Trendelenburg Gait: Difference between revisions
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'''Original Editor '''[[User:Glenn Demeyer|Glenn Demeyer]] | '''Original Editor ''' - [[User:Glenn Demeyer|Glenn Demeyer]] | ||
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== Definition/ Description == | == Definition/ Description == | ||
The | The Trendelenburg gait, or gluteus medius gait, is an abnormal gait pattern that is observed in patients who have weak [[Hip Anatomy|hip abductor muscles]]. This condition makes it difficult to support the body's weight on the affected side. The abductor muscles themselves are normal but they have a mechanical disadvantage. During the stance phase of gait, the hip abductors function ineffectively and the pelvis tilts away from the affected side. In an attempt to lessen this effect, the individual compensates by leaning laterally over the affected hip. This brings the center of gravity over the hip and reduces the degree of pelvic drop. <ref> Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> <ref> Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18(2):222-227.</ref> Level of evidence: A2 | ||
[[Image:Trendelenburg gait.jpg|center|400px]] | |||
See also: [[Trendelenburg Test]] | |||
== Clinically Relevant Anatomy == | == Clinically Relevant Anatomy == | ||
The hip abductor muscles - gluteus medius and minimus - are the anatomical components primarily involved in the Trendelenburg gait pattern. Hip abduction involves movement of the femur away from the midline of the body in the frontal plane. In stance phase, the hip abductors also function to stabilize the pelvis and keep it level when the contra-lateral limb is raised. Gluteus medius and minimus are both innervated by the superior gluteal nerve<ref name="Moore">Moore KL, Agur AM, Dalley AF. Essential clinical anatomy. 4th ed. Baltimore: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins, 2011.</ref>. | |||
[[Image:Posterior Hip Muscles.PNG|center|200px]] | |||
The gait cycle is divided into two main phases, a stance and a swing phase, each consisting of numerous sub phases. The human gait cycle has six determinants that function independently, to generate the normally fluid, continuous movements of ambulation. <ref> Pease W, Bowyer B, Kadyan V. Human walking. In: DeLisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR, eds. Physical Medicine and Rehabilitation: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams Wilkins; 2005:156-167.</ref> <ref> Whittle M. Normal gait. In: Whittle MW. Gait Analysis: An Introduction. 3rd ed. Philadelphia, PA: Butterworth-Heinemann; 2002:42-86.</ref> <ref> Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J Bone Joint Surg Am. 1953;35(3):543-558.</ref> | The gait cycle is divided into two main phases, a stance and a swing phase, each consisting of numerous sub phases. The human gait cycle has six determinants that function independently, to generate the normally fluid, continuous movements of ambulation. <ref> Pease W, Bowyer B, Kadyan V. Human walking. In: DeLisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR, eds. Physical Medicine and Rehabilitation: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams Wilkins; 2005:156-167.</ref> <ref> Whittle M. Normal gait. In: Whittle MW. Gait Analysis: An Introduction. 3rd ed. Philadelphia, PA: Butterworth-Heinemann; 2002:42-86.</ref> <ref> Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J Bone Joint Surg Am. 1953;35(3):543-558.</ref> | ||
{| width="100%" cellspacing="1" cellpadding="1" | |||
|- | |||
| {{#ev:youtube|5j4YRHf6Iyo|300}}<ref>Roda D. The gait cycle: a breakdown of each component. Available from: http://www.youtube.com/watch?v=5j4YRHf6Iyo [last accessed 2013/11/24]</ref> | |||
| {{#ev:youtube|GV6CAZiv5Zo|300}}<ref>Oberhofer K. Muscle activation during gait. Available from: http://www.youtube.com/watch?v=GV6CAZiv5Zo [last accessed 2013/11/24]</ref> | |||
|} | |||
<br> In the above right video, ''Muscle Activation During Gait'', concentric muscle contraction is indicated in yellow, isometric contraction in orange and eccentric contraction in purple. | |||
== Epidemiology/ Etiology == | == Epidemiology/ Etiology == | ||
Trendelenburg gait occurs when the | Trendelenburg gait occurs when the individual has weakness of the abductors of the hip (Musculus gluteus medius). <ref> Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> Patients who have significantly shorter height and greater body mass index sustained the Trendelenburg gait.<ref> Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.</ref> Level of evidence: B<u><br></u> | ||
== Differential Diagnosis == | == Differential Diagnosis == | ||
This disturbance in the gait cycle is frequently observed in children with the development of congenital dislocation of the hip (CDH), dysplasia of the hip (DDH) and congenital coxa vara. Coxa vara can also occur from other disorders | This disturbance in the gait cycle is frequently observed in children with the development of congenital dislocation of the hip (CDH), [[Hip Dysplasia|dysplasia of the hip]] (DDH) and congenital [[Coxa Vara / Coxa Valga|coxa vara]]. Coxa vara can also occur from other disorders such as [[Legg-Calve-Perthes Disease|Legg-Calvé-Perthes disease]] or [[Slipped Capital Femoral Epiphysis|slipped capital femoral epiphysis]] (SCFE) - these are two of the most common causes of hip pain or limp.<ref> Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.</ref> <ref> Kelsey JL. Epidemiology of slipped capital femoral epiphysis: a review of the literature. Pediatrics 1973.</ref> <ref> Yochum TR, Rowe LI. Essentials of skeletal radiology. Baltimore: Williams and Wilkins, 1987; 465-68.; 51: 1042-50.</ref> The Trendelenburg gait can also occur as the result of a neuronal injury. A lesion of the superior gluteal nerve (SGN), which is the main nerve stimulating the hip abductors, can lead to weakness.<ref> Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.</ref> <ref> Jacobs LG, Buxton RA. The course of the superior gluteal nerve in the lateral approach to the hip. J Bone Joint Surg [Am] 1989;71:1239-43.</ref> This nerve also supplies the gluteus medius, gluteus minimus and tensor fascia lata muscles.<ref> Bülbül M, Ayanoğlu S, Öztürk K, İmren Y, Esenyel C, Yeşiltepe R, et al. How reliable is the safe zone of Hardinge approach for superior gluteal nerve? Trakya Univ Tıp Fak Derg 2009;26:134-6.</ref> Other conditions in which a Trendelenberg gait may be observed include muscular dystrophy and hemiplegic cerebral palsy.<ref name="Flynn">Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg 2001;9:89-98.</ref> | ||
== Diagnostic Procedures == | == Diagnostic Procedures == | ||
The surgeon will base a diagnosis of hip pain on data obtained from clinical and [[Diagnostic Imaging of the Hip for Physical Therapists|X-ray assessments]]. These two data sources will provide information regarding: | |||
*The level of the proximal osteotomy | |||
*The amount of valgus, extension and derotation at the proximal osteotomy | |||
*The level of the distal osteotomy | |||
*The amount of varus and lengthening at the distal osteotomy.<ref> Saleh M, Milne A (1994) Weight-bearing parallel-beam scanography for the measurement of leg length and joint alignment. J Bone Joint Surg Br 76(1):156–157.</ref> <ref> Paley D (2002) Normal lower limb alignment and joint orientation. In: Paley D (ed) Principles of deformity correction. Springer, Berlin, pp 1–18.</ref> <ref> Gage JR (1991) Gait analysis in cerebral palsy, 1st edn. Clinics in developmental medicine, vol 121. Mac Keith Press, London.</ref> Level of evidence: B | |||
== Examination == | == Examination == | ||
The modified McKay criteria is useful to assess | The modified McKay criteria is useful to assess if a patient has Trendelenburg gait. These criteria measure pain symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement. Level of evidence: A2<br> | ||
{| width="293" | {| width="293" cellspacing="1" cellpadding="1" border="1" style="width: 293px; height: 236px;" | ||
|- | |- | ||
| Grade | | '''Grade''' | ||
| Criteria | | '''Criteria''' | ||
|- | |- | ||
| Excellent | | Excellent | ||
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== Medical Management == | == Medical Management == | ||
While no treatment modalities currently exist for patients with compensated Trendelenburg gait, medical management can attempt to deal with the causes underlying a Trendelenburg gait. Open reduction and Salter innominate osteotomy (SIO) without preoperative traction is effective in the management of development dysplasia of the hip in children younger than 6 years. <ref> Bohm P, Brzuske A. Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am 2002;84:178–86.</ref> Level of evidence: A2 | |||
Pelvic support osteotomies cause a significant improvement in | Pelvic support osteotomies cause a significant improvement in outcomes relating to posture, gait and walking tolerance in patients who had untreated congenital dislocations.<ref> Lance PM (1936) Osteotomies sous-trochanterienne dans le traitement des luxations congenitales inveterees de la hanche. Masson Cie, Paris.</ref> <ref> Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595.</ref> Level of evidence: B<br> | ||
Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters | Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters for individuals with somatic dysfunctions, as measured by a GaitMat II system. Further research is needed to better understand the relationship between somatic dysfunctions and gait deviations. <ref> Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults [published online ahead of print October 25, 2005]. Neuroepidemiology. 2006;26:52-60.</ref> Level of evidence: C<br> | ||
There is a significant difference in the incidence of a positive Trendelenburg gait between surgical approaches, using trochanteric osteotomy or not. This shows the effectiveness of distal trochanteric transfer.<ref> Fernandez DL, Isler B, Müller ME. Chiari’s osteotomy: a note on technique. Clin Orthop 1984;185:53-8.</ref> Level of evidence: A2 | There is a significant difference in the incidence of a positive Trendelenburg gait between surgical approaches, using trochanteric osteotomy or not. This shows the effectiveness of distal trochanteric transfer.<ref> Fernandez DL, Isler B, Müller ME. Chiari’s osteotomy: a note on technique. Clin Orthop 1984;185:53-8.</ref> Level of evidence: A2 | ||
| Line 58: | Line 79: | ||
== Physical Therapy Management == | == Physical Therapy Management == | ||
Trendelenburg gait is an abnormal gait caused by weakness of the | Trendelenburg gait is an abnormal gait caused by weakness of the hip abductors. Therefore, the main purpose of physical therapy with regards to this impairment is to strengthen the abductors of the hip. An appropriate exercise to strengthen the hip abductors is to have the patient lay side-lying on the less affected side and abduct the upper leg towards the ceiling. To make the exercise more challenging, a weight or theraband can be placed around the active limb. Other exercises in the revalidation of Trendelenburg gait include functional closed-chain exercises, lateral step-ups and functional balance exercises. It is also important to [[Therapy Exercises for the Hip|strengthen the rest of the leg]] on the affected side. Level of evidence: D<br> | ||
{{#ev:youtube|mxWissvKVj0|300}} | |||
The use of an Electromyogram (EMG) reduces the Trendelenburg gait by an average of 29 degrees. The average stride length has | The use of an Electromyogram (EMG) reduces the Trendelenburg gait by an average of 29 degrees. The average stride length has been shown to increase from 0,32 ± 0,3m to 0,45 ± 0,2m and the speed of gait has been shown to increase from 1,6 ± 0,4 kmh−1 to 3,1 ± 0,5 kmh−1. <ref> J. S. Petrofsky. Microprocessor-based gait analysis system to retrain Trendelenburg gait. Medical and Biological Engineering and Computing , Volume 39, Number 1, 140-143, DOI: 10.1007/BF02345278.</ref> Levels of evidence: B | ||
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == | |||
<div class="researchbox">
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== References == | == References == | ||
Revision as of 04:50, 25 November 2013
Original Editor - Glenn Demeyer
Top Contributors - Uchechukwu Chukwuemeka, Scott Buxton, Glenn Demeyer, Kim Jackson, Redisha Jakibanjar, Shaimaa Eldib, Oyemi Sillo, Emma De Moerloose, Olivia Wayteck, Manisha Shrestha, Ahmed M Diab, Daphne Jackson, Lenaertz Kiara, WikiSysop, Candace Goh, Claire Knott, Lauren Lopez, Admin and Carina Therese Magtibay
Definition/ Description[edit | edit source]
The Trendelenburg gait, or gluteus medius gait, is an abnormal gait pattern that is observed in patients who have weak hip abductor muscles. This condition makes it difficult to support the body's weight on the affected side. The abductor muscles themselves are normal but they have a mechanical disadvantage. During the stance phase of gait, the hip abductors function ineffectively and the pelvis tilts away from the affected side. In an attempt to lessen this effect, the individual compensates by leaning laterally over the affected hip. This brings the center of gravity over the hip and reduces the degree of pelvic drop. [1] [2] Level of evidence: A2
See also: Trendelenburg Test
Clinically Relevant Anatomy[edit | edit source]
The hip abductor muscles - gluteus medius and minimus - are the anatomical components primarily involved in the Trendelenburg gait pattern. Hip abduction involves movement of the femur away from the midline of the body in the frontal plane. In stance phase, the hip abductors also function to stabilize the pelvis and keep it level when the contra-lateral limb is raised. Gluteus medius and minimus are both innervated by the superior gluteal nerve[3].
The gait cycle is divided into two main phases, a stance and a swing phase, each consisting of numerous sub phases. The human gait cycle has six determinants that function independently, to generate the normally fluid, continuous movements of ambulation. [4] [5] [6]
| [7] | [8] |
In the above right video, Muscle Activation During Gait, concentric muscle contraction is indicated in yellow, isometric contraction in orange and eccentric contraction in purple.
Epidemiology/ Etiology[edit | edit source]
Trendelenburg gait occurs when the individual has weakness of the abductors of the hip (Musculus gluteus medius). [9] Patients who have significantly shorter height and greater body mass index sustained the Trendelenburg gait.[10] Level of evidence: B
Differential Diagnosis[edit | edit source]
This disturbance in the gait cycle is frequently observed in children with the development of congenital dislocation of the hip (CDH), dysplasia of the hip (DDH) and congenital coxa vara. Coxa vara can also occur from other disorders such as Legg-Calvé-Perthes disease or slipped capital femoral epiphysis (SCFE) - these are two of the most common causes of hip pain or limp.[11] [12] [13] The Trendelenburg gait can also occur as the result of a neuronal injury. A lesion of the superior gluteal nerve (SGN), which is the main nerve stimulating the hip abductors, can lead to weakness.[14] [15] This nerve also supplies the gluteus medius, gluteus minimus and tensor fascia lata muscles.[16] Other conditions in which a Trendelenberg gait may be observed include muscular dystrophy and hemiplegic cerebral palsy.[17]
Diagnostic Procedures[edit | edit source]
The surgeon will base a diagnosis of hip pain on data obtained from clinical and X-ray assessments. These two data sources will provide information regarding:
- The level of the proximal osteotomy
- The amount of valgus, extension and derotation at the proximal osteotomy
- The level of the distal osteotomy
- The amount of varus and lengthening at the distal osteotomy.[18] [19] [20] Level of evidence: B
Examination[edit | edit source]
The modified McKay criteria is useful to assess if a patient has Trendelenburg gait. These criteria measure pain symptoms, gait pattern, Trendelenburg sign status, and the range of hip joint movement. Level of evidence: A2
| Grade | Criteria |
| Excellent | Stable, painless hip; no limp; negative Trendelenburg sign; full range of movement |
| Good | Stable, painless hip; slight limp; slight decrease in range of movement |
| Fair | Stable, painless hip; limp; positive Trendelenburg sign; and limited range of movement, or a combination of these |
| Poor | Unstable or painful hip or both; positive Trendelenburg sign |
Medical Management[edit | edit source]
While no treatment modalities currently exist for patients with compensated Trendelenburg gait, medical management can attempt to deal with the causes underlying a Trendelenburg gait. Open reduction and Salter innominate osteotomy (SIO) without preoperative traction is effective in the management of development dysplasia of the hip in children younger than 6 years. [21] Level of evidence: A2
Pelvic support osteotomies cause a significant improvement in outcomes relating to posture, gait and walking tolerance in patients who had untreated congenital dislocations.[22] [23] Level of evidence: B
Osteopathic Manipulative Treatment (OMT) could result in improved gait parameters for individuals with somatic dysfunctions, as measured by a GaitMat II system. Further research is needed to better understand the relationship between somatic dysfunctions and gait deviations. [24] Level of evidence: C
There is a significant difference in the incidence of a positive Trendelenburg gait between surgical approaches, using trochanteric osteotomy or not. This shows the effectiveness of distal trochanteric transfer.[25] Level of evidence: A2
Physical Therapy Management[edit | edit source]
Trendelenburg gait is an abnormal gait caused by weakness of the hip abductors. Therefore, the main purpose of physical therapy with regards to this impairment is to strengthen the abductors of the hip. An appropriate exercise to strengthen the hip abductors is to have the patient lay side-lying on the less affected side and abduct the upper leg towards the ceiling. To make the exercise more challenging, a weight or theraband can be placed around the active limb. Other exercises in the revalidation of Trendelenburg gait include functional closed-chain exercises, lateral step-ups and functional balance exercises. It is also important to strengthen the rest of the leg on the affected side. Level of evidence: D
The use of an Electromyogram (EMG) reduces the Trendelenburg gait by an average of 29 degrees. The average stride length has been shown to increase from 0,32 ± 0,3m to 0,45 ± 0,2m and the speed of gait has been shown to increase from 1,6 ± 0,4 kmh−1 to 3,1 ± 0,5 kmh−1. [26] Levels of evidence: B
Recent Related Research (from Pubmed)[edit | edit source]
Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1P_FVbJaBNrJLX-vBT68G_MUDLFt45eZjVTRMowVr7ll0euk-L|charset=UTF8|short|max=10: Error parsing XML for RSS
References[edit | edit source]
- ↑ Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
- ↑ Pomeroy VM, Chambers SH, Giakas G, Bland M. Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II. Clin Rehabil. 2004;18(2):222-227.
- ↑ Moore KL, Agur AM, Dalley AF. Essential clinical anatomy. 4th ed. Baltimore: Lippincott Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins, 2011.
- ↑ Pease W, Bowyer B, Kadyan V. Human walking. In: DeLisa JA, Gans BM, Walsh NE, Bockenek WL, Frontera WR, eds. Physical Medicine and Rehabilitation: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams Wilkins; 2005:156-167.
- ↑ Whittle M. Normal gait. In: Whittle MW. Gait Analysis: An Introduction. 3rd ed. Philadelphia, PA: Butterworth-Heinemann; 2002:42-86.
- ↑ Saunders JB, Inman VT, Eberhart HD. The major determinants in normal and pathological gait. J Bone Joint Surg Am. 1953;35(3):543-558.
- ↑ Roda D. The gait cycle: a breakdown of each component. Available from: http://www.youtube.com/watch?v=5j4YRHf6Iyo [last accessed 2013/11/24]
- ↑ Oberhofer K. Muscle activation during gait. Available from: http://www.youtube.com/watch?v=GV6CAZiv5Zo [last accessed 2013/11/24]
- ↑ Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
- ↑ Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.
- ↑ Hensinger RN: Limp. Pediatr Clin North Am 1986; 33:1355.
- ↑ Kelsey JL. Epidemiology of slipped capital femoral epiphysis: a review of the literature. Pediatrics 1973.
- ↑ Yochum TR, Rowe LI. Essentials of skeletal radiology. Baltimore: Williams and Wilkins, 1987; 465-68.; 51: 1042-50.
- ↑ Hardinge K. The direct lateral approach to the hip. J Bone Joint Surg [Br] 1982;64:17-9.
- ↑ Jacobs LG, Buxton RA. The course of the superior gluteal nerve in the lateral approach to the hip. J Bone Joint Surg [Am] 1989;71:1239-43.
- ↑ Bülbül M, Ayanoğlu S, Öztürk K, İmren Y, Esenyel C, Yeşiltepe R, et al. How reliable is the safe zone of Hardinge approach for superior gluteal nerve? Trakya Univ Tıp Fak Derg 2009;26:134-6.
- ↑ Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. J Am Acad Orthop Surg 2001;9:89-98.
- ↑ Saleh M, Milne A (1994) Weight-bearing parallel-beam scanography for the measurement of leg length and joint alignment. J Bone Joint Surg Br 76(1):156–157.
- ↑ Paley D (2002) Normal lower limb alignment and joint orientation. In: Paley D (ed) Principles of deformity correction. Springer, Berlin, pp 1–18.
- ↑ Gage JR (1991) Gait analysis in cerebral palsy, 1st edn. Clinics in developmental medicine, vol 121. Mac Keith Press, London.
- ↑ Bohm P, Brzuske A. Salter innominate osteotomy for the treatment of developmental dysplasia of the hip in children: results of seventy-three consecutive osteotomies after twenty-six to thirty-five years of follow-up. J Bone Joint Surg Am 2002;84:178–86.
- ↑ Lance PM (1936) Osteotomies sous-trochanterienne dans le traitement des luxations congenitales inveterees de la hanche. Masson Cie, Paris.
- ↑ Milch H (1941) The ‘pelvic support’ osteotomy. J Bone Joint Surg Am 23(3):581–595.
- ↑ Rosano C, Brach J, Longstreth Jr WT, Newman AB. Quantitative measures of gait characteristics indicate prevalence of underlying subclinical structural brain abnormalities in high-functioning older adults [published online ahead of print October 25, 2005]. Neuroepidemiology. 2006;26:52-60.
- ↑ Fernandez DL, Isler B, Müller ME. Chiari’s osteotomy: a note on technique. Clin Orthop 1984;185:53-8.
- ↑ J. S. Petrofsky. Microprocessor-based gait analysis system to retrain Trendelenburg gait. Medical and Biological Engineering and Computing , Volume 39, Number 1, 140-143, DOI: 10.1007/BF02345278.
