Chapter 3 Biomechanics of Gait

Walking, although seemingly simple, is a complex and remarkable human movement that involves a

series of coordinated actions. This activity is characterised by the continuous changes in the ground

reaction forces, while maintaining balance and movement in a specific direction. While it might appear

effortless for most people, walking poses significant challenges for individuals with disabilities or gait

disorders, such as in patients with cerebral palsy. Learning to walk is a developmental milestone that

takes months to master. Even for healthy individuals, walking can become challenging with age.

Replicating the complexity of walking in robots, particularly maintaining balance, remains a formidable

engineering challenge. While two-legged machines can be designed to mimic walking, ensuring their

stability during movement is a persistent hurdle. Understanding and predicting human walking is

essential for various reasons. It is critical for designing prostheses and orthoses that provide support to

individuals with gait disorders, enhancing their mobility and quality of life. Moreover, it is essential for

developing functional electrical stimulation methods, which help activate muscles in individuals with

paralysis or spinal cord injuries. Controlled muscle activation at the right time and sequence can

potentially help paralyzed patients to regain the ability to walk.

3.1 Gait cycle

Understanding the gait cycle is crucial for various fields, including sports science, physical therapy,

orthopaedics, and ergonomics, since it provides valuable insights into human locomotion and can help

diagnose and treat gait abnormalities or injuries. Essentially, normal gait is characterised by a rhythmic

and alternating pattern of movements involving the trunk and limbs, resulting in the forward progression

of the body’s centre of gravity while having at least one of the feet on the ground at all times. In order

to understand the mechanics of walking, we need to look into the details of gait cycle. The gait cycle

represents a single sequence of functions performed by a lower limb during walking. It commences

when the reference foot contacts the ground and concludes with the subsequent floor contact of the

same foot.
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Figure 3.1 Different phases of the gait cycle

3.1.1 Phases of gait cycle

The gait cycle can be divided into two main phases, the stance phase and the swing phase, as shown in

Figure 3.1. The cycle typically starts with the forward propulsion of the body from the standing position

and thus propels one leg forward. During the stance phase, the foot remains in contact with the ground.

In contrast, the “swing phase” involves the period when the foot is off the ground, moving forward in

preparation for the next step. Each of these phases consists of specific events and sub-phases that

contribute to the overall efficiency and stability of walking (Figs. 3.1 and 3.2).

Stance phase: The gait cycle commences with the heel strike, the instant when one foot (right) first

touches the ground (Fig. 3.2). Simultaneously, the opposite foot (left) transitions into the swing phase,

setting the stage for coordinated movement. Following the heel strike, the foot elegantly rolls forward,

ensuring that the entire sole comes into contact with the ground. This phase, referred to as "foot flat" or

"loading response," establishes a stable foundation for weight-bearing (Fig. 3.2). At midstance, the

body's centre of gravity directly aligns over the supporting leg. This midpoint in the stance phase

signifies a moment of equilibrium and stability, crucial for the subsequent phases of walking. The next

phase, heel-off, involves the lifting of the heel. This action contributes to the forward progression of the

body. The toe off phase marks the pivotal transition from the stance phase to the swing phase (Fig. 3.2).
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During this phase, the toe of the supporting foot firmly pushes off the ground, propelling the body

forward and initiating the swing phase. The duration between heel-off and toe-off is known as push-

off.

Swing phase: With the foot (right) leaving the ground, it enters the initial swing phase (Fig. 3.2). During

this stage, the limb moves freely forward, preparing for the impending heel strike of the same foot. The

mid-swing phase is distinguished by the limb's graceful and unhindered forward swing. The knee

remains flexed during this part of the cycle, allowing continued progression of the limb. As the limb

extends its forward swing, it prepares itself for the upcoming heel strike (Fig. 3.2). The knee gradually

extends during this phase, culminating the swing phase.

In a typical gait cycle, the stance phase accounts for approximately 60 percent of the gait cycle

(Fig. 3.2). The swing phase constitutes about 40 percent of the gait cycle. Single support, when only

one leg is in contact with the ground, lasts for roughly 40 percent of the gait cycle (Fig. 3.2). Double

support, when both feet are in contact with the ground, takes up approximately 20 percent of the gait

cycle (Fig. 3.2). The double support phase is succeeded by the right single support phase, during which

only the right leg is in contact with the ground. This phase spans from 10 percent to 50 percent of the

gait cycle (Fig. 3.2). This phase is followed by another double support phase, where both legs touch the

ground, covering up to 60 percent of the cycle. The right leg then enters into the swing phase, moving

Figure 3.2: Graphical representation of the gait cycle indicating the phases and instances.
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freely through the air while the left leg supports the body's weight (Fig. 3.2). Finally, the right leg returns

to the ground in the heel strike position, completing one full gait cycle. It may be noted, however, that

the timespan of different phases within a gait cycle is not rigidly defined, since there can be variations

in gait for individuals owing to factors, such as, walking speed, terrain, and personal biomechanics.

Motion capture systems, force plates, and other advanced instrumentations have been used to precisely

measure and analyse the gait cycle, as discussed later.

3.1.2 Gait cycle parameters

The time a n d step parameters have influence on the gait cycle. The time parameters are step time,

double support time, stride time, and cadence. Step time is defined as the time taken to complete

one step, from heel strike to toe off. Double support time is the duration when both feet are in contact

with the ground, simultaneously. Whereas, the stride time is defined as the time required to complete

one full gait cycle, from one heel strike to the next. Cadence quantifies the number of steps taken

per unit of time, usually expressed as steps per minute. Typically, the cadence during normal

walking ranges from 100 to 115 steps per minute, which reflects the speed of walking.

The step parameters are step length, stride length, step width, and toe-out angle (Fig. 3.3). The

step length is defined as the distance between successive heel contacts of opposite feet, indicating how

far each foot travels during one step. In normal gait, the right step length is equal to the left step length.

The stride length defined is the distance between successive heel contacts of the same foot, spanning

the entire gait cycle. In normal gait, it is typically twice the step length. Step width measures the side-

to-side distance between the lines formed by both feet, providing information about the width of the

step and the individual's base of support. The Toe-out angle quantifies the angle at which the foot is

placed concerning the forward direction during walking, revealing the orientation of the feet throughout

the gait cycle (Fig. 3.3).

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Figure 3.3: The step parameters of a gait cycle

Let us now discuss the effect of speed on the gait parameters. When analysing the influence of

increased walking speed on various gait parameters, several observations become evident. As walking

speed increases, individuals tend to take longer steps. This is reflected in the increased stride length.

Simultaneously, the step width decreases to provide more balance, while walking at an increased speed.

At faster walking speeds, individuals naturally aim to optimize their gait for efficiency. A narrower step

width requires less lateral movement and reduces energy expenditure, making it more suitable for brisk

walking and running. With an increase in walking speed, both the step period (the time to complete a

step) and the double support period (the time when both feet are in contact with the ground) decrease.

This reduction in time for double support is intuitive, as faster walking involves less time with both feet

on the ground.

3.1.3 Basic differences between running and walking cycles

The basic differences in phases between running and walking cycles are discussed in the following.

Double support phase: In walking, there is a distinct double support phase where both feet are in

contact with the ground, simultaneously. This phase provides stability and is a key characteristic of

walking gait. In running, the double support phase essentially does not exist. There are instances during

the running gait cycle where both feet are off the ground. This absence of double support contributes

towards the continuous nature of running.

Stance to swing phase ratio: In walking, the stance phase typically accounts for the majority of the

gait cycle, roughly 60 percent. in this phase, one foot is on the ground while the other swings forward.
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In running, the ratio of stance to swing phases reverses. The stance phase becomes shorter, and the

swing phase becomes longer.

Double swing phase: In running, there is a phenomenon known as the double swing phase. During

certain instances of the gait cycle, both legs are off the ground, creating two separate swing phases as

opposed to walking's single swing phase. This characteristic sets running apart from walking and allows

for a faster and more dynamic mode of locomotion. In walking, at least one foot is in contact with the

ground at all times.

Apart from these basic differences in phases stated above, there are a lot of differences in

running and walking, such as, the ground reaction force pattern, muscle excitation joint forces and

moments. In the analysis of human gait, the centre of gravity (CoG) and the ground reaction force

(GRF) play a critical role in the mechanics of walking, details of which are discussed in the following.
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3.1.4 Ground reaction forces

Ground Reaction Force (GRF) is the

force exerted by the ground on an

individual contact with it during

activities like, walking or running.

This force is essential for generating

motion. The GRF varies during the

gait cycle, and it primarily exists

during the stance phase of walking

(Fig. 3.4). There are three

components for the GRF: vertical,

anterior-posterior, and medial-lateral

components. While the vertical

component supports the body's

weight, the anterior-posterior

component aids in forward

progression and braking during

Figure 3.4: Variations in the components of GRF during a
walking. The activation of muscles gait cycle; vertical (V-GRF), anterior-posterior (AP-GRF),

around each joint generates the and medial-lateral (ML-GRF).

medial-lateral ground reaction force.

Although there are variations in GRF in the anterior-posterior and medial-lateral directions

during the gait cycle, these variations are relatively small as compared to the predominant vertical

component of the GRF (Fig. 3.4). During normal walking, the first peak of the GRF typically occurs at

around 15 percent of the gait cycle, representing the initial impact when the foot strikes the ground (Fig.

3.4). Subsequently the second peak, occurring at approximately 48 percent, corresponds to the push-off

phase as the foot leaves the ground (Fig. 3.4). However, it may be noted that these values are subject-

specific. The variation in the direction of the GRF vector will be discussed in Section 3.2.1.
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3.1.5 Centre of gravity

The centre of gravity (CoG) is a point in the human body through which the total body weight of a

person or object is considered to act. It is typically located around the midsection of the body,

approximately at the level of the navel or belly button (Fig. 3.5). In gait analysis, it is crucial to optimize

the path of the CoG in order to minimize energy consumption. The

most efficient gait pattern involves the CoG traveling in a straight

line during the gait cycle. The line of gravity is an imaginary vertical

line that extends from the CoG to the supporting surface,

representing the force of gravity acting on the body. Maintaining the

CoG within the base of support is preferred for stability and

efficiency. During various postures and movements such as,

forward bending or leaning backward, the location of the CoG may

shift outside the base of support, affecting balance and requiring

Figure 3.5: Location of centre
additional muscular effort to maintain stability. of gravity; (a) actual, (b)
projection on the base of
3.1.6 Moment arm of ground reaction force support.

GRF can create moments (torques) about the joints in the body such as, the hip, knee, or ankle. These

moments are influenced by the distance (moment arm) between the joint centre and the line of action

of the GRF. Muscles around the joints must generate opposing moments to counteract the moments

created by GRF, thereby maintain balance and control joint motion. For example, when the GRF is

posterior to the ankle joint (at heel strike), it

creates a clockwise moment about the ankle

joint centre C, as shown by GRF 1 in Figure

3.6. As the foot flattens and the GRF passes

through the ankle joint centre C, the moment

decreases (GRF 2 in Fig. 3.6). In contrast,

during toe-off, the GRF is anterior to the

ankle joint centre C, creating a counter- Figure 3.6: Ankle moment during a gait cycle.
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clockwise moment (GRF 3 in Fig. 3.6). The magnitude of these moments depends on the distance

between the GRF and the ankle joint centre C, as presented in Figure 3.6. Greater distances result in

larger moments, requiring more muscular effort to counterbalance and control joint motion. These

variations in ankle moments during a gait cycle highlight the dynamic nature of walking and the

continuous adjustments made by the musculoskeletal system to maintain balance and forward

progression. Muscles around the ankle joint must generate appropriate forces to counteract these

moments and ensure smooth and controlled motion throughout the gait cycle.

3.1.7 Determinants of gait cycle

Human locomotion is a complex phenomenon, involving numerous simultaneous movements in 3D

spatial coordinate system, making it challenging to analyse without a unifying principle. The unifying

principle is based on the concept that locomotion involves the movement of the centre of gravity (CoG)

along the most energy-efficient path. Moreover, this understanding allows for a qualitative analysis of

the key factors that determine gait. The six main determinants are pelvic rotation, pelvic tilt, knee

flexion during stance, knee and foot mechanisms, and lateral pelvic displacement. These determinants,

work in a synergistic way to ensure that, during locomotion, the centre of gravity traverse through space

along a smooth pathway requiring the least energy expenditure. Saunders et al. (1953) suggested that

gait disorders can be analysed in terms of changes in these primary determinants so that the therapeutic

interventions can be applied to correct the disorders. Before we discuss the gait determinants, let us

comprehend the meaning of “displacement of CoG”.

The path described by the CoG, during normal walking of a healthy person, is similar to a

smooth sinusoidal wave (Fig. 3.7). It is evident from Figure 3.7a that the COG is displaced twice along

the vertical direction (inferior-superior direction) and the total vertical displacement is approximately

equal to 1.8 inches (Saunders et al., 1953). However, this value can vary for different individuals based

on the body height. The peaks in the oscillation of this vertical displacement occurs at mid-stance (30%

of gait) and mid-swing (80% of gait). In contrast, during the double support (at 55% of gait cycle), the

CoG achieves its lowest vertical position. Even at the peak of vertical displacement, the CoG lies

slightly below the level corresponding to that of standing. In simpler words, one may appear to be
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slightly shorter during walking than during standing. Similar to vertical displacement, the CoG traverses

along the medial-lateral direction (Fig. 3.7b). and along the anterior-posterior direction (Fig. 3.7c). The

total medial-lateral displacement is approximately equal to the total vertical displacement (Saunders et

al., 1953). However, the frequency of the variation in medial-lateral displacement is equal to that of gait

whereas it is twice in the case of vertical displacement and anterior-posterior direction (Fig. 3.7).

Figure 3.7: Variation in the displacement of CoG along different directions during a gait cycle; (a)
vertical, (b) medial-lateral, (c) anterior-posterior. Adapted from Saunders et al. (1953) and Jansen et
al. (2014). The values in this figure are for the sake of representation only and can vary for different
subjects.
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In order to understand the effect of

various determinants on the path traversed by

CoG, we need to first discuss a hypothetical

gait known as compass gait. Compass gait is

characterised by the minimal knee bending

(knee remains relatively straight), where the

pelvis moves through a series of arches,

centred at the ground contact point and with a

radius equal to the leg's length (Fig, 3.8). In

Figure 3.8: Illustration of compass gait. The pelvis
Figure 3.8, sharp inflexion points exist at the
is denoted by a single bar with a small cuboid
intersection of the arcs, which would lead to representing CoG of the body. The pathway of CoG
is a series of interconnecting arcs. The legs are
abrupt change in the direction of forward
represented by rigid bars articulating only at the hip.
acceleration. Consequently, according to the

Newton’s 1st law of motion, greater force will be required for sudden changes in acceleration, resulting

in increased energy expenditure. Moreover, the vertical displacement of the CoG associated with the

compass gait is almost double as compared to the normal gait.

1st Determinant: Pelvic rotation

Pelvic rotation is associated with hip

movement, specifically internal and

external rotation during the stance phase.

On average, the magnitude of this

rotation is approximately 4 degrees on

either side of the central axis. The pelvic

rotation results in flattening of the path

of CoG by elevating the lower

Figure 3.9: Effect of pelvic rotation on path of CoG.
extremities of the arc (Fig. 3.9). The dotted line within the box denotes the path of
compass gait.
Consequently, the angle of inflection at
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the intersection of arcs is reduced resulting in lesser energy expenditure.

2nd Determinant: Pelvic tilt

In the gait cycle of a healthy person, the pelvis is tilted downwards on the contralateral limb, which is

known as positive Trendelenburg. Since the pelvis is tilted downwards, the knee joint of the

contralateral limb must flex to provide enough clearance for the swing phase. The pelvic tilt results in

a relative adduction of the limb in the stance phase and relative abduction of the limb in the swing

phase. Unlike the effect of pelvic rotation, the peak of the arc is lowered due to the pelvic tilt, resulting

in flattening of the path of CoG.

3rd Determinant: Knee flexion in the stance phase

During heel strike, the knee joint executes full extension. Thereafter, the knee joint undergoes flexion

and continues until foot flat. Later, the knee undergoes extension again, which is immediately followed

by flexion during heel-off. This extension-flexion-extension-flexion period occurs during the stance

phase and is also called as “double knee lock”. The peaks in the path of CoG is lowered by the knee

flexion, resulting in reduced energy expenditure during gait.

4th and 5th Determinants: Foot and knee mechanisms

In order to comprehend the role of foot and knee mechanisms on smoothing the pathway of CoG, let us

draw two intersecting arcs as shown in Figure 3.10. The effect of the foot rotations on the displacement

patterns of knee and CoG is presented in Figure 3.10. The angular displacements of the ankle, foot and

knee are related and they have a major role in reducing the energy expenditure during a gait cycle. The

first arc is defined with respect to the initial stages of stance phase (Fig. 3.10). This arc is traced as the

ankle rotates with respect to the point of heel strike. The second arc is made by the foot rotating about

a point at the fore-foot, during the later stages of stance phase. During heel contact, the foot is

dorsiflexed and the knee joint is fully extended, such that the lower limb is as long as possible. Thereby,

the centre of gravity (CoG) reaches its lowest vertical position. The rapid plantarflexion of the foot,

along with the initiation of knee flexion, helps to maintain the CoG at roughly the same level as it moves

forward, slightly flattening and subsequently reversing the curve (path traced by the CoG). Similarly,
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the knee flexion during heel-off facilitates the flattening and slight reversal of the curve. By smoothing

out the abrupt inflexions at the point of intersection of the arcs, a sinusoidal path is established that

reduces energy expenditure and results in a smoother gait.

6th Determinant: Lateral displacement of pelvis

The CoG of the body displaces laterally during the gait cycle, as discussed earlier (Fig. 3.7b). This

displacement is produced by lateral shift of the pelvis or by relative hip adduction (Saunders et al.,

1953). The amount of lateral displacement would have been more if the limbs in the human body were

parallel to each other. The tibiofemoral angle, along with the relative hip adduction, avoid the case of

parallel limbs and thereby reduces the lateral displacement (Saunders et al., 1953). This in turn,

smoothens the gait as well as reduces the energy expenditure.

Figure 3.10 Effect of foot rotation on the displacement patterns of knee and CoG.
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3.2 Gait analysis

Let us now explore the details of gait analysis. Gait analysis is a critical component of biomechanics

and is used to assess and study human walking patterns. It provides valuable insights into the forces and

movements that influence walking. Several key factors are important in gait analysis, as outlined below:

• Gravity Force: This force represents the weight of the body and acts vertically downward. It is a

constant force that influences the body's motion during walking.

• Muscle Forces: Muscles play a crucial role in generating the forces needed for walking. Muscle

controls the joint movements and provide propulsion during each instance of the gait.

• Inertia Forces: Inertia is the resistance of an object to changes in its state of motion. In gait analysis,

inertia forces come into play as the body accelerates and decelerates during walking.

• Mass of the Body: The mass of each body segment, including the arms, legs, and trunk, affects how

the body moves and responds to external forces. It is a key factor in calculating moments and

accelerations during walking.

• Ground Reaction Forces: These forces are exerted by the ground on the body and are essential for

maintaining balance and forward motion during walking. Ground reaction forces act in the opposite

direction of the gravity force and vary throughout the gait cycle.

When a person is standing, the ground reaction force is equal in magnitude to the person's weight but

acts in the opposite direction to the force of gravity. This balance of forces is crucial for maintaining an

upright stance. During walking, the ground reaction forces change continuously as each foot alternates

between the stance and swing phases of the gait cycle. Gait analysis involves measuring and quantifying

these forces and movements to understand how they contribute to normal and abnormal walking

patterns. It is used in different fields, including orthopaedics, sports science, physical therapy, and

biomechanical research, to diagnose and to treat gait abnormalities, design assistive devices, and to

improve rehabilitation strategies.

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3.2.1 Variation of ground reaction force during gait cycle

Understanding the variation in ground reaction force (GRF) throughout a gait cycle is essential

for comprehending human walking. As discussed in Section 3.1.4, the vertical component is the

largest component which has a peak value more than bodyweight during gait cycle. It is worth

mentioning that gait analysis often focuses on the two force components in a two-dimensional plane,

Figure 3.11: Variation of ground reaction force vector during the stance phase of gait cycle

neglecting the medial-lateral component.

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The line of action of the GRF vector varies during the stance phase of a gait cycle, as presented

in Figure 3.11. In contrast, the GRF is not present during the swing phase, since the leg is not in

contact with the ground. Understanding the timing and magnitude of these forces is important for

evaluating and diagnosing gait abnormalities and optimizing walking patterns. Moreover, the alignment

of the GRF vector is crucial in maintaining balanced and efficient movement during walking. In healthy

individuals, the GRF vector passes close to the body's centre of gravity, contributing to smooth and

coordinated gait. However, in individuals with gait disorders or

abnormalities, the GRF vector deviates from the ideal alignment,

passing outside the body, as shown in Figure 3.12. This deviation

increases the moment arm or lever arm, which is the

perpendicular distance from the joint axis to the line of action of

the force vector. This misalignment leads to considerable increase

in moment or torque around the joints owing to the deviation of

the GRF vector from its normal path through the body.

A larger moment arm leads to a greater moment or torque

created by the GRF. In order to maintain balance and prevent

falls, the body's muscles must counteract the increased moments, Figure 3.12: Effect of the alignment
of GRF on the lever arm; Moment
caused by the misalignment of the GRF. However, the muscles arms are denoted by r1, r2, and r3,
respectively. The GRF’ vector
have relatively small moment arms, meaning they exert their
corresponds to the ground reaction
force closer to a joint. In order to counteract the larger moments force vector of a person with gait
abnormality.
created by the misaligned force vector, muscles need to exert

considerably greater force. Hence, gait disorders that cause deviations in the alignment of the GRF

vector can lead to increased joint moments. In order to compensate for these moments and maintain

stability, muscles must generate more force, which can be challenging and may result in fatigue and

difficulty in walking. The deviations in GRF and joint moments in individuals with pathological gait,

in particular for cerebral palsy patients, are notable and can have a substantial impact on their gait

patterns and overall mobility.

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Ground reaction force in cerebral palsy patients: In patients with cerebral palsy, the vertical

component of the GRF during the gait cycle differs markedly from that of normal individuals. This

discrepancy is evident in Figure 3.13, where different gait patterns of cerebral palsy patients (crouch,

recurvatum, jump, and mild) are compared with the ground reaction force of a normal gait (blue line).

Cerebral palsy patients often exhibit higher peak values and deviations in the vertical component of the

GRF as compared to the normal gait. Different gait patterns in cerebral palsy patients result in distinct

deviations in the GRF. For example, the "jump" pattern (represented by a triangle) shows a considerable

difference in the GRF in comparison to the normal gait (Fig. 3.13).

Joint moments in cerebral palsy patients: Joint moments, specifically plantar dorsiflexion moments,

are also affected in patients with cerebral palsy. These joint moments play a crucial role in controlling

movement during walking. In patients with cerebral palsy, misalignment of the GRF leads to longer

moment arms, which in turn increase the joint moments around the hip, knee, or ankle joints. In order

to maintain balance and stability while walking, muscles must generate additional force to counteract

the increased joint moments. This compensation is necessary to prevent falls and maintain mobility.

Different gait patterns of cerebral palsy patients lead to varying degrees of deviations from the normal

joint moment curve (Fig. 3.13).

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The common gait abnormalities of the knee in cerebral palsy patients can be classified into four

types: jump, crouch, recurvatum, and mild (Sutherland and Davids, 1993; Lin et al., 2000). Jump gait

was characterised by increased knee flexion in early stance phase, through initial double support, with

correction of the knee motion to normal or near normal extension in mid-stance and late-stance. In

crouch gait, there was increased knee flexion through the stance phase. Recurvatum gait described

increased knee extension in mid-stance and late-stance phase. The mild group was defined as those who

walked better than the other three groups and closer to the normal motion (Lin et al., 2000). The cerebral

palsy patients experienced deviations in ground reaction forces and joint moments during walking due

Figure 3.13: Effect of gait abnormalities in cerebral palsy patients on, (a) vertical component of
GRF, (b) ankle joint moments (adapted from Lin et al., 2000).
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to the altered mechanics of their gait. These deviations require increased muscle forces to maintain

stability, which can result in unique gait patterns and challenges in mobility.

3.2.2 Gait abnormalities

Let us look into common forms of gait abnormalities and their associated characteristics:

1) Antalgic gait: When an individual experiences pain in one limb, there is a tendency to adjust the

gait to reduce the amount of weight-bearing on the affected side, thus minimizing pain. In order to

reduce the muscle activation surrounding the affected side and thereby minimize the joint

compression, the patient tend to lean over the affected side. This altered gait pattern is called as

antalgic gait. The term "antalgic" is derived from the Greek words "anti" meaning against and

"algia" meaning pain. This gait abnormality shortens the stance phase of the affected side as

compared to that of unaffected. Common causes of this gait abnormality are osteoarthritis,

rheumatoid arthritis, tendinitis.

2) Trendelenburg gait: This gait abnormality

is characterised by the trunk shift over. Let

us assume that a patient is suffering from

weakened abductor muscle on his left side

(Fig. 3.14). During the stance phase on left

lower limb, weakened abductor muscles

allow the pelvis to tilt down on the right

side. In order to compensate this muscle

weakness, trunk rotates to the weakened

side thereby reduces the demand on

Figure 3.14: Illustration to explain Trendelenburg
abductor muscle to maintain a level pelvis
gait (a) pelvic tilt in normal gait, (b) excessive
pelvic tilt in Trendelenburg gait.
(Fig. 3.14). Common cause of this gait

abnormality is weak hip abductor muscles (gluteus medius and gluteus minimus).
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3) Ataxic gait: This gait abnormality causes irregular steps that affect one’s ability to walk in a straight

line when walking heel-to-toe. This gait is common in patients with cerebellar ataxia (damage to

the cerebellum).

4) Propulsive gait: Propulsive gait is a type of walking pattern characterised by a forward-leaning

posture. The steps in a propulsive gait are often short and shuffling, with the feet being dragged

along the ground. This gait abnormality is often associated with neurological conditions, such as

Parkinson’s disease, that affects movement and posture control.

5) Scissors gait: As the name suggests, this gait abnormality is characterised by the scissor-like gait

pattern. The knees and thighs tend to hit or cross each other, while walking. This type of gait usually

affects patients with spastic diplegia cerebral palsy.

6) Spastic gait: Spasticity is abnormal muscle tightness due to prolonged muscle contraction. Spastic

gait is a consequence of walking with a stiff leg. When attempting to lift this stiff leg while walking,

it either drags or moves in a semi-circular motion (known as circumduction). This gait pattern is

frequently observed in patients with cerebral palsy, multiple sclerosis, or hemiplegia.

3.3 Gait measurement techniques

Gait analysis provides valuable insights into various aspects of gait, including its use in detecting and

monitoring disorders and diseases. This is particularly relevant for identifying pathological gait owing

to neurological conditions such as Parkinson's disease or musculoskeletal problems like arthritis and

tendonitis. Moreover, gait analysis is instrumental in addressing age-related changes in gait patterns,

which affect a large portion of the population. Additionally, it plays a pivotal role in the development

of prosthetics and orthotics, offering support and rehabilitation for individuals with gait disorders.

Clinical gait analysis serves as a comprehensive approach in understanding gait anomalies,

enabling early disease diagnosis and facilitating treatment of patients through rehabilitation, and

evaluating pathologic gait and athletic performance. Traditionally, gait analysis relied on subjective

methods involving therapist observation and judgment. While these methods provide valuable

qualitative information about a patient's gait, they lack the precision and objectivity offered by modern
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techniques. Another traditional method involves plantar pressure monitoring, which offers insights into

plantar pressure distribution but cannot capture gait parameters during the swing phase. Overall, these

subjective methods raise concerns about accuracy and precision, posing challenges for precise

diagnosis, follow-up, and treatment of gait disorders.

Advancements in technology have introduced objective techniques for gait analysis. These

techniques offer enhanced measurement accuracy and precision, using non-wearable and wearable

sensors to collect reliable data on various gait parameters. The availability of extensive data enables the

diagnosis and tracking of gait abnormalities, effectively. Objective techniques are categorized into non-

wearable sensors and wearable sensors, with the former including systems like imaging devices and

force sensors. The non-wearable system requires the use of controlled research facilities, where the

sensors are located in a laboratory setup to capture data on patient’s gait. Whereas, wearable sensor

systems capture data on the gait of a patient's everyday activities outside a gait laboratory. Therefore,

it can be carried out anywhere and t h e data can be a n a l y s e d later. A third type of hybrid system uses

a combination of both non-wearable sensor and wearable sensors. The following section provides an in-

depth overview of non-wearable sensor systems used in gait analysis. These systems extract various

gait parameters through digital image processing and floor sensors.

3.3.1 Image processing systems

A typical image processing system comprises of one or more optical sensors employed to collect data

pertinent to gait analysis. Various image processing methods such as silhouette-based, optical flow

analysis, depth-based methods are employed for gait analysis. In this section, depth-based or range

imaging system is discussed in detail. It encompasses techniques employed to compute and generate a

distance map from a given viewpoint (Jain et al., 1995). These techniques enable the extraction of vital

elements of the image with improved efficiency and real-time processing speed.

In gait analysis, range imaging systems contribute to the extraction of depth-related features

and enhance the accuracy of gait parameter measurements. It includes methods like time of flight,

stereoscopic 3D, and structured light to measure the distance of objects from a viewpoint, enabling the

creation of 2D representations with depth information. Other methods are laser range scanners and
 22

infrared thermography.

Time-of-flight system: Utilizing infrared light, this system determines the depth information by

measuring the time it takes for an emitted signal to return after being reflected by an object. It calculates

distance based on the speed of light and the time difference between signal emission and reception.

Stereoscopic vision system: This system uses a stereo camera setup with two or more image sensors

to simulate human binocular vision, enabling depth perception. It relies on finding corresponding points

in different images and calculates depth based on similar triangles between optical sensors, light

emitters, and object in the scene.

Structured light system: This method involves projecting structured light patterns onto objects to

capture their 3D topography using a 2D imaging camera. Well-known examples include the Microsoft

Kinect sensor, which reconstructs object shapes based on 3D surface patterns.

3.3.2 Floor sensor systems

The floor sensor systems utilize sensors positioned along the floor on designated 'force platforms.' These

platforms measure gait information through pressure sensors and ground reaction force sensors (GRF).

Force plates and force platform: These sensors measure GRF exerted by the feet during contact with

the ground. They can also provide essential data on moments required for gait analysis. Force plates are

often arranged in as platform (Fig. 3.15).

Figure 3.15: Force platforms embedded in the walkway. Adapted from Baptista et al. (2023)
 23

Pressure measurement system: These systems involve sensors that quantitatively measure foot

pressure distribution during the stance phase

of walking (Fig. 3.16). They identify

discrepancies in plantar pressure profiles

between the left and right feet, aiding in the

assessment of gait characteristics. However,

they do not measure the horizontal or shear

components of applied forces. Pressure

measurement systems and force platforms can

Figure 3.16: Plantar pressure distributions and the
quantify the centre of pressure. location of centre of pressure (Wang et al., 2019).

3.3.3 Wearable sensors

Gait analysis utilizing wearable sensors involves the placement of these devices on different anatomical

locations of the patient's body, such as the feet, knees, or hips, to quantify diverse characteristics of

human gait. A brief overview of the most commonly used sensors are outline below.

• Inertial Sensors: These sensors measure specific forces, angular rate of movement, and body

orientation using a combination of accelerometers, gyroscopes, and magnetometers.

• Pressure sensing insoles: Pressure sensors are embedded within footwear to measure the

distribution of foot pressure during the stance phase of walking, providing valuable insights into

weight-bearing patterns and gait abnormalities.

• Electromyography (EMG): EMG sensors record the electrical activity generated by skeletal

muscles. They can be used non-invasively with surface electrodes or invasively with wires or

needle electrodes to analyse muscle activity.

• Ultrasound and Ultra-Wideband: These sensors are employed to measure the stride length and the

distance of separation between feet, providing additional gait parameters.

• Goniometers: These sensors are used to measure joint angles. Several types of goniometers are

available based on the working principal. One of them is strain gauge-based goniometers, where

the change in resistance is based on flexion, thus providing information about joint movement.
 24

Wearable sensor systems offer the advantage of capturing gait data in real-world environments,

enabling a more comprehensive understanding of an individual's gait as compared to non-wearable

sensors. These sensors can be particularly useful for monitoring patients' progress during rehabilitation,

evaluating sports performance, and identifying gait abnormalities outside of controlled laboratory setup.

3.3.4 Motion capture systems: marker-based versus marker-less

The measurement of human motion stands as one of the most intriguing yet formidable challenges. This

section delves into optical motion tracking solutions. Such solutions can be broadly classified into two

categories: marker-based systems and marker-less systems.

Marker-based motion capture system: Marker-based systems use reflective markers placed

strategically at specific anatomical landmarks of human body (Fig. 3.17). These markers serve as

tracking points for capturing motion data. The position of these markers is recorded using a calibrated

multi-camera system. This approach enables

the tracking of intricate body movements,

including joint positions and body segment

orientations. Due to factors like cost,

complexity, and the requisite technical

expertise required for operation, marker-

based systems are primarily employed in

specialized laboratories, particularly for

clinical rehabilitation and other specific Figure 3.17: Marker-based motion capture system.
(Source: Cerfoglio et al., 2021)
applications.
 25

Marker-less motion capture system: Over the past decade, significant interest has been directed

toward marker-less solutions. These systems aim to alleviate the cost and operational complexities

associated with marker-based counterparts while simplifying the motion capture process. Marker-less

systems typically employ depth-sensing camera systems, often referred to as RGB-D cameras, capable

of capturing both colour and depth information. A prime example of such a camera system is the

Microsoft Kinect. In Figure 3.18, four cameras are presented, which are used in the motion capture

system. In addition, the subject is trying to climb rehabilitation stair (Fig. 3.18). Marker-less systems

find extensive use in clinical and biomechanical research, however, they do come with notable

limitations. These limitations encompass a shorter measurement range, sensitivity to bright sunlight,

and potential interference between multiple sensors. Most crucially, marker-less systems tend to exhibit

a lower accuracy and precision in motion tracking as compared to the marker-based systems, which

remain the gold standard in 3D gait measurement.

Figure 3.18: Marker-less motion capture (mocap) system (Source: Columbo et al., 2013).
 26

Let us now explore the details of a typical marker-based motion capture system. A

comprehensive setup is illustrated in Figure 3.19, showing two infrared cameras, mounted on the

ceiling. In the central area of the walkway, four force plates are embedded into the floor (Fig. 3.19).

Additionally, the system employs fourteen reflective markers, indicated by the white circles in Figure

3.19. These markers are strategically placed on the subject's body to capture the movements accurately.

Essentially, a typical marker-based motion capture system uses multiple cameras, reflective markers,

and an integrated force platform or instrumented walkway. The marker data is meticulously recorded

and stored in a file, comprising the x, y, and z

coordinates of each marker at every sample

point, offering precise gait analysis at any given

instance during the data acquisition. The

Cartesian Coordinate System (CCS) for each

adjacent body segment (for a particular joint)

involves defining axes based on palpable or X-

ray identifiable bony landmarks. The common

origin, shared by both the CCSs, serves as the

reference point for determining the linear

translation in the joint (Fig. 3.20). Subsequently,

the Joint Coordinate System (JCS) is established

Figure 3.19: Motion capture system with reflective
based on the two CCSs. Two of the JCS axes are markers (white), infrared cameras and force plates.
(Adapted from Naruse et al., 2017)
fixed to the body and one remains 'floating'.

Finally, the joint motion, encompassing three rotational and three translational components, is

determined based on the JCS (Wu et al., 2002). In the case of a hip joint, the bony landmarks used are

as follows:

• anterior superior iliac spine (ASIS)

• posterior superior iliac spine (PSIS)

• femoral epicondyle (FE)

 27

Based on the bony landmarks, the coordinate system of the pelvic bone is defined as follows:

(a) The X-axis is formed by the line, parallel to a line

lying in the plane defined by the two ASISs and the

midpoint of the two PSISs (Fig. 3.20). The positive

X-direction points anteriorly.

(b) The Z-axis is formed by the line connecting the

two ASISs. Positive Z-direction points laterally .

(c) The Y-axis is formed by the line perpendicular to

the X- and Z-axis. Positive Y-axis points cranially.

The origin of the pelvic coordinate system coincides

with the hip centre of rotation, which is generally

considered to be same as the centre of hip joint (Fig.

3.20).

In the case of femur, the coordinate system is defined

as follows:

(d) The y-axis is formed by the line joining the Figure 3.20: Hip joint coordinate system;
pelvic coordinate system (XYZ), femoral
midpoint between medial and lateral FEs and the coordinate system (xyz), and the JCS for the
right hip joint (e1 e2 e3).
origin. Positive y-direction points cranially.

(e) The z-axis is formed by the line perpendicular to y-axis, lying in the plane defined by the origin and

the two FEs. Positive z-direction points laterally.

(f) The x-axis is formed by the line perpendicular to the y- and z-axis. The positive y-axis points

anteriorly (Fig. 3.20).

The hip joint coordinate system is formed with two fixed axes (e 1 and e 3 ) and one floating axes (e 2 ).

Here e 1 coincides with the Z-axis of the pelvic coordinate system, e 3 coincides with the y-axis of the

femur coordinate system. The floating axis, e 2 coincides with axis perpendicular to e 1 and e 2 . The

flexion/extension and mediolateral translations are defined using e 1 , whereas the internal/external
 28

rotation and proximo-distal translation are defined based on e 3 . The e 2 is used to define the

abduction/adduction and antero-posterior translation. After acquisition of the marker data using the

motion capture system, kinematic and kinetic analyses are carried out, which has been discussed later

in Chapter 4.

Marker-based motion capture, though regarded as the gold standard owing to its rich body of

literature, non-invasive nature, and high accuracy, comes with its own set of challenges. One notable

challenge is its susceptibility to soft tissue artefact. Soft tissue artefact corresponds to the error

associated with the relative motion between the region of skin upon which the markers are attached and

the underlying bone. This may arise due to the muscular contractions, skin movement and inertial effects

(Cappozzo et al., 1996). The magnitude of error associated with soft tissue artefacts depends on the

physical characteristics of the subject, marker locations, and the movement involved (Holden et al.,

1997; Schwartz et al., 2004; Fuller et al., 1997).

Among other motion capture systems, the biplanar fluoroscopic imaging system stands out as

an advanced technology that allows for the simultaneous capture of X-ray images in two planes.

Moreover, this technique eliminates the skin movement artefacts associated with the marker-based

movement capture systems. It permits the capture of high-quality digital images, providing detailed

insights into skeletal kinematics and joint motion during dynamic physical tasks (Taylor et al., 2011).

This system has been employed in a range of medical fields, including orthopaedics, spinal surgery, and

joint kinematics analysis, because of its high precision in estimating joint kinematics during natural

movements (Phan et al., 2018). Although this technology provides valuable insights in joint kinematics;

the associated radiation risks have been a major limitation.

 29

References

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reaction forces. Res. Biomed. Eng., 39: 915–924.

Cappozzo, A., Catani, F., Leardini, A., Benedetti, M. G., and Croce, U. D. (1996). Position and
orientation in space of bones during movement: Experimental artefacts. Clin. Biomech., 11(2):
90–100.

Cerfoglio, S., Galli, M., Tarabini, M., Bertozzi, F., Sforza, C., and Zago, M. (2021). Machine learning-
based estimation of ground reaction forces and knee joint kinetics from inertial sensors while
performing a vertical drop jump. Sensors (Basel, Switz.), 21(22): 7709.

Colombo, G., Facoetti, G., and Rizzi, C. (2013). Virtual testing laboratory for lower limb prosthesis.
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pin-mounted markers. Hum. Mov. Sci., 16(2-3): 219–242.

Holden, J. P., et al. (1997). Surface movement errors in shank kinematics and knee kinetics during gait.
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Jansen, K., De Groote, F., Duysens, J., and Jonkers, I. (2014). How gravity and muscle action control
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Lin, C. J., Guo, L. Y., Su, F. C., Chou, Y. L., and Cherng, R. J. (2000). Common abnormal kinetic
patterns of the knee in gait in spastic diplegia of cerebral palsy. Gait Posture, 11(3): 224–232.

Phan, C. B., Nguyen, D. P., Lee, K. M., and Koo, S. (2018). Relative movement on the articular surfaces
of the tibiotalar and subtalar joints during walking. Bone Joint Res., 7(8): 501–507.

Naruse, H., Fujisawa, T. X., Yatsuga, C., Kubota, M., et al. (2017). Increased anterior pelvic angle
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Saunders, J. B., Inman, V. T., and Eberhart, H. D. (1953). The major determinants in normal and
pathological gait. J. Bone Joint Surg. Am., 35-A(3): 543–558.

Schwartz, M., Trost, J. P., and Wervey, R. (2004). Measurement and management of errors in
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Sutherland, D. H., and Davids, J. R. (1993). Common gait abnormalities of the knee in cerebral palsy.
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Taylor, K. A., Terry, M. E., Utturkar, G. M., et al. (2011). Measurement of in vivo anterior cruciate
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Multiple Choice Questions (MCQ):

1. The lateral distance between the lines of the two feet is called as ________

A) Walking base

B) Step length

C) Stride length

D) Compass gait

2. The distance between successive instants of heel contact (strike) of the same foot is called
_____________.

A) Step length

B) Stride length

C) Walking base

3. Swing phase constitute____% of the gait cycle.

A) 60

B) 40

C) 20

D) 15

4. What happens to the time duration of swing phase when the walking speed increases?

A) Increases

B) Decreases

C) Remains constant
 32

5. The energy consumption in gait cycle is _________ when the centre of gravity (CoG) of the body
follows a straight line.

A) Maximum

B) Minimum

C) Unaltered

6. The human gait has _______ determinants to minimize energy expenditure.

A) 3

B) 4

C) 6

D) 7

7. The ratio of the time frame of stance phase to swing phase reverses during running as compared to
normal walking.

A) True

B) False

8. When the ground reaction force of gait disorder patients passes outside the body, the moment arm
around the joints __________.

A) Increases

B) Decreases

C) Remains same.
 33

9. Clinical gait analysis involves ____ measurement/(s).

A) Objective

B) Subjective

C) Both objective and subjective

10. _________ technique is used for recording the electrical activity produced by skeletal muscles

A) Inertial Measurement Unit

B) Electromyography

C) Goniometry

11. Which of the following is a non-wearable sensor system?

A) Goniometer

B) Force Plate

C) Wireless EMG

D) Accelerometer

12. Which is a major limitation of marker-less system for optical motion tracking?

A) Short-range and inoperability in bright sunlight

B) Requiring a controlled environment

C) Artefacts from skin movement

13. The single support phase constitute approximately____% of the gait cycle

A) 60

B) 40

C) 20

D) 30
 34

14. While running, _________ phase/(s) exist.

A) Double swing

B) Double support

C) Both double swing and double support

15. By reducing walking base, the lateral displacement of centre of gravity is _______.

A) Reduced

B) Increased

C) Unaltered

Answer key to the MCQs:

1. A; 2. B; 3. B; 4. A; 5. B; 6. C; 7. A; 8. A; 9. C; 10.B; 11. B; 12.A; 13. B; 14. A; 15. A.