Understanding how a patient walks is one of the most fundamental skills in orthotics and prosthetics. Whether you are fitting a transtibial prosthesis, prescribing an ankle-foot orthosis, or assessing a child with cerebral palsy, everything you observe, measure, and decide flows from your understanding of gait. Yet in many clinical settings across Pakistan, formal gait analysis remains underused — not because clinicians lack interest, but because the tools and training have not always been accessible.
This article offers a practical introduction to gait analysis: what it is, how to observe it systematically, and how to apply it directly to your everyday clinical work.
What Is Gait Analysis?
Gait analysis is the systematic study of how a person walks. It can range from simple observational assessment — watching a patient walk down a corridor — to sophisticated 3D motion capture in a specialist laboratory. For most O&P practitioners in Pakistan, observational gait analysis is the primary tool, and when done rigorously it is extraordinarily informative.
The goal is not simply to describe what you see. It is to distinguish between primary deviations — caused directly by the patient’s underlying condition — and compensatory deviations, which are adaptations the body makes to manage the primary problem. Treating a compensation as if it were a primary deviation is one of the most common errors in O&P practice, and it leads to devices that make things worse rather than better.
The Gait Cycle: A Quick Refresher
The gait cycle runs from initial contact of one foot to the next initial contact of the same foot. It is divided into two main phases:
Stance phase (approximately 60% of the cycle) begins when the foot contacts the ground and ends when it leaves it. Within stance, the key sub-phases are initial contact, loading response, mid-stance, terminal stance, and pre-swing.
Swing phase (approximately 40% of the cycle) covers the period when the foot is in the air, from toe-off to the next initial contact. It is divided into initial swing, mid-swing, and terminal swing.
Understanding which sub-phase a deviation occurs in is critical. A patient who drops their foot at initial contact has a very different problem from one who cannot clear their foot during mid-swing — even though both produce a similar-looking “foot drop.”
The Eight Determinants of Gait
Saunders, Inman, and Eberhart described eight mechanical determinants of gait that the human body uses to minimise the rise and fall of the centre of gravity and therefore reduce energy expenditure. These include pelvic rotation, pelvic tilt, knee flexion in stance, foot and ankle mechanics, and knee and hip motion in swing. Orthotic and prosthetic devices can either support or disrupt these determinants, and knowing which is happening in your patient is essential.
For example, a rigid ankle-foot orthosis set in slight dorsiflexion may support a weak tibialis anterior but will simultaneously block the smooth heel-to-toe rocker mechanism that normally smooths the centre-of-gravity arc. Understanding this trade-off allows you to choose the right AFO design, adjust the footwear, or counsel the patient about what to expect.
Systematic Observational Gait Analysis
Rather than watching a patient walk and hoping something catches your eye, use a structured approach:
Step 1: Prepare the environment. Ask the patient to walk at their natural pace. Ensure you can observe from the front, behind, and both sides. Have them walk barefoot where possible, then with their device.
Step 2: Observe globally first. Before focusing on any specific joint or segment, watch the whole patient. What is your overall impression of their symmetry, rhythm, and energy expenditure? A patient who looks exhausted after walking ten metres is telling you something important even before you identify any specific deviation.
Step 3: Observe segment by segment. Work systematically from the foot upwards — ankle, knee, hip, pelvis, trunk — in each plane of movement. The sagittal plane (side view) shows you flexion and extension; the frontal plane (front/back view) shows you abduction, adduction, and lateral trunk shift; the transverse plane (above) shows you rotation, though this is harder to see without instrumentation.
Step 4: Compare with and without the device. This is especially important in orthotics. A patient’s natural compensations without the orthosis often reveal what the device needs to address. Sometimes removing the device temporarily during assessment is the most informative thing you can do.
Step 5: Document what you see. Use a simple gait deviation checklist or the Rancho Los Amigos Observational Gait Analysis system. Consistent documentation allows you to track change over time and communicate clearly with physiotherapists, physicians, and other team members.
Common Gait Deviations and Their O&P Implications
Foot drop (insufficient dorsiflexion in swing): The patient cannot lift the foot adequately to clear the ground. Common causes include weakness of the dorsiflexors, spasticity of the plantarflexors, or inadequate foot clearance from the prosthetic foot. Management typically involves a dorsiflexion-assist AFO, adjustment of prosthetic foot alignment, or both.
Trendelenburg gait (lateral trunk lean over the stance limb): Caused by weakness of the hip abductors, particularly gluteus medius. The trunk leans towards the weak side to reduce the demand on the abductors. In lower-limb prosthetics this is often seen when the prosthetic socket does not provide adequate mediolateral stability.
Excessive knee flexion in stance: This can indicate quadriceps weakness, a painful knee, or a prosthetic alignment problem. It dramatically increases energy expenditure and, if prolonged, can lead to knee buckling. Ground reaction AFOs are often prescribed for this presentation.
Vaulting: The patient rises on the toes of the sound limb during swing of the affected limb. This is almost always a compensatory mechanism for insufficient clearance — look for the cause in inadequate knee flexion, insufficient ankle dorsiflexion, or a prosthesis that is too long.
Hip hiking: Another compensation for insufficient clearance, in which the patient hikes the pelvis up on the swing side. Often seen in stroke rehabilitation with an AFO that is too rigid, preventing adequate knee flexion initiation.
Building Gait Analysis Into Your Practice
You do not need a motion laboratory to do meaningful gait analysis. A clear corridor, a systematic approach, and — increasingly — a smartphone can take you a long way. Video gait analysis, where you record the patient walking and review the footage frame-by-frame, is widely used in resource-limited settings and allows you to see things that are simply too fast for the human eye to catch in real time.
At OPPAK Academy, our online modules and workshops on gait analysis are designed specifically for Pakistani O&P clinicians working in a variety of settings, from large rehabilitation hospitals to smaller district-level clinics. Systematic observation is a skill that improves with deliberate practice, and even fifteen minutes of structured observation after each patient can accelerate your learning significantly.
This article is part of the OPPAK Academy Blog series on clinical skills for orthotists and prosthetists. If you found it useful, share it with a colleague or leave a comment below.