The definition of the gait cycle is based on a reference extremity (for example, the right foot) from a defined event such as heel contact until the next occurrence of that event (contact with the heel of that same foot). The gait cycle is often based on 100% and can be further broken down into the stance phase and the swing phase (Fig. 14-1). The stance phase is defined as the portion of the gait cycle where the foot is in contact with the ground whereas the swing phase is the portion where the foot is off the ground. A step is defined as contact on one foot until contact with the other (right to left or left to right). A stride is defined as contact with the one foot until contact with the same foot (right to right or left to left). The stance phase of the gait cycle is typically about 60% of the gait cycle, whereas the swing phase is about 40% (see Fig. 14-1). The reason why the stance and swing phases are not 50% is due to the relatively short period of double support (10%) within the gait cycle. This small portion of support phase is the period where the weight is transferred from one limb to the other.

Fig. 14-1 Terminology to describe the events of the gait cycle. Initial contact corresponds to the beginning of stance when the foot first contacts the ground at 0% of gait cycle. Opposite toe off occurs when the contralateral foot leaves the ground at 10% of gait cycle. Heel rise corresponds to the heel lifting from the ground and occurs at approximately 30% of gait cycle. Opposite initial contact corresponds to the foot contact of the opposite limb, typically at 50% of gait cycle. Toe off occurs when the foot leaves the ground at 60% of gait cycle. Feet adjacent takes place when the foot of the swing leg is next to the foot of the stance leg at 73% of gait cycle. Tibia vertical corresponds to the tibia of the swing leg being oriented in the vertical direction at 87% of gait cycle. The final event is, again, initial contact, which in fact is the start of the next gait cycle. These eight events divide the gait cycle into seven periods. Loading response, between initial contact and opposite toe off, corresponds to the time when the weight is accepted by the lower extremity, initiating contact with the ground. Midstance is from opposite toe off to heel rise (10% to 30% of gait cycle). Terminal stance begins when the heel rises and ends when the contralateral lower extremity touches the ground, from 30% to 50% of gait cycle. Pre swing takes place from foot contact of the contralateral limb to toe off of the ipsilateral foot, which is the time corresponding to the second double-limb support period of the gait cycle (50% to 60% of gait cycle). Initial swing is from toe off to feet adjacent, when the foot of the swing leg is next to the foot of the stance leg (60% to 73% of gait cycle). Mid swing is from feet adjacent to when the tibia of the swing leg is vertical (73% to 87% of gait cycle). Terminal swing is from a vertical position of the tibia to immediately before heel contact (87% to 100% of the gait cycle). The first 10% of the gait cycle corresponds to a task of weight acceptance—when body mass is transferred from one lower extremity to the other. Single-limb support, from 10% to 50% of the gait cycle, serves to support the weight of the body as the opposite limb swings forward. The last 10% of stance phase and the entire swing phase serve to advance the limb forward to a new location. (From Neumann DA: *Kinesiology of the musculoskeletal system: foundations for physical rehabilitation*, ed 2, St Louis, 2010, Mosby.)

The stance phase has been described as having two basic functions: weight acceptance and single limb support; whereas the swing phase has one primary function: limb advancement.¹⁶ Figure 14-1 depicts the phases within the stance and swing phases of the gait cycle. Contact with the floor is often made with the heel (often called heel contact or initial contact). Perry¹⁶ has described the first 15% of the gait cycle portion as when the foot functions as a heel rocker or first rocker. During this part of the gait cycle, impact forces tend to be large at 1 to 1.5 times body weight, depending on the speed of locomotion. Once the foot becomes flat on the ground the tibia advances forward over the stance foot. Perry¹⁶ has described this as the ankle rocker or second rocker. This phase of the gait cycle is also called midstance phase. The terminal stance phase begins when the heel is raised off the ground (about 40% of the stance phase) until the opposite foot makes ground contact. The final phase of stance phase of the gait cycle is the pre-swing phase, which begins with heel strike of the contralateral limb and ends with toe off. When the heel is lifted from the floor (heel off), this can also be described as the toe rocker or third rocker.

The swing phase of the gait cycle has three portions: pre-swing, mid-swing and terminal swing phases. The pre-swing phase begins with double limb support and ends with toe off. This phase is primarily made up by the foot moving off the ground and is critical for limb advancement. This phase takes place as the gait cycle is 60% and 75% complete. Mid-swing phase is from 75% to 85% of the gait cycle, when the swing limb advances in front of the stance limb. The terminal swing phase completes the remainder of the swing phase until heel contact.

CHARACTERISTICS OF NORMAL GAIT

Many factors can influence gait, such as age, pain, strength, range of motion (ROM), walking speed, and fitness level. The extent of the influence of such factors can be quantified by taking simple measurements to characterize and assess a person’s walking performance with a tape measure, goniometer, and stop watch. The measures are stride or step length, step width (walking base), foot progression angle, walking speed, and cadence. Typical stride length reported from the literature has a range of 1.33 to 1.63 m in healthy individuals.4,5,7,9–12,15,18 Males generally have a greater step length than females. Step width or the horizontal distance between feet while walking has a range of 0.61 to 9.0 cm.^11,12,17,20 Foot progression angle or angle of toe out has been reported to range between 5.1° and 6.8°. Various definitions for foot placement can be seen in Figure 14-2. The average typical walking speed is 1.49 m/sec for men and 1.40 m/sec for women, ranging between 3 to 4 miles per hour for both genders.^{2–4,14,18,21} Average walking speed can be measured over a specific distance with a stop watch. Speed can be calculated by taking the distance over the elapsed time taken to walk the prescribed distance. Walking speed is based on cadence (number of steps per minute) and step length. Average cadence has a range of 107 to 125 steps per minute.^{2–4,14,18,21} To increase walking speed, one can increase cadence or step length. Self selected walking speed is typically slower for women than in men. With the slower gait speed there appears to be a shorter step length and faster cadence for women than men. Keep in mind that all measurements of gait are largely dependent on walking speed.

Fig. 14-2 Terms used to describe foot placement on the ground. (From Whittle MW: *Gait analysis: an introduction*, ed 4, St Louis, 2008, Butterworth-Heinemann.)

As walking speed increases, stance time generally decreases in comparison to swing time. Most of the reduction in stance time comes from a reduction in double support time (due to the reduction in stance time on both limbs). Overall, these simple measures of gait can give the clinician an impression of the overall gait pattern. These measures are often called the temporal spatial measures of gait.

Normal gait is not entirely symmetrical.¹⁸ Small asymmetries in gait are often considered typical. With slower walking speeds, greater amounts of asymmetry have been observed in healthy individuals with normal gait. Thus one must be able to identify if these subtleties in normal gait have clinical relevance.

Movement patterns of the joints can provide additional insight to an individual’s gait. Researchers in motion analysis laboratories have provided detailed three-dimensional data on the range of joint motion during walking. Sagittal plane motion patterns are the largest motions and represent the most studied parameters, whereas frontal plane and transverse plane motion patterns are smaller motions that have been less studied. Estimations of these motions can be visually observed by the health professional at a distance from the side for sagittal motions or from the front or behind for frontal plane motions as the patient is walking. Pure transverse plane rotation is difficult to observe in a clinical setting because an aerial perspective is required. One likely has to combine side and front views to estimate transverse plane motion.

Motions of the Foot, Ankle, Knee, Hip, and Pelvis

Foot

There are several joints within the foot, with some motion occurring at each of the joints during gait. However, most of the required motion at the foot is from the first metatarsophalangeal joint. At the instant of heel off during the terminal stance phase of gait, the first metatarsophalangeal joint typically hyperextends 45° to 55° as the ankle actively plantarflexes. The first metatarsophalangeal joint then returns to nearly 0° during the remainder of the gait cycle. A limitation in this passive hyperextension may cause compensations in other joints in the chain.¹⁹

Rearfoot motion is movement based on the motion of the posterior aspect of the heel relative to the posterior aspect of the lower leg in the frontal plane. This has been used as an estimation of the triplanar motion of pronation that occurs during the stance phase of gait when the foot everts, abducts, and dorsiflexes. When the posterior aspect of the heel is more everted relative to the lower leg the foot is considered to be in a more pronated position. With foot contact, the rearfoot is slightly inverted and immediately begins to evert or pronate until the midstance phase. At the instant of heel off during the beginning of terminal stance phase, the rearfoot is nearly neutral and then begins to invert until toe off. This inversion of the rearfoot is thought to describe the triplanar motion of supination during terminal stance when the foot inverts, adducts and plantarflexes.

Ankle

At ground contact, the ankle is primarily in a neutral position (0°, at a right angle to the tibia, neither plantarflexed nor dorsiflexed). After contact, the ankle plantarflexes about 5° so that the foot becomes flat on the ground.¹⁶ This motion is controlled eccentrically by the ankle dorsiflexor muscles. Next, the tibia rotates over the stance foot resulting in maximum ankle dorsiflexion. This motion is generally controlled eccentrically by the ankle plantarflexor muscles. During the pre-swing phase of gait, the ankle plantarflexes to propel the person forward. An inadequate amount of plantarflexion may be due to a lack of ankle power, resulting in a reduction in step length during gait. During swing, the ankle must dorsiflex to allow for foot clearance as that leg steps forward for ground contact.

Joint Motion and Energy Expenditure

Coordinated lower extremity movement patterns are thought to minimize the vertical oscillation of the body center of mass (COM). The body COM is nearly at the height of a person’s navel and is in the center of the body anterior to the sacrum. Movement of the COM oscillates up and down and from side to side during normal gait (Fig. 14-3). Vertical oscillation of the COM has been related to energy expenditure. Greater energy expenditure is thought to be related to greater oscillation of the body COM. In general, the COM oscillates nearly 5 cm in the vertical direction and horizontally toward the stance limb.⁶ The COM is typically highest during midstance and lowest during double support phases of gait. Lower extremity gait deviations may result in excessive COM motion, resulting in greater fatigue due to the higher metabolic cost.

Fig. 14-3 Center of mass (COM) displacement during gait. The vertical and the medial-lateral displacements of the COM are illustrated in A and B, respectively. The COM is at its lowest and most central position, in the medial-lateral direction, in the middle of double-limb support (5% and 55% of the gait cycle)—a position of relative stability with both feet on the ground. Conversely, the COM is at its highest and most lateral position at midstance (30% and 80% of the gait cycle)—a position of relative instability. During single-limb support, the trajectory of the COM is never directly over the base of support. This factor is illustrated in B, with the vertical projection of the COM always medial to the footprints. (From Neumann DA: *Kinesiology of the musculoskeletal system: foundations for physical rehabilitation*, ed 2, St Louis, 2010, Mosby.)

Muscle Activation

Timing of muscle activation appears to be critical; generally occurring in short bursts during gait (Fig. 14-4). Much of the muscle action within the gait cycle is eccentric. Eccentric forces by the muscles are used control the rate of joint motion.

Foot and Ankle

The tibialis anterior is active eccentrically at heel contact to control the rate of ankle plantar flexion until the foot is flat on the ground. A second period of activity by the tibialis anterior is during early swing phase when it dorsiflexes the ankle to allow for foot clearance. The extensor digitorum and extensor hallucis longus have a similar role in helping control the rate of plantar flexion during the loading response. They may also be activated during the late mid-swing and terminal swing for propulsion in combination with the ankle plantar flexors. The ankle plantarflexors (gastrocnemius and soleus) are active most of the stance phase; eccentrically during the first 10% to 40%, when they control the rate for tibial advancement over the foot, to a high burst of concentric activity at pre-swing (at heel off) until inactivity at toe off.¹³ The tibialis posterior is primarily active between 5% and 35% of the gait cycle and is thought to limit excessive foot pronation. Later in stance, the tibialis anterior and posterior function concentrically to help supinate the foot to create a rigid lever for effective push off by the ankle plantarflexors.¹⁹

Knee

During terminal swing the quadriceps muscle group begins to become activated in preparation for weight acceptance during stance. At the instant of heel contact, the quadriceps is highly active eccentrically to control the rate of knee flexion and absorb impact forces during the loading response phase. Later during midstance while in single limb support, the quadriceps act concentrically to extend the knee. During pre-swing, there may be some quadriceps activity to help flex the hip. The hamstrings are most active near the instant of heel contact and through approximately the first 10% of the stance phase. Before heel contact, the hamstrings slow the rate of knee extension, and early in stance, assist with hip extension and enhance knee stability with coactivation with the quadriceps. Minimal activation of the hamstrings is necessary during pre-swing and swing.13,16,19

Hip

The gluteus maximus is active during terminal swing to slow the rate of hip flexion and to prepare for weight acceptance during stance. This muscle becomes most active at the instant of heel contact for hip extension with assistance from the hamstrings and to prevent trunk flexion. The gluteus maximus remains active during the first 30% of the gait cycle.¹⁶ The iliacus and psoas muscles are active eccentrically during toe off to slow down the rate of hip extension, and then are concentrically active to flex the hip during pre-swing. These hip flexors are active only during the first 50% of swing and are partially assisted by the quadriceps for limb advancement and foot clearance. The hip abductors (gluteus medius, gluteus minimis, and tensor fascia lata) help control pelvis motion in the frontal plane during single leg stance.¹⁹ The gluteus medius is also active in terminal swing in preparation for heel contact. It is assisted by the gluteus minimus during the first 40% of the gait cycle to control pelvis tilt toward the swing limb during stance and may control the alignment of the femur in the frontal plane. The hip adductors and rotators are also active during stance. The hip rotators’ role during gait may be important to enable control of the motion between the pelvis and femur during stance.¹³

GAIT ABNORMALITIES

The ability to move our bodies from one location to another is an important aspect of functional independence. The normal gait pattern described thus far is the method many of us choose to use to achieve this end. However, pain during gait or a variety of permanent or temporary neurological or musculoskeletal impairments will affect normal gait. The consequence of nearly every deviation from normal gait is increased energy consumption to move a given distance, decreased gait speed, abnormal joint loading, and in some cases, decreased safety. For some people, the additional energy required for ambulation may be so great that frequent rests are necessary even over relatively short distances. The health professional must be able to identify and describe gait abnormalities in order to make appropriate recommendations to the patient or other health care professionals to minimize the impact of the gait abnormality on functional independence.

Just as normal gait is a complex interaction of musculoskeletal and neuromuscular systems, adaptations or compensations in response to pain or limitations in either system are frequently equally complex. Indeed, there may be many ways for a person to compensate for or adapt to a given impairment. As a consequence, the same impairment may not result in the same gait abnormality among different people. Further, the way that a person compensates for a musculoskeletal or neuromuscular limitation may change, leading to different gait abnormalities over time for one person with the same limitation.

The clinical presentation and potential causes of several common gait abnormalities are briefly discussed in the remainder of this chapter. As previously noted, it is important to remember that the joints that make up the lower extremities work together as a series of linked segments or kinetic chain. As with any linked system, motion at one segment can greatly influence the motion of another. Therefore observed gait abnormalities may be due to pain or a limitation in any portion of the kinetic chain.

Antalgic Gait

Antalgic gait is a general term used to describe a gait pattern accompanied by pain. It can take on a number of forms, but generally there will be an observable reduction in motion at the painful joint as well as asymmetry in temporal–spatial gait parameters, with a reduction in stance time on the involved limb and a rapid swing phase of the uninvolved limb being most common. Patients who experience pain during walking as a consequence of weight bearing frequently find it more comfortable to walk if they reduce the magnitude of the loads delivered to the painful leg during the stance phase of gait. This is typically accomplished by leaning the trunk toward (hip pain) or away (knee or ankle pain) from the side of the painful lower extremity joint during the stance phase.

Lateral Trunk Bending

As described, lateral trunk bending may be observed among patients attempting to minimize joint compression loads and pain during ambulation. Lateral trunk bending may also be observed as a compensation for weakness of the hip abductors. During the stance phase of walking, patients with marked hip abductor weakness may lean toward the stance leg of the weak abductors in order to minimize the force required of these muscles to prevent downward movement of the pelvis on the side of the swing leg (contralateral pelvis drop). This lateral trunk bending is a compensation for ipsilateral hip abductor weakness and is most commonly referred to as Trendelenburg gait. Among people who have bilateral hip abductor weakness, the clinician may observe lateral trunk bending toward each side during the single leg stance phase of each leg, a presentation most commonly referred to as waddling. People who walk with a wide step width (walking base) or have unequal leg length may also demonstrate increased lateral trunk bending.

Contralateral Pelvis Drop

Excessive downward movement of the pelvis for the swing leg may also occur during walking. This is most frequently observed as a consequence of a musculoskeletal impairment, such as hip abductor weakness, or a neuromuscular disease affecting gluteus medius recruitment. Specifically, this occurs when the hip abductors do not produce enough force to resist the torque created by the weight of the trunk acting medially to the hip joint during the single leg stance phases of the gait cycle. This gait deviation is known as increased contralateral pelvic drop or as the Trendelenburg sign.

Posterior Trunk Lean

Patients who demonstrate a posterior trunk lean may do so during either the early stance or early swing phase of the gait cycle. During early stance, a patient may lean posteriorly in order to move the line of gravity of the trunk behind the hip joint. This tends to reduce the demands placed on the hip extensors to resist hip flexion during the loading phase and, as such, is a gait deviation frequently employed by individuals with weak hip extensors. Conversely, individuals may lean posteriorly during early swing in an effort to pull the femur anteriorly and advance the swing leg as a compensation for hip flexor insufficiency or hip extensor spasticity.

Anterior Trunk Lean

Anterior trunk lean is most commonly observed during the stance phase of gait. However, timing of the anterior trunk lean may vary according to the impairment causing this gait abnormality. Anterior trunk lean during early stance is often a compensation for quadriceps weakness. Shortly after heel strike, the magnitude and direction of the reaction force from the ground is posterior to the knee joint, which tends to produce knee flexion under the eccentric control of the knee extensors. If the knee extensors cannot generate enough force to resist knee flexion, a person may lean forward to move the ground reaction force anterior to the knee joint (Fig. 14-5). Moving the ground reaction force anterior to the knee joint changes the effect of the ground reaction force to one that tends to cause knee extension rather than knee flexion, therefore diminishing the need for knee extension strength to resist knee flexion. Quadriceps weakness is a common consequence of poliomyelitis. Therefore this compensation is a common gait deviation among such individuals.

Fig. 14-5 Anterior trunk bending: in normal walking, the line of force early in the stance phase passes behind the knee; anterior trunk bending brings the line of force in front of the knee, to compensate for weak knee extensors. (From Whittle MW: *Gait analysis: an introduction*, ed 4, St Louis, 2008, Butterworth-Heinemann.)

Anterior trunk lean during midstance or terminal stance is often a compensation for decreased ankle dorsiflexion range of motion. In order to continue to ambulate forward, the ankle typically dorsiflexes before initial contact of the contralateral leg to allow the person’s COM to pass anterior to the stance leg base of support. Among individuals with ankle plantarflexor spasticity, a plantarflexor contracture, or pes equinus deformity, the ankle may not permit sufficient dorsiflexion at this stage of the gait cycle and the person may need to lean the trunk forward to move their COM anterior to the foot (Fig. 14-6).

Fig. 14-6 Individuals with an ankle plantar flexion contracture will make initial contact with the ground with the forefoot region. At midstance, bringing the heel to the ground will result in knee hyperextension. Forward lean of the trunk occurs in terminal stance as a strategy to maintain forward progression of the center of mass. (From Neumann DA: *Kinesiology of the musculoskeletal system: foundations for physical rehabilitation,* ed 2, St Louis, 2010, Mosby.)

Excessive Ankle Plantarflexion

Increased ankle plantarflexion is frequently observed in both the stance and swing phase of the gait cycle. Increased ankle plantarflexion during and after midstance of the stance leg is commonly referred to as vaulting (Fig. 14-7). This is frequently a compensatory mechanism intended to increase ground clearance for the swing leg and is common among individuals with an impairment that prevents shortening of the swing leg during the swing phase, such as an ankle plantarflexion contracture, ankle dorsiflexor weakness, knee or hip extensor spasticity, or hip flexor weakness. Ankle plantarflexion of the stance leg may also be an indication of decreased ankle dorsiflexion ROM, particularly if the person demonstrates heel rise very shortly after contralateral toe off (early in midstance). In either case, the effect is a characteristic bouncing appearance, indicative of large vertical oscillations of the person’s COM.

Fig. 14-7 Vaulting: the subject goes up on the toes of the stance phase leg to increase ground clearance for the swing phase leg. (From Whittle MW: *Gait analysis: an introduction*, ed 4, St Louis, 2008, Butterworth-Heinemann.)

Increased ankle plantarflexion may also be observed in the swing phase of the gait cycle. This gait deviation is frequently the result of injury to the common fibular nerve, weakness of the ankle dorsiflexors, or spasticity or contracture of the ankle plantarflexors (Fig. 14-8, A). Compensations for increased swing phase ankle plantarflexion are typically necessary to avoid tripping due to toe drag during contralateral leg stance phase. These compensations often include vaulting on the stance leg, increased hip or knee flexion of the swing leg (steppage gait) (Fig. 14-8, B), or hip circumduction of the swing leg (described later). A combination of these compensations may also be used in order to increase ground clearance during the swing phase.

Fig. 14-8 A, Weak ankle dorsiflexors may result in a foot drop during swing phase, requiring excessive hip and knee flexion for the toes to clear the ground as the limb is advanced forward during swing. B, Steppage: Increased hip and knee flexion improve ground clearance for the swing phase leg; in this case, necessitated by a foot drop. (A, From Neumann DA: *Kinesiology of the musculoskeletal system: foundations for physical rehabilitation*, ed 2, St Louis, 2010, Mosby. B, Modified from Whittle MW: *Gait analysis: an introduction*, ed 4, St Louis, 2008, Butterworth-Heinemann.)

Hip Circumduction

Individuals who advance the swing leg in a lateral semicircular pattern rather than in a straight plane from posterior to anterior are said to be circumducting the hip. Hip circumduction is a common compensation used to advance the swing leg if a person lacks hip flexion, knee flexion, or ankle dorsiflexion ROM, because ground clearance is increased using this swing pattern. Individuals may also circumduct the hip if they lack hip flexion strength to swing the leg forward. In this case, the swing leg may be advanced by first externally rotating the hip and using the hip adductors rather than the hip flexors to pull the femur forward.

Increased Knee Flexion

Excessive knee flexion is most noticeable during either the loading response or terminal stance phase of the gait cycle, when the knee would normally be nearly fully extended. Increased knee flexion at initial contact will almost certainly be accompanied by initial contact with the midfoot or forefoot rather than the heel. As the remainder of the foot comes in contact with the ground, the center of pressure first moves posteriorly and finally anteriorly during stance rather than the typical posterior to anterior progression (Fig. 14-9, A). One consequence of this is that much of the forward momentum of the COM may be lost during early stance, minimizing the gait economy normally preserved by the foot and ankle rockers. Increased knee flexion during stance phase may be the consequence of a number of impairments including a knee flexion contracture, knee pain or knee joint effusion, or a hip flexion contracture (Fig. 14-9, B).

Fig. 14-9 A, The typical progression of the center of pressure is from the heel (starting at the *dark red dots*) to the forefoot and toes (at the *light red dots*) as on the left figure. This was obtained with a pressure platform while walking barefoot. Ground contact with the forefoot as on the left figure shifts the center of pressure largely anterior where it then travels posterior toward the heel before moving anterior again toward the forefoot and toes. B, Excessive knee flexion: in late stance phase there is increased knee flexion, caused by a flexion contracture of the hip. (B, From Whittle MW: *Gait analysis: an introduction*, ed 4. St Louis, 2008, Butterworth-Heinemann.)

Increased knee flexion and hip flexion during gait is referred to as crouch gait and is commonly observed among individuals with spastic diplegia as a consequence of cerebral palsy (Fig. 14-10). Among such individuals, increased knee flexion may be due to spasticity of the hamstrings, hip flexors, or both. Careful gait and clinical analysis is required in order to develop the best course of surgical or conservative treatment for these patients.

Fig. 14-10 Position of body at midstance in a 12-year-old child with crouch gait, following Achilles tendon lengthening for spastic diplegia. (Adapted from Sutherland DH, Cooper L: The pathomechanics of progressive crouch gait in spastic diplegia, *Orthop Clin North Am,* 9:143-154, 1978. In Whittle MW: *Gait analysis: an introduction*, ed 4, St Louis, 2008, Butterworth-Heinemann.)

GAIT PATTERN INSTRUCTION

Instructing patients in the proper use of assistive devices and identifying appropriate gait patterns are relevant clinical tasks for the physical therapist assistant (PTA). Several patterns are outlined here.

A four-point gait pattern is describe as advancing the crutch opposite the uninvolved limb first, followed by the involved limb, then advancing the crutch toward the uninvolved limb, then finally advancing the uninvolved limb (Fig. 14-11). If the injured limb is the left leg, the four-point gait pattern looks like this:

Fig. 14-11 Four-point gait. One crutch or leg is moved at a time in the pattern: left crutch—right leg—right crutch—left leg. (B, From Whittle MW: *Gait analysis: an introduction*, ed 4, St Louis, 2008, Butterworth-Heinemann.)

< ?xml:namespace prefix = "mml" />Right crutch×left foot×left crutch×right foot

The four-point gait pattern attempts to duplicate the normal reciprocal motion that occurs between the upper extremities and the lower limbs during normal gait.

A three-point gait pattern is commonly taught using bilateral axillary crutches (Fig. 14-12). The sequence of events begins by advancing both crutches and the involved limb first followed by the uninvolved.