Foot Clearance: We don't think about it until we are face down in the mud, and we have all been there.
/How many times have you tripped over something so small and insignificant you can barely believe it ? We have all tripped over a small elevation in a cracked sidewalk or a curled up rug corner. But sometimes we look back and there is no evidence of a culprit, not even a Hobbit or an elf. How can this happen ?
Minimum foot clearance (MFC) is defined as the minimum vertical distance between the lowest point of the foot of the swing leg and the walking surface during the swing phase of the gait cycle. In other simpler words, the minimum height all parts of the foot need to clear the ground to progress through the swing phase of the limb without contacting the ground. One could justify that getting as close to this minimal amount without catching the foot is most mechanically advantageous. But, how close to vulnerability are you willing to get ? And as you age, do you even want to enter the danger zone ? Obviously, insufficient clearance is linked to tripping and falling, which is most concerning in the elderly.
Trips or falls from insufficient foot clearance can be related to insufficient hallux and toe(s) dorsiflexion (extension), ankle dorsiflexion, knee flexion and/or hip flexion, failure to maintain ipsilateral pelvis neutral ( anterior/posterior pelvis posture shifting), even insufficient hip hike generated by the contralateral hip abductors, namely the gluteus medius in most people’s minds. It can also be from an obvious failed concerted effort of all of the above. Note that some of these biomechanical events are sagittal and some are frontal plane. However, do not ever forget that the swing leg is moving through the axial plane, supported in part by the abdominal wall, starting from a posteriorly obliqued pelvis at swing initiation into an anteriorly obliqued position at terminal swing. We would be remiss as well if we did not ask the reader to consider the “inverted pendulum theory” effect of controlling the dynamically moving torso over the fixed stance phase leg (yes, we could have said “core stability” but that is so flippantly used these days that many lose appreciation for really what is happening dynamically in human locomotion). If each component is even slightly insufficient, a summation can lead to failed foot clearance. This is why a total body examination is necessary, every time, and its why the exclusive use of video gait analysis alone will fail every time in finding the culprit(s).
When we examine people we all tend to look for biomechanical issues unless one grasps the greater global picture of how the body must work as a whole. When one trips we first tend to look for an external source as the cause such as a turned up rug or an object, but there are plentiful internal causes as well. For example, we have this blog post on people tripping on subway stairs. In this case, there was a change in the perceptual height of the stairs because of a subconscious, learned and engaged sensory-motor behavior of prior steps upward. However, do not discount direct, peripheral and lower fields of view vision changes or challenges when it comes to trips and falls. Do not forget to consider vestibular components, illumination and gait speed variables as well. Even the most subtle change in the environment (transitions from tile to carpet, transitions from treadmill to ground walking etc) can cause a trip or fall if it is subtle enough to avoid detection, especially if one is skirting the edge of MFC (minimal foot clearance) already. And, remember this, gait has components of both anticipatory and reactive adjustments, any sensory-motor adaptive changes that impair the speed, calculation and timely integration of these adjustments can change gait behaviors. Sometimes even perceived fall or trip risk in a client can easily slip them into a shorter step/stride length to encourage less single leg stance phase and more double support phase gait. This occurs often in the elderly. This can be met with a reduced minimal foot clearance by design which in itself can increase risk, especially at the moment of transition from a larger step length to a shorter one. Understanding all age-related and non-age related effects on lower limb trajectory variables as described above and only help the clinician become more competent in gait analysis of your client and in understanding the critical variables that are challenging them.
Many studies indicate that variability and consistency in a motor pattern such as those necessary for foot clearance are huge keys for predictable patterns and injury prevention, and in this case a predictor for trips and falls. Barrett’s study concluded that “greater MFC variability was observed in older compared to younger adults and older fallers compared to older non-fallers in the majority of studies. Greater MFC variability may contribute to increased risk of trips and associated falls in older compared to young adults and older fallers compared to older non-fallers.”
Once again we outline our mission, to enlighten everyone into the complexities of gait and how gait is all encompassing. There are so many variables to gait, many of which will never be noted, detected or reflected on a gait analysis and a camera. Don’t be a minimalist when it comes to evaluating your client’s gait, simply using a treadmill, a camera and some elaborate computer software are not often going to cut the mustard when it really counts. A knowledgeable and engaged brain are arguably your best gait analysis tools.
Remember, what you see in someone’s gait is not their problem, it is their adaptive strategy(s). That is all you are seeing on your camera and computer screen, compensations, not the source of the problem(s).
Shawn and Ivo
the gait guys
References (some of them):
1. Gait Posture. 2010 Oct;32(4):429-35. doi: 10.1016/j.gaitpost.2010.07.010. Epub 2010 Aug 7.
A systematic review of the effect of ageing and falls history on minimum foot clearance characteristics during level walking. Barrett RS1, Mills PM, Begg RK.
2. Gait Posture. 2007 Feb;25(2):191-8. Epub 2006 May 4. Minimum foot clearance during walking: strategies for the minimisation of trip-related falls. Begg R1, Best R, Dell’Oro L, Taylor S.
3. Clin Biomech (Bristol, Avon). 2011 Nov;26(9):962-8. doi: 10.1016/j.clinbiomech.2011.05.013. Epub 2011 Jun 29. Ageing and limb dominance effects on foot-ground clearance during treadmill and overground walking. Nagano H1, Begg RK, Sparrow WA, Taylor S.
4. Acta Bioeng Biomech. 2014;16(1):3-9. Differences in gait pattern between the elderly and the young during level walking under low illumination. Choi JS, Kang DW, Shin YH, Tack GR.
3. Clin Biomech (Bristol, Avon). 2011 Nov;26(9):962-8. doi: 10.1016/j.clinbiomech.2011.05.013. Epub 2011 Jun 29. Ageing and limb dominance effects on foot-ground clearance during treadmill and overground walking. Nagano H1, Begg RK, Sparrow WA, Taylor S.
4. Acta Bioeng Biomech. 2014;16(1):3-9. Differences in gait pattern between the elderly and the young during level walking under low illumination. Choi JS, Kang DW, Shin YH, Tack GR.
