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Is Gait Dysfunction a Symptom, or an Objective Finding?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Kevin Kirby, Sep 5, 2014.

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    In a thread where we are discussing Pediatric Flatfoot Correction with Foot Orthoses, a colleague made the following statement:

    My question to all of you is do you agree that gait dysfunction IS a symptom?

    I was taught at the California College of Podiatric Medicine, and have been teaching for the past three decades, that gait dysfunction is an objective finding, not a symptom. Rather symptoms are the subjective complaints of the patient, that don't include their objective findings nor any gait abnormality descriptions.

    Therefore, if a 7 year old boy has a maximally pronated subtalar joint throughout the stance phase of gait, a severe flatfoot deformity, an apropulsive gait pattern but the boy and the parents complain of no pain in the child and they have no complaints regarding their walking or running, should this child be considered to be asymptomatic or symptomatic??

    Maybe this is the difference in terminology from one country to another. But here in the USA, the above child would definitely be considered asymptomatic, not symptomatic.
  2. I tend to agree with you Dr. Kirby.
    Was she trying to indicate that gait dysfunction in the feet can sometimes be traced to abnormality up the chain? Or extrinsic factors such as excessive weight?
    Hard to connect what she meant by that but maybe there was more to it?
    The use of the word "symptom" would probably not be best in that case.
  3. I still don't know what "gait dysfunction" is. Can someone define it please?
  4. Boots n all

    Boots n all Well-Known Member

    KK, whilst the question is a good one, l disagree with you making it personal by naming the other Pod, why not keep it professional?

    "Do you agree or disagree with the following statement. Gait dysfunction IS a symptom."


    "A question for my fellow Podiatrists, do you agree that gait dysfunction IS a symptom?
    I was taught at the California College of Podiatric Medicine...."

    Otherwise you turn it into a person slinging match, lets discuss the subject matter, otherwise you just put people off from having their say.
  5. Good point. Don't at all mean to turn it into a "person slinging match", whatever that is. I would be happy if one of the administrators could edit her name out if that is more appropriate for all of you others following along since I can no longer edit the original post. I just want to know if other podiatrists also think that this other podiatrist's opinions hold true in their part of the world. In my part of the world, gait findings are objective, not symptoms, and a child with an abnormal gait pattern with no subjective complaints is asymptomatic.

    Now, David, after all of that, do you have an answer for my question??
  6. Griff

    Griff Moderator

  7. David Smith

    David Smith Well-Known Member

    Dysfuntional = not working normally - therefore define normal - AAaah!

    For me a normal gait is one that allows the person to operate sucessfully within the usual parameters of their lifestyle activities and without causing pathology or might otherwise be reasoned to cause pathology over a certain time span or that pathology might result if activities outside thier usual scope of activity were to be undertaken.
    In short 'if it aint broke dont fix it' - unless- it might be reasonable to assume that it might break if preventative measures are not taken.
    That's ambiguous enough to allow someone to use their training, skill, reasoning and judgement to make an appropriate decision for and with the individual presented to them. So function outside of those criteria could be called dysfuntional (for that individual)

    So within those parameters the painful or functional problem the patient presents with is the symptom and our job is not to define normal and therefore apply the label of 'dysfunctional' but rather make a change that resolves the painful symptom or enables the required function.

    Often tho and probaly most times the change from pathological function to non pathological function will approximate what we might commonly regard as a standard reference - position or RoM or strength or symmetry - that some might label as normal, since that's the way most of us work best.

    REgards Dave Smith
  8. Jeff Root

    Jeff Root Well-Known Member

    I’m not a podiatrist but I was an EMT/firefighter for many years. We were taught the difference between signs and symptoms. A symptom is something that the patient experiences and reports while a sign is something you can clinically observe or measure. For example, the patient reports that they feel like they have a fever. That would be a symptom. You feel their forehead and they feel hot or you measure their temperature and find it is elevated. These would be signs. An objective finding would be a sign but not all signs are objective, especially when it comes to gait observations. In fact, a lot of clinical biomechanics is based on subjective findings resulting from observation or imperfect measurement techniques.

    As Simon suggested, gait dysfunction is hard to define, especially when you are dealing with minor to moderate gait variances. A term we don’t hear used all that often is gait anomaly. The definition of anomaly is:
    1. Deviation or departure from the normal or common order, form, or rule.
    2. One that is peculiar, irregular, abnormal, or difficult to classify: "Both men are anomalies: they have . . . likable personalities but each has made his reputation as a heavy" (David Pauly).

    I like the term anomaly for describing gait mechanics that deviate from the norm. The norm in this case could be an average or a generally accepted set of parameters, depending on how the term is being used or defined by the clinician. For example, if a clinician observes excessive abduction of the foot during gait, he/she is basing this observation on their training and understanding of what constitutes a normal range of abduction during gait. Whether this abduction leads to symptoms or dysfunction (dysfunction = impaired function) or not is another question entirely and must be based on other criteria, not just the increased degree of abduction which is being observed.
  9. efuller

    efuller MVP

    I'm still trying to get my head around what is objective. I remember having a discussion with the sagittal plane theorists about whether the use of the FSCAN was an objective test. "It's computerized and the data is stored so therefore it must be objective." (paraphrased) However, they never actually manipulated the numbers to create quantifiable data. They just looked at the pretty pictures on the computer and offered an opinion as to what it meant. Is that objective or subjective?

    Perhaps that definition doesn't really apply to medical charting. But in the case of looking at a computer screen and offering an opinion, that is just as subjective as a gait exam. We see a gait and we think it's maximally pronated, but it's not like taking a temperature where we get an actual number.

    In thinking about an apropulsive gait, I know what Kevin is talking about. Yet, I've never seen anyone measure it. I would really like to take some experienced gait observers and have them rank the amount of propulsiveness that they see and compare that to the measurement of ankle joint power. Ankle joint power (moment x angular velocity) can be calculated through the use of inverse dynamics. So, when we say there is an apropulsive gait is that an opinion, a finding or an objective finding? I dont think I have an answer. I would write my opinion of what I see in the objective part of the medical record. (SOAP noting technique, is everyone taught that?) Does that make my opinion objective?

  10. Thanks, Jeff and Joe, for answering my question. Maybe others can offer their opinion on what a symptom actually means to them: does it mean subjective complaints only or does it mean subjective complaints and objective signs and findings?

    Here's what the online medical dictionaries say a symptom is:

    And for the term, asymptomatic:

  11. Orthican

    Orthican Active Member


    For us in my world we use the term gait "anomaly" then describe the anomaly. Dysfunction is used but more infrequently but still dysfunction is observational and not a symptom. An anomaly is not a symptom. As was stated previously symptoms are what is subjectively reported by the patient. Symptoms reported by the patient most certainly can lead to a gait deviation or anomaly but as I see it not the other way around.
  12. The data coming from the F-Scan is objective. The interpretation of the F-scan data is often subjective, due to lack of agreement on its biomechanical significance.

    Subjective, Objective, Assessment, Plan=SOAP. As Eric alluded to, that is standard medical charting procedure worldwide, to my knowledge. Measuring a maximally pronated subtalar joint is objective. The patient reporting that their foot is pronated is subjective.

    An asymptomatic flatfooted child has no subjective complaints, but very often has observable, quantifiable and objective gait findings which are abnormal. In my opinion, to not offer specialized expert biomechanical treatment to an asymptomatic child with abnormal gait findings due to their medially deviated subtalar joint axis and flatfoot deformity is unethical.

  13. musmed

    musmed Active Member

    Hi All
    what gait are we talking about?

    The gaits I know are:
    Slipped femoral epiphysis
    adductor gait of Osteoarthritis of the hip.
    normal Gait
    gait of polio
    gait of dsysplastic femoral articulation
    Trendelenburg gait

    Some will definitely be or become symptomatic with time while others will not.

    I feel sometimes people do not look above the short sock line sometimes.

    finally sunny here
    buckets of rain for 4 weeks
    want some= send self addressed envelope.

    Paul Conneely
  14. A scientist from the pigeon-toed tribe decides to measure the angle of gait of all of the members of the tribe; she finds that everyone in her tribe has an adducted angle of gait, the average angle of gait is 15 degrees adducted with a range of 5 to 25 degrees adducted.

    One day a member of the Liam Gallagher tribe visits the village and the scientist notices that the Liam Gallagher tribesman has a marked abducted angle of gait. "You're abnormal" she says to the Gallagher, "it's not normal to have an abducted angle of gait. I've measured everyone in my tribe and formed a normative database, you fall outside of that norm therefore you are abnormal, dysfunctional, an anomoly". "What are you talking about?" says the mono-browed Gallagher tribes-man, "of course I'm normal, all the Liam Gallagher tribe walk like this. Come back to my village with me and I'll show you". So together they go back to the Liam Gallagher village.

    When they get to the village the scientist from the pigeon toed tribe observed many Liam Gallaghers walking with an abducted angle of gait. Being a good scientist she decides to measure them all. She looked at her data for the Liam Gallagher tribe and found that everyone in this tribe had an abducted angle of gait; the average angle of gait was 15 degrees abducted with a range of 5 to 25 degrees abducted.

    The scientist decided that in order to better express the variation in the angle of gait, she should pool the data from her own tribe with data of the Liam Gallaghers. She calculates that the average angle of gait as neither abducted nor adducted with a range of 25 degrees abducted to 25 degrees adducted.

    The more astute will have realised that the normative range is dependent of the sampled population- if you've only ever seen the Pigeon-toed tribe, you might think that the Liam Gallaghers are anomolies, dysfunctional or whatever... No-one in her sample population had an angle of gait that was neither abducted nor adducted, yet this is now the average. The data from the two tribes was discreet and shouldn't have been pooled in the first place.

    Being a not so good scientist, she decides that this average of neither abducted nor adductedd angle of gait is clinically normal / ideal and then proceeds to attempt to make everyone walk in this fashion.....Go figure.
  15. Jeff Root

    Jeff Root Well-Known Member

    Normative values are used in all aspects of medicine. Your silly example doesn't mean that they aren't useful in podiatry to some people. I refuse to get drawn into another one of these pointless debates with you Simon.
  16. steven rostron

    steven rostron Welcome New Poster

    I agree that with regards to patients that a symptom is something that they complain of I.e it hurts in a certain place. The above is not a symptom but is purely observational.
    What is normal for one person is individual to them.
  17. Jeff Root

    Jeff Root Well-Known Member

    The issue is one of comparative anatomy. Forget signs, symptoms and pathology for the moment and simply look at how one individual compares to another structurally. Tibial varum vs. tibial valgum, ff varus vs. ff valgus, ff adductus vs. ff abducuts are more extreme. However, the degree of tibial varum between subject A and subject B, the degree of ff varus between subject A and B, and the degree of ff adductus between subject A and B can be extremely useful clinical information for those who are trained and choose to use these comparative values or observations. These structural conditions can be used for making treatment decisions be they surgical or non-surgical in nature. If a patient has a severe bunion and you're going to treat it surgically, you had probably better take a look at the intermetatarsal angle to determine if that might be a contributing factor. Should we conclude that the high IM angle is 'normal" for that individual and therefore simply ignore it? Or if you correct it surgically, what is the IM angle that you should attempt to create post surgically? Doesn't this require some range of normative value to guide the surgeon? So why should the nonsurgical approach be different? You can't isolate function without considering structural influences. The issue is not normal vs. abnormal, the degree of variation is what is important to consider and how that variation might be contributing to symptomatology.
  18. As a podiatric surgeon, I routinely use the accepted normal ranges of metatarsal alignment as a guideline to reestablishing more normal alignment, function and decrease pain in the joints of the forefoot with my foot surgeries. I have been doing so now for over 30 years and nearly every podiatric surgeon here in the USA that I know and every orthopedic surgeon that I know does the same. I don't see any reason why we can't apply these same orthopedic and podiatric surgical guidelines to the anatomy of the foot and lower extremity for use by those podiatrists who do not do surgery.

    The problem is not that structure doesn't affect function. Significant changes in bone structure would have to affect function using the known laws of physics. The problem is, rather, that we can't agree, as a medical profession, how structure exactly does affect function, simply due to a lack of good research on the subject and our previous history of podiatric theory being accepted as dogmatic fact without adequate research being available to either support it or refute it.

    It's about time for podiatry to start doing the research that is necessary to show that changes in foot and lower extremity structure either do, or do not, change weightbearing function of the foot and lower extremity.
  19. steven rostron

    steven rostron Welcome New Poster

    Thank you for replying to my post . Continuing with the person having bunion surgery, they surely are having this due to being unable to manage their symptoms with conservative measures. My point was that if someone is asymptomatic then intervening due to observations such as 'abnormal gait' is unlikely to be the most appropriate way forward. If somebody is symptomatic then they should be given the most appropriate management, surgically or otherwise.
  20. Jeff Root

    Jeff Root Well-Known Member

    Here is a link to a simple article that uses the concept of normal values for radiographic evaluation of hallux valgus. We can see that when x-rays are taken with the subject shod, the osseous relationships or angles change. As a result, it is necessary to establish standard positions such as angle and base of gait, relaxed calcaneal stance position, neutral calcaneal stance position, etc. and standard radiographic angles for taking films and measurements since these osseous relationships have greater meaning and reliability only when we standardize or define the conditions in which they were taken. It is important to appreciate both the limitations and the benefits of such techniques. In my opinion, the same holds true for biomechanical examination and gait analysis findings and interpretations. Needless to say, I have wondered way off topic for this thread! Sorry!

  21. It is interesting that the orthopedic surgery profession has no problems measuring deformities of the leg and then doing surgical corrections of these deformities for certain pathologies. Why does the podiatric profession now have such a problem with measuring angular deformities of the feet and lower extremities, even when they aren't doing surgery on the feet or legs?

  22. Trevor Prior

    Trevor Prior Active Member

    I am in agreement with Kevin. We also use ranges of measures to determine the nature of our surgical procedures, albeit, this has limitations. I also agree with Kevin that structure can influence function with the limitations he highlights. As far as I am aware, most of the studies to date that have tried to link structure to function have highlighted specific structural aspects and found it difficult to identify set patterns.

    This is not surprising considering that the structure of the whole body and, in particular, the pelvis down, will have an effect on how the foot loads. This will then be influenced by relative muscle flexibility, strength and recruitment patterns, let alone the surface and footwear. To take a small number of structural variables in isolation of function elsewhere is likely to affect the results. That is why this type of research is so difficult.

    The paper by McPoil & Cornwall that identified 4 pronation patterns for walking is a good example – why are there 4 patterns - most probably because of the combination of a range of factors of the whole lower limb. I have observed that I tend to find patterns of structural alignment and wonder if this is a direction for research.

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