Gait and Posture 12 (2000) 34 45

www.elsevier.com/locate/gaitpost

Review

Symmetry and limb dominance in able-bodied gait: a review

Heydar Sadeghi a,b,c,d,*, Paul Allard a,c, Francois Prince a,b,c, Hubert Labelle a,b,e
b

a
Research Center, Sainte-Justine Hospital, 3175 Cote-Ste-Catherine, Montreal, Quebec, Canada H3T 1C5
Marie-Enfant Hospital, Rehabilitation Center of Sainte-Justine Hospital, 5200 Belanger East, Montreal, Quebec, Canada H1T 1C9
c
Department of Kinesiology, Uni6ersity of Montreal, 2100 Edouard-Montpetit Bl6d, Montreal, Quebec, Canada H3C 3J7
d
Department of Kinesiology, Tarbiat Moallem Uni6ersity, Ministry of Sciences, Research and Technology, Tehran, I.R. Iran
e
Department of Orthopedic Surgery, Sainte-Justine Hospital, 3175 Cote-Ste-Catherine, Montreal, Quebec, Canada H3T 1C5

Received 10 November 1999; received in revised form 7 May 2000; accepted 26 May 2000

Abstract
As one of the most universal of all human activities, gait in the able-bodied has received considerable attention, but many
aspects still need to be clarified. Symmetry or asymmetry in the actions of the lower extremities during walking and the possible
effect of laterality on gait are two prevalent and controversial issues. The purpose of this study was to review the work done over
the last few decades in demonstrating: (a) whether or not the lower limbs behave symmetrically during able-bodied gait; and (b)
how limb dominance affects the symmetrical or asymmetrical behavior of the lower extremities. The literature reviewed shows that
gait symmetry has often been assumed, to simplify data collection and analysis. In contrast, asymmetrical behavior of the lower
limbs during able-bodied ambulation was addressed in numerous investigations and was found to reflect natural functional
differences between the lower extremities. These functional differences were probably related to the contribution of each limb in
carrying out the tasks of propulsion and control during able-bodied walking. In current debates on gait symmetry in able-bodied
subjects, laterality has been cited as an explanation for the existence of functional differences between the lower extremities,
although a number of studies do not support the hypothesis of a relationship between gait symmetry and laterality. Further
investigation is needed to demonstrate functional gait asymmetry and its relationship to laterality, taking into consideration the
biomechanical aspects of gait. 2000 Elsevier Science B.V. All rights reserved.
Keywords: Gait asymmetry; Limb dominance; Symmetry; Laterality indices

1. Introduction
Gait is a basic requirement for daily activity [1] and
is known to be one of the most universal and complex
of all human activities. It is a complex motor skill
governed by several inter-linked pathways from the
cortex to the muscles [2]. The high interaction between
the central nervous system and various muscles allows
the individual to keep the body upright, while at the
same time moving around in an orderly, stable manner.
The interest in asymmetrical gait arises from questions
regarding limb coordination in producing the smooth
* Corresponding author. Tel.: + 1-514-3454931 ext. 6195; fax:
+1-514-3454801.
E-mail address: sadeghih@ere.umontreal.ca (H. Sadeghi).

rhythmical motion of the able-bodied. Gait interpretation can be affected by assuming lower limb symmetry,
since asymmetry is frequently considered to indicate
gait pathology. Therefore, accepting that gait is asymmetrical in the able-bodied population is an important
issue for clinicians and may also be an important
consideration in physical activities, gait evaluation, clinical decisions for patients requiring rehabilitation for
one or both lower extremities, and artificial limb design.
Our intent in this review paper was to summarize the
work done over the last few decades regarding the
assumption of lower limb symmetry during able-bodied
gait. Limb laterality and its possible effect on the
symmetrical or asymmetrical behavior of the lower
extremities during gait is also considered. This paper
consists of three unequal parts. After defining gait

0966-6362/00/$ - see front matter 2000 Elsevier Science B.V. All rights reserved.
PII: S 0 9 6 6 - 6 3 6 2 ( 0 0 ) 0 0 0 7 0 - 9

H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

symmetry and asymmetry, the first part deals with the

biomechanical aspects of symmetry or asymmetry of
the lower limbs during gait. Laterality and its effect on
gait is reviewed in the second part, while the indices
used and proposed to quantify gait symmetry and
laterality are described in the third part.

2. Symmetry and asymmetry

2.1. Gait symmetry definition

Gait symmetry has been defined as a perfect agreement between the actions of the lower limbs [3,4] while
Gundersen et al. [5], Griffin et al. [6], Hesse et al. [7]
and Gabbard [8] suggested using the term gait symmetry when no statistical differences are noted on
parameters measured bilaterally. Anatomical or physiological criteria have also been used to describe symmetrical or asymmetrical behavior in able-bodied gait. It
seems that the common idea in the different definitions
is that the term gait symmetry can be applied when
both limbs behave identically.

2.2. Support for gait symmetry

Historically, gait symmetry was assumed in the literature for the sake of simplicity in data collection and
analysis. In fact, simplification might be one of the
main reasons that many gait studies relied on unilateral
data collection [922] or pooled right and left limb data
[16,2326]. Gait symmetry was not tested in any of
these investigations, since gait symmetry was assumed.
In contrast, some gait experiments where both lower
extremities were included in the observations looked for
gait symmetry and confirmed its presence. For example,
symmetry was reported for foot-floor contact and photographic recording at the level of hips and knees
during three successive walking cycles [27]. The similarity between the lower extremities was also addressed
during gait for the vertical and horizontal reaction
forces of 214 normal subjects [28]. This author suggested that a normal gait pattern could be characterized
by marked population variability, step-to-step consistency and symmetry of the ground reaction forces from
both feet. Using bilateral and three-dimensional electrogoniometer data in 12 able-bodied subjects, Hannah
et al. [23] demonstrated joint motion symmetry in all
three planes of the hip and in the sagittal plane of the
knee during natural walking, using time and frequency
domain analysis. Hamill et al. [29] found no significant
differences between the limbs in 11 vertical, five anterior posterior and four medio-lateral characteristics of
the ground reaction forces during walking and running.
These results were later confirmed by Menard et al. [30]
who did not find significant asymmetry in any averaged

35

ground reaction force patterns at natural walking speed

in nine able-bodied subjects. Perfect symmetry was
reported in energy efficiency between both limbs [31].
Wall et al. [32] and Hesse et al. [7] also claimed that
normal gait is symmetrical. Symmetrical electromyographic (EMG) activities were observed for homologous muscles during level walking without
objective documentation. Although in a few studies
EMG data were collected from the dominant limb
[17,18,25,33], in many others data were collected only
from the right [9,11,33] or left [34] lower limb. In some
cases, the side was not even specified [3547]. Carlsoo
et al. [46] noted that the muscle actions are virtually the
same for the right and left legs in able-bodied gait.
Recording raw EMG data from hemiplegics and normal controls, Marks and Hirschberg [48] stated that the
EMG patterns of activity in both legs in the former
were identical to normal subjects. Arsenault and colleagues [17] pooled the data across subjects, reported an
almost perfect similarity of the profiles for muscle
activities for different subjects, and noted that both
EMG profiles and amplitudes are highly repeatable
within subjects. Although they did specify it in their
previous work [18], these investigators acknowledged
that pooling data smoothes out individual participation
and that these overall averages cannot be perceived as
the real profile of EMG activity [17]. O0 unpuus conclusions [49] corroborate this finding. Pierotti et al. [50]
reported symmetry on average EMG patterns in normal subjects for six knee muscle activities during free,
slow and fast gait.
In short, although it seems that gait symmetry has
been assumed for simplicity of data collection and
analysis, gait symmetry was actually reported in only a
few studies using quantitative biomechanical data,
where both lower limbs were evaluated. Also, there are
not enough studies where a substantial number of
subjects participated. Gait parameters which provide
information about the effect but not the cause of the
movement might also affect interpretation of lower
limb behavior. Unclear definitions of symmetry, using a
single gait parameter or applying simple statistical
methods for comparison, are additional limitations of
these studies.

2.3. Support for gait asymmetry

In pathological gait, marked differences have been
noted between the affected and unaffected limbs. The
most prominent asymmetries found in amputee gait
were related to shortened support times and decreased
ground reaction forces for the prosthetic limb compared to the natural limb [51]. In patients with an
anterior cruciate ligament deficiency, Devita [52] and
his colleagues showed how muscle moments were affected by functional bracing. Asymmetrical properties

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H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

were also reported for 34 gait variables in a group of 31

hemiplegic subjects [6]. In another study, the gait of
hemiparetic patients was characterized by slower velocity and more asymmetry as they swayed more laterally
on the unaffected leg compared to healthy persons [53].
Gait asymmetries in patients with limb length inequality have also been reported [54]. These few examples
illustrate how gait asymmetry can be a direct consequence of abnormality. However, the issue of gait
asymmetry resulting from disability is not considered
here since our purpose was to review the evidence
regarding whether or not the lower limbs in able-bodied
subjects behave symmetrically.
In able-bodied gait, differences between the right and
left limbs have been reported frequently. Singh [55] and
DuChatinier and Rozendal [56] claimed that the lower
limbs are not used equally during walking. Asymmetrical behavior of the lower extremities was observed in
spatio-temporal and kinematic parameters such as velocity profiles [57,58], step [59] and stride [60,61] length,
foot placement angle [60], maximum knee flexion [59]
and range of joint motion [62]. Rosenrot et al. [63,64]
stated that the duration of the initial and terminal
double support periods were not identical, as would be
expected in young healthy subjects. Gundersen et al. [5]
also reported gait asymmetry in temporal and kinematic parameters. Using spatio-temporal parameters,
Wheelwright and his colleagues [65] reported asymmetrical behavior of the lower limbs in 134 normal children
aged 318 years old. Although spatio-temporal
parameters can provide an overall impression of gait,
from another perspective they might not be considered
informative parameters since they are only able to
provide insight into the effect (e.g. stride length) of the
movement and not the cause (e.g. force) [66,67]. In
other words, regardless of whether one accepts or rejects the symmetrical or asymmetrical behavior of the
lower limbs, it would be reasonable to concentrate on
more informative biomechanical parameters which
provide insight into both effect and cause of the movement. The idea of gait asymmetry will be discussed in
the next section using kinetic and EMG data which
consider the cause of lower limb motion during ablebodied gait.
Gait asymmetry was also addressed in able-bodied
subjects where kinetic data were examined. Asymmetry
was found in plantar flexor strength and calf circumference [68] and for forces and moments in both sagittal
and frontal planes [69]. Differences were noted between
the right and left lower limbs of 62 able-bodied subjects
for the peak vertical, anterior posterior and medio-lateral components of ground reaction forces [70]. In
1989, Herzog and his colleagues [4] found that asymmetries were much larger than expected in 34 ground
reaction force data of a control group. Devita et al. [52]
suggested that normal walking can be characterized by

asymmetrical kinetics between left and right limbs

about the lumbar sacral region (L5 S1 joint). In 1992,
Dickey and Winter [71] identified an asymmetrical contribution for the muscular work done at the hip level in
able-bodied subjects. Using ground reaction force data,
Crowe et al. [72,73] claimed that consistent gait asymmetry should be assumed in the oscillation of the body
center of mass. Using time and frequency domain analysis, Giakas and Baltzopoulos [74] investigated the
variability and symmetry of ground reaction force measurements during walking of ten healthy young male
subjects. This study confirmed that human gait is a
symmetrical movement based on harmonic analysis,
while substantial asymmetries characterized time domain variables in the medio-lateral component of
ground reaction forces. Using EMG data, Arsenault et
al. [25] reported asymmetries in EMG amplitude profiles for the soleus and rectus femoris muscles. Subsequently, O0 unpuu and Winter [75] found asymmetrical
activities in seven selected muscles recorded simultaneously by EMG during walking. Gait asymmetry was
also documented by differences in the neuromuscular
drive from muscles involved for a given movement as
measured by EMG [76]. To summarize, based on these
observations, it may be concluded that gait is asymmetrical. However, can we argue that it is acceptable to
conclude that able-bodied gait is asymmetrical just
because of the existence of statistically significant differences between two corresponding parameters (which we
call local asymmetry) calculated from the right and left
limbs? If this is the case, how can we explain the effect
of other factors such as compensation and/or adaptation that directly influence lower limb behavior during
gait? Although this study mainly considers the issue of
gait symmetry in the able-bodied population, giving an
example of amputee gait provides insight into how
other issues such as compensation affect lower limb
behavior locally. In below-knee amputee gait, hip flexors on the amputated side compensate for the lack of
normal ankle function during push-off [77,78]. This
causes gait asymmetry as shown when this parameter is
compared with its corresponding value on the sound
limb. However, this asymmetrical behavior is most
likely related to compensation [78] rather than the
asymmetrical behavior of the lower limbs. To some
extent, compensation might also occur in able-bodied
gait. Based on this assumption it would be reasonable
to find some other way to explain the idea of gait
asymmetry which includes the global behavior of the
lower limbs rather than local parameters. We believe
that the idea of functional gait asymmetry which has
been proposed and discussed in recent gait studies
[79,80] might be a way to explain global asymmetrical
behavior of the lower limbs in relation to local
parameters.

H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

2.4. Functional gait asymmetry

The aim of locomotion is to propel the body forward
while supporting the body against gravity [81]. Gait
asymmetry is explained in part by functional task discrepancies describing the relative contribution of control and propulsion during healthy able-bodied walking
performance. Hirasawa [82] and Vanden-Abeele [83]
were among the first to interpret gait asymmetry in
able-bodied subjects based on the support and mobility
associated with each limb. Hirasawa [84] confirmed his
previous finding [82] in stating that one lower limb is
mainly responsible for support and body weight transfer during walking while the contralateral limb contributes more to propulsion. Evaluating the lateral
component of ground reaction forces during walking of
28 healthy subjects, Matsusaka et al. [85] reported that
medio-lateral balance was mostly controlled by the left
limb. For 53 males and 39 females walking at slow, free
and fast speeds, Hirokawa [86] associated propulsion
with the right limb while the left limb was found to be
responsible for support. A few years later, Sadeghi et
al. [79] reported that propulsion was related to the leg
with predominantly muscle power generation whereas
support and control functions were associated with the
limb having predominantly power absorption behavior.
This study suggested that gait asymmetry in able-bodied subjects can be explained in terms of the actions
taken by the lower limbs to propel the body segments
and to control forward progression. Sadeghi et al. [87]
further tested the concept that the power activity of the
leading limb (propulsion) was related to that of the
trailing limb (stabilizing). They also reported that the
interaction between muscle powers in able-bodied gait
could reflect specific propulsion and control strategies
that are related to each limb.
According to the information discussed here, ablebodied gait seems to be naturally asymmetrical and this
asymmetrical behavior could be associated with the
different contributions of the lower limbs in carrying
out propulsion and control tasks. However, the main
reasons for able-bodied gait asymmetry remain unclear
and need to be determined. Do they include laterality,
the environment, skill or some other factor?
3. Limb dominance
The human body cannot just be viewed from a
biomechanical standpoint [88] since movement occurs
as a result of the integration of biomechanical and
neurophysiological factors. Although laterality and its
possible effect on human movement such as gait has
recently become an issue of interest in biomechanics,
laterality has a longer history in related sciences including neurophysiology [14,15,85,89 91] and motor control [85,9294].

37

Table 1 shows that not many studies to date examined the relationship between gait parameters and laterality, and even fewer investigated laterality and
similarities or dissimilarities in the behavior of the
lower limbs. The lack of collaboration between
biomechanists and researchers in other fields such as
neurophysiology and motor control may also account
for the fewer number of studies. In the next section, the
concept of limb dominance (laterality, limb preference)
and its possible effect in relation to symmetrical or
asymmetrical behavior of the lower limbs will be reviewed. Limb dominance is defined first and then laterality and its effect on gait symmetry or asymmetry is
discussed.

3.1. Limb dominance definition

In general, limb dominance is related to the notion
that the two hemispheres of the human brain are
functionally dissimilar [95,96]. Limb preference and laterality are also used to express the preferential use of
one limb in voluntary motor acts [8,52,76,92,9699].
Peters [92] attempted to define lower limb laterality by
emphasizing the different roles of the lower limbs. The
author used the term preferred foot for the foot or leg
used to manipulate an object or to lead out, as in
jumping. The foot that is used in activities is the
preferred foot while the non-preferred foot provides
postural and stabilizing support. However, a definition
in terms of role differentiation is not satisfactory in
some cases unless qualifications are made. One example
is balancing, in which head, arm, torso, and leg collaborate to achieve postural stability. Is the preferred leg
used for postural support or dynamic counter-balancing? Nevertheless, the definition of limb dominance is
sufficient to be specified here. In the literature, mobilization and stabilization are also used to characterize
the dominant and non-dominant lower limbs, respectively [92,100,101]. A reasonable argument could be
offered regarding the notion of a dominant foot. The
mobilizing or manipulating limb is the preferred (dominant) foot, whereas the foot that is used to support the
actions of the preferred foot is the non-preferred limb.
It appears that several studies on bilateral task behavior
[102104] support the general contention that humans
are typically right-footed for actions of mobilization
and left-sided for postural stabilization. Complementing this conclusion is the physiological observation of
contralateral control and general left-hemispheric dominance for motor asymmetries. From another perspective, Prevics neurodevelopmental theory [105] offers
explanations for foot dominance in the unilateral and
bilateral context. According to this theory, the idea that
there is no clearly dominant limb in the bilateral context seems reasonable, that is, one foot provides necessary postural support while the other executes

38

H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

voluntary (mobilizing) action as the complementary

role action. However, to accept this proposition, one
must assume that the neurological demands placed on
each action (mobilization and stabilization) are equivalent. With most bilateral tasks, it seems that the greatest neurological demand is with mobilization (e.g.
kicking a ball). Perhaps the most interesting aspect of
Prevics theory is the notion that antigravity extension
(postural support) on the left side of the body emerges
before voluntary motor control (mobilization) on the
contralateral (right) side. This suggests that the dominant foot for either unilateral or bilateral task behaviors is the left one for most individuals. Although the
theory appears reasonable with regards to potential
neurodevelopmental structural changes, experimental
observations of unilateral task behavior in children and
adults have generally been nonsupportive [106 109],
that is, individuals frequently exhibited a preferential
bias for the right side, or there was no statistical
difference between the use of the right and left limbs.
To prevent any confusion because of a wide range of
terms suggested in different studies and to use a relevant, consistent definition, throughout the present
study, limb dominance refers to the leg that is used for
mobility while the non-dominant limb contributes to
support. Laterality is also used as a more general term
to express the existence of limb dominance.

3.2. Limb dominance, motor control, neurophysiology

and gait
Despite a shorter history in studies that consider the
issue of symmetrical or asymmetrical behavior of the
lower limbs, laterality has a longer history in other
scientific fields such as neurophysiology or motor control than in gait analysis. For example, in 1865 Broca
[110] was the first to draw attention to and use the term
laterality. He claimed that we talk with our left hemisphere and said that motor organization and brain
functions of the right and left hemispheres are different.
It has since been established that the left hemisphere is
specialized for precise control of fine motor actions on
both sides, while the right hemisphere is related to
bilateral somatosensory spatial ability, emotional expression, and motor functions [90,93,94,111]. Guyton
[91] claimed that the left hemisphere is dominant in
about 95% of humans while in the remaining 5% both
sides develop simultaneously. Rarely does the right side
alone become highly developed. Waziri [89] and Guyton [91] reported that Wernikes area of the cortex will
eventually become larger on the left hemisphere than
the right in more than one half of newborn babies.
Sutherland and his colleagues [14,15] also reported that
the large majority (90%) of individuals with left-sided
cerebral hemispheric dominance were right-footed.

Table 1
Studies that considered laterality and/or its effect on symmetrical/asymmetrical behavior of lower limbs during able-bodied gaita
Author(s)

Parameters

Statistic

Laterality

Symmetry

Singh [55]
Chodera et al. [61]
Damholt and Termansen [68]
Hirasawa [82]
Vanden-Abeele [83]
Rosenrot [63,64]
Claeys [28]
Hamill et al. [29]
Hannah et al. [23]
Matsusaka et al. [85]
Burnie and Brodie [120]
O0 unpuu [49]
Arsenault et al. [25]
Herzog et al. [4]
O0 unpuu and Winter [75]
Gundersen et al. [5]
Baker and Hewison [122]
Devita et al. [52]
Pierotti et al. [50]
Wheelwright et al. [65]
Menard et al. [30]
Crowe et al. [73]
Sadeghi et al. [79]
Hesse et al. [7]
Hart and Gabbard [124]

ST and foot pressure

ST
Kinetics
ST and kinematic
Descriptive
ST
Kinetic
Kinetic
Kinematic
Kinetic
Kinetic
EMG
EMG
Kinetic
EMG
ST and kinematic
Kinetic
EMG
ST
ST
Kinetic
ST and kinetic
Kinetic
Kinetic
Laterality test

Descriptive and t-test

Descriptive
PCC and t-test
T-test
Descriptive
PCC
T-test
T-test
TFDA and PCC
T-test
T-test
ANOVA
PCC
T-test and SI
ANOVA
MANOVA and t-test
ANOVA
PCC and VR
T-test
CV and PCC
Fourier series
PCA and t-test
TFDA, ANOVA and SI
T-test
Descriptive

No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
Yes
No
No
No
No
Yes
Yes
No

Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes

a
ST, spatio-temporal; PCC, Pearson coefficient correlation; TFDA, time and frequency domain analysis; VR, variance ratio; CV, coefficient of
variation; SI, symmetry index; EMG, electromyography; PCA, principal component analysis.

H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

Laterality and its possible relation to the lower extremities have also been considered from a structural
and functional point of view in the literature. Structural
and functional biases are of interest in athletics, dancing, use of some musical instruments, and operation of
machines [92]. Earlier explanations of laterality associated with the structure of the human body (anatomical
asymmetry) were influenced by the idea that dominance
extends to the entire body half. Bell [112] claimed that
in right-handed people the left side is the weaker side of
the body. Von Bonin [113] stated that we are generally
right-handed and left-footed. His statement was based
on X-ray studies by Ingelmark [114] who measured the
leg and arm lengths of right- and left-handers. His work
remains the most comprehensive and carefully conducted study on anatomical leg asymmetries to date.
He reported that 85% of right-handed subjects aged
6 13 years had a longer right leg and 85% of righthanded subjects aged 14 20 years had a longer left leg.
Ingelmark also reported that for left-handers, the situation was reversed: the 6 13 age group had a longer left
leg, whereas the 14 20 age group had a longer right
leg. This result is in agreement with Chibber and Singh
[115] who reported that in humans, the left lower limb
was heavier than the right lower limb. Chibber and
Singh [116] also found that the muscular tissue of the
left limb was significantly heavier than the right. Crosssectional studies indicate that the left leg tends to be
longer [92,117,118] and heavier [92,115]. A hint of the
possible connection between laterality and neuroanatomical variables comes from Irving et al. [119]
who counted the number of motor neurons in the
lumbar and sacral regions of the human spinal cord.
All of their five subjects showed remarkable rightleft
asymmetries in cell counts at the third sacral vertebral
level. A larger neural drive on the dominant side could
explain more energy generation by the plantar flexor
muscles [75]. However, little has been reported about
the relationship between laterality and neuroanatomical
variables. Further studies along these lines might be of
interest.
The influence of lateral dominance has been addressed in gait but to date there has been no conclusive
study on the possible effect of lateral dominance on the
symmetrical or asymmetrical behavior of the lower
limbs during able-bodied gait. Laterality was assessed
mainly as a secondary objective after evaluating the
idea of gait symmetry. Hamill et al. [29] tested the
influence of lateral dominance after reporting the presence of gait symmetry. They did not find any statistically significant differences between the dominant and
non-dominant limb when ground reaction force
parameters were compared. No significant difference
was also reported between peak torque values recorded
for the dominant and non-dominant limb of 18 preadolescent males during 15 knee flexions and extensions

39

[120]. In another study, the relationship between foot

width and limb dominance was examined in 996 subjects [121] and no significant relationship was reported.
Gundersen et al. [5] claimed that there is no relation
between footedness and gait asymmetry and that even
when footedness has been identified, gait asymmetry
could not be predicted by lateral dominance. Baker and
Hewison [122] also found no significant differences
between dominant and non-dominant limbs using temporal and kinematic data.
In contrast, several studies suggested that the asymmetrical behavior of the lower limbs was affected by
laterality. Asymmetry in toed-out and heel positions
relative to walking direction [61] were associated with
asymmetry in motor control function and in the effect
of brain hemispheric dominance. Kerstein et al. [123]
observed that lower limb amputees rehabilitated faster
when it was the non-dominant limb that had been
amputated. These authors also claimed that the dominant limb compensates better for interrupted proprioception and tactile inputs. Damholt and Termansen [68]
found that the dominant leg was stronger in plantar
flexion, while Hirasawa [82] suggested that the dominant leg played a stabilizing function. In the analysis of
proximal and axial neuromotor mechanisms of the
human body, Vanden-Abeele [83] might be among the
first to suggest a relationship between laterality and
functional gait asymmetry in the lower limbs. O0 unpuu
[49] observed a relationship between plantar flexion,
EMG profiles and limb dominance. Arsenault et al.
[17,25] hypothesized that the different functional behavior of the lower limbs might be related to the different
recruitment profiles of the dominant versus the nondominant leg. While Gundersen et al. [5] concluded that
asymmetry cannot be related to lateral dominance,
Singh [55] and Rosenrot [63] claimed that one lower
limb appears as the dominant limb during gait. Based
on the definition of the dominant leg by Hirasawa [82],
Matsusaka et al. [85] reported that medio-lateral balance in walking was controlled by the left limb, which
was the non-dominant side. Although Gundersen et al.
[5] concluded that asymmetry cannot be predicted from
lateral dominance, O0 unpuu and Winter [75] found
some evidence to suggest that plantar flexor EMG
activity was related to limb dominance. In 1991, Devita
and his colleagues [52] also documented that the dominant right limb of their subjects generated between 56
and 61% of total positive work during walking at
natural speed. A theory proposed by Previc [105] indicated that asymmetry in the lower limbs should correlate positively with measures that reflect unilateral
dominance. According to Wheelwright et al. [65], gait
asymmetry may be related to the position of the foot
during the swing phase, reflecting the subjects
laterality.

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H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

Laterality was also considered in the literature as

another explanation for the functional behavior of the
lower limbs during gait. For example, Sadeghi et al.
[79] stated that functional asymmetry in the gait of
able-bodied subjects might be related to limb dominance. Although they did not directly examine this
speculation, five activities kicking a ball, hopping on
one foot, throwing a ball, writing and opening a jar
were used to determine limb preference.
With 47 right- and 32 left-footed subjects, Hart and
Gabbard [124] examined the mobilizing feature of footedness in a unilateral and bilateral context. The subjects
were asked to perform two tasks: draw their initials in
a sandbox with one foot, and roll a golf ball around a
circle as quickly and accurately as possible, while they
were positioned in an adjustable chair with bare feet
flat on the ground and a knee angle of approximately
90. Hart and Gabbard found that 98% of right footers
and 84% of left footers used the preferred limb and
concluded that there is a strong relationship between
limb preference and mobilization tasks in a bilateral
and unilateral context.
Although laterality might be considered as one explanation of the existence of functional gait asymmetry in
able-bodied gait, it seems that the basic question of foot
dominance has not been settled. Researchers are still far
from accepting this speculation as proven until the
relationship between gait asymmetry and laterality has
been objectively examined. More information is needed
about the behavior of the lower limbs in all stability,
mobility and stability/mobility activities. Even then, it
is important to know if a single definition would be
appropriate for limb dominance and asymmetry. Although the general operational meaning of limb dominance seems reasonable with most bilateral conditions,
especially when mobilization rather than stabilization is
paramount, it is simply not representative of the multiple functional characteristics of footedness. Until more
research is conducted to identify the dominant limb in
all contexts, it seems reasonable that foot dominance
should be defined operationally in terms of a behavioral
context (stability, mobility, bilaterality). It can be also
be defined in terms of the demands of the levels of
complexity of the particular task(s) performed.
One other concern about gait symmetry or asymmetry and laterality is the way observations were
quantified. The following section briefly reviews the
different ways of quantifying symmetry and laterality.

4. Quantifying symmetry and laterality

Fig. 1 presents a way of categorizing different means
of determining whether or not symmetry and laterality
exist between the lower limbs using indices

Fig. 1. Quantification of symmetry and laterality.

[3,4,23,25,65,69,75,76,90,119,125136] and statistical

analysis [5,23,58,79,137,138].
To determine asymmetries in ground reaction force
patterns in normal gait, Robinson et al. [129] proposed
an equation called the symmetry index (SI) which was
also used by Herzog et al. [4]:
SI=

(XR XL)
100%
0.5(XR + XL)

where XR and XL are the values of the gait variable

measured for the right and left limb, respectively. When
SI= 0, the gait is symmetrical. Using such an equation,
however, may have major limitations because differences are reported against their average value. For
example, if a large asymmetry is present, the average
value does not correctly reflect the performance of
either limb. Also, parameters that have large values but
relatively small inter-limb differences will tend to lower
the index and reflect symmetry. In spite of these limitations, Becker et al. [136] were able to show that the
successful surgical treatment of ankle fractures in
young adults resulted in improved gait symmetry in
terms of plantar pressure distribution.
To quantify gait symmetry or asymmetry, the value
derived for a gait parameter at the right limb divided by
the associated values at the left limb (R= XR/XL, called
the ratio index) has been applied. A ratio of one was
indicative of a reciprocal gait pattern while higher or

H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

lower values reflected asymmetries. Ganguli et al. [139]

and Seliktar and Mizrahi [140] applied this index to
investigate peak velocity of below-knee amputees, while
Andres and Stimmel [125] used it to assess lower limb
prosthetic alignment. The ratio index was also applied
by Wall and Turnbull [32] to determine temporal gait
asymmetries in 25 patients with residual hemiplegia. A
similar approach involving the ratio of the standard
deviations was considered by Kljajic et al. [141]. To
represent perfect gait pattern symmetry, Vagenas and
Hoshizaki [142] developed a new ratio:
Ia =

(L R)
100
max(L, R)

where R and L are the right and left limb values,

respectively. The scores were recorded to reflect trichotomized values of 1, 0 and 1. Asymmetries larger
than 1% were given a value of 91 and in all other
cases, 0 represented symmetry. As Wall and Turnbull
[32] pointed out, using the ratio index has limitations
particularly from a clinical viewpoint. The two main
potential limitations are relatively small asymmetry and
a failure to provide information regarding the location
of asymmetry. In addition, because of the large percentage of stride time spent in total support and the relatively small difference between the affected and
unaffected sides, low sensitivity could be another limitation of the ratio index.
Using statistical approaches to determine similarities
or dissimilarities between the lower limbs might eliminate the main limitations of using the ratio index. Few
studies have assessed asymmetry using several gait
parameters in a single analysis, though statistical tools
are available. Analyses have included correlation coefficients [25,50], coefficients of variation [143], and variance ratios [44,50,142]. Gundersen et al. [5] did a
two-way multivariate analysis of variance (MANOVA)
with repeated measures because the temporal and kinematic variables were not independent of each other. A
NewmanKeul post-hoc test was also performed for
the variables and showed a significant within-subject
difference between limbs. They also used a Pearson
product-moment correlation to determine the relationships among 12 measured gait variables. Paired t-tests
were also used by Allard et al. [58] between right and
left limb data to determine the presence of gait asymmetry. In their study, no statistically significant differences between the limbs for the spatio-temporal
parameters were observed. Differences were noted between the mechanical energies, which mostly occurred
in the sagittal plane and were generally associated with
energy absorption. Sadeghi et al. [79] also applied ttests for paired data to determine whether or not there
were significant differences between spatio-temporal
parameters, muscle powers and their associated mechanical energies, identified by applying principal com-

41

ponent analysis (PCA) to the data for each lower limb.

Hannah et al. [23] claimed that time and frequency
domains can be considered indices of symmetry when a
correlation coefficient of 1.0 is obtained. Giakas and
Baltzopoulos [74] later applied frequency domain analysis, suggesting that it is an appropriate method to
evaluate gait symmetry, since it allows better comparisons between normal and pathological subjects, if variability is known.
Using sophisticated statistical models could provide
better insight into understanding a complex phenomenon such as gait asymmetry. This is because many
factors are involved, including a large number of gait
parameters that should be evaluated at the same time,
e.g. laterality, disability, functional behavior of the
lower limbs, compensatory mechanisms, etc. This might
explain why recent gait studies have applied advanced
multivariate data analysis to examine the similarity or
dissimilarity in the behavior of the lower limbs during
walking performance. PCA, as a classification and data
structure detection method, was used by Sadeghi et al.
[79] to identify the most informative biomechanical
muscle powers in both limbs during gait of 19 young
healthy subjects. PCA was also used to characterize the
large number of variables calculated for hemiplegic
patients [144]. This study also evaluated gait symmetry
in stroke patients. Recently, Sadeghi et al. [80] applied
PCA as a curve structure detection method, to identify
the main functional tasks of hip sagittal muscle power
curves. Functional gait asymmetry was reported because of the task priority performed by the hip flexors/
extensors during the gait cycle. The Time Fourier Series
was used by Crowe et al. [72,73], who reported consistent gait asymmetry in the oscillation of the body center
of mass during gait.
While symmetry indices or statistical approaches
were used to evaluate gait asymmetry, laterality (Fig. 1)
was mainly determined by self-report or questionnaires
[79,80,87,101,145152]. Observations and testing were
also used to identify laterality. The few well-known and
common tests used to determine laterality include kicking a ball, leading off, stepping up on a chair, pressing
a sheet of paper down with the foot, and choice of foot
for picking up a pebble, one or more of which were
used by different researchers [95,153162].

5. Summary and conclusion

Symmetrical behavior of the lower limbs during gait
has often been assumed, mainly for simplicity in data
collection and analysis, while gait asymmetry seems to
reflects a natural functional difference between the
limbs. This functional difference does not appear to be
the consequence of abnormality, but rather relates to
the contribution of each limb to propulsion and control
tasks. Laterality may be another explanation for the

42

H. Sadeghi et al. / Gait and Posture 12 (2000) 3445

presence of functional differences between the lower

extremities. Basically, an action towards a goal is carried out by the preferred limb, while support is provided by the other limb. However, more work is needed
to evaluate gait symmetry and to determine its possible
relationship to laterality. For example, gait symmetry
and the influence of laterality could be examined by a
research team involving both biomechanists and neurophysiologists, since gait is the result of the integration
of biomechanical, neuro-physiological and motor control actions. In addition, it would be important to use
gait parameters which provide information about both
the cause and the effect of the movement, and to avoid
considering redundant measurements. For example,
muscle power appears to be a good indicator of a
persons ability both to propel the body and to control
balance during gait.

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