diagnosis. Often the site of symptom presentation is not the location
of biomechanical fault. Altered upper body and trunk movement patterns may reflect
alteration in lateral or rotational plane instability. Special attention to the joint above
and below the symptom presentation is essential. Through the course of the video
evaluation, the observed asymmetry or gait abnormality should be correlated to the
clinical examination findings. The goal is to identify a particular biomechanical pattern
that could be affecting the individual’s symptoms.
Examining individuals dynamically provides a perspective on how they use their
combination of strength, flexibility, and muscle memory to achieve gait. Ignoring the
biomechanical cause of the imbalance will likely result in the dysfunction becoming
adopted into their repetitive gait pattern. Modern gait analysis is a tool to produce
objective, quantitative parameters that identify the source of dysfunction in an indi-
vidual or population. Understanding the concepts behind repetitive loading of running
will enable a more directed approach to diagnosis and treatment intervention.

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