On Looking: Eleven Walks With Expert Eyes (22 page)

He was right. I went through intensive rehabilitative therapy. It was so successful that, one day six months later as Johnson and I went out to take a walk from his office, neither of us even commented on the fact that I was walking with no apparent limp. Walking again represented that most desirable of conditions: ordinariness.

Johnson is tall and his smile is wide, neither feature revealing
that he used to be a professional dancer. It was an injury while lifting another dancer that prompted him to seek his own care, and ultimately to earn a doctorate in physical therapy. Now he is the director of physical therapy at the Spine Center, a neurologic division of Columbia University Medical Center. He met me for a walk on a Friday before a long weekend, and the city was filled with people trying to get out of it. A rain had just scoured the air and pedestrians reveled in their shirtsleeves and coatlessness.

We looked left: people walking; we looked right: people walking. All seeming to be unwittingly submitting themselves for the gait test. I confessed to Johnson straightaway that I already felt there were two kinds of gaits: unremarkable and lame. People either seemed to get along fine or they had a limp, a weakness, or were afflicted with youth or age. It was not clear to me that there would be more that we could see.

Johnson spent the next ninety minutes disabusing me of that notion. Three steps into our walk, he had found his first subject.

“. . . If you look at this woman while she’s walking, she’s carrying a very heavy bag”—on her right shoulder—“and her body is listed all the way over to the left as she negotiates her heels, her arm is swinging on the left to give her momentum. Notice her shoulder height on the right? Rather than have it relax and pull on her neck, she actually activates her upper trapezius and hikes the whole side of her body up . . . there’s a good chance the scalene muscles on that side are going to be tight.”

The woman was wearing high-heeled boots, a short dress, and looked like a very ordinary urban walker. But on closer inspection, it did appear as though her right side, holding the bag, was frozen in an uncomfortable position. And her left arm swung excessively to and fro, conducting an orchestra at her toes.

“She’s holding on for dear life. A potential patient,” he added.

I wondered if everyone begins to appear to be a potential
patient when you are a physical therapist. As she swung away from us, I asked Johnson what the most common disorder he saw on the street was.

“One thing you see a lot is the habitual stooped posture, a forward head with a big kyphosis, especially in older individuals. Many wind up with stenotic spines, and when they lean forward, they actually create room for the tissues and the nerves in the back and it brings relief.” Two seconds later, his exhibit materialized. “There, that individual . . .”

A tall, large man in a suit, his hair gray and thinning, was stepping off our sidewalk into the street. His neck brought his head forward rather than up, and his back was hunched, just as Johnson had said. The front of his suit hung lower than the back. I thought aloud how hard he must be to tailor.

“Indeed! That follows from his body: can you see how his hands are facing backwards, how the palms are facing you? That’s a product of internal rotation of the shoulders. As he stoops, the back becomes rounded, the head goes forward, and the shoulders, too. And so does the front of his suit.

“It’s basically our succumbing to gravity. It takes less musculature work to hang on the ligaments. Over time the ligaments yield; even the bones deform. If you have osteoporosis and the bones are soft, the vertebrae of the spine start to wedge to support that”—actually reshaping themselves so they are smaller in front and larger in back.

We were not just seeing a man crossing a street; we were seeing vertebrae in the process of wedging.

One minute later, clothing again served to accentuate a disorder in the making:

“Look at the pants,” he said, of a heavyset man. Okay, I did: the pants were blue. Also, they were so long that they gathered in rolls above the man’s shoes.

Johnson patiently unpacked what he saw: “So look at how the cuffs are, and the shoes. The cuffs are bunched up more on the outside of the leg than the inside, and on the shoes you can see uneven wear where it looks like it’s worn more on the outside than the inside. If you look at the way he walks, his knee is valgus—it’s basically a moment where your knees come together and your feet go out. It effectively shortens your leg, particularly on the outside, while your inside becomes effectively longer. So your pelvis moves somewhat differently, and you end up wearing your shoes unevenly.”

From disorderly cuffs and worn shoes, the astute gait observer can infer structural problems. Maybe his arch tends to drop, or maybe the ball of his hip is turned slightly forward in the socket of the pelvis. Over time, and after millions of steps, a subtle anatomical variation turns into an acquired deformity.

What had seemed like “unremarkable” gaits were looking more remarkable. Johnson and I moved onto the edge of the sidewalk and paused. A nearby subway unloaded a phalanx of walkers onto the sidewalk, and walkers hurried to make a short light across the street. This particular intersection frequently came up in discussions in his clinic, he said, because the street was extra-wide and the walk signal was extrashort. Many patients cannot make it across the street without hurrying or breaking into a run. Every gait disorder was accentuated under the stress.

Looking out onto the corner and the sidewalk, Johnson’s
assessments were rapid fire: “She hyperextends her knees, using the inert tissues—the ligament and the calcus—to absorb the shock. Her knees rotate in, see? She’s a likely knee-injury candidate, hip injury candidate.” He added, “She would not be a good candidate to be a runner.”

Another: “If you look at that individual”—an older woman with thinning hair, an extralong jacket, and a defeated air—“she’s waddling. Every time she steps on her right leg she leans way to the right and her left hip drops: that’s called a Trendelenburg sign. It’s weakness of the glute medius muscle and muscles of the side of the hip.”

Followed by: “He’s very thin”—an older man with a black hat, looking fragile—“and he’s bowlegged on the right leg, which means it’s taking a lot of weight on the inside of the right knee, and he’s not bending the knee, he’s landing on it, keeping it stiff. So he has a painful knee joint. He lacks muscle definition: that leads to a lack of control on that limb. His foot slaps down, and comes way inside the knee, where the heel lands. This contributes to his weaving back and forth, too.”

Johnson found lots of so-called gait “faults,” but he was also admiring of the people we saw: more than anything, one becomes aware of how many different but successful ways there are to propel oneself around one’s day. Nor is every odd gait a pathology. A Hasidic man in too-large shoes flopped by us, prompting Johnson to remember a recent patient: “. . . an Orthodox gentleman who had a gait that was contributing to pain in his back: a tear of his annulus or his disk in his back, which is worse when you’re leaning forward. So we worked a lot on posture, to get him into a more upright posture. But he refused to do it. He explained to me that it wasn’t the posture of a humble man.”

It was a revelation that gait might reveal religion. Or profession: a middle-aged man passed by balancing a ladder by one rung
over his left shoulder. “His gait speaks to the fact that he’s walked with ladders like that quite a bit.”

It is no surprise that “balancing a ladder” indicates that one might be “a person whose work employs ladders.” But we could also see roughly how long he had been so employed. Because despite balancing an unwieldy object on one shoulder, it looked as though if we were able to surreptitiously slide that ladder off of him, his gait would change not a whit. Were he inefficient in his gait when hoisting ladders, an injury would have had him retired long ago. In the same way, a furniture mover who can strap five boxes of books onto his back and head off down the street like a normal—if slow-moving—walker is one who knows what he is doing. Hire that man. He has found a walk that is efficient and low in stress, and he is unlikely to be injured moving your dictionaries.

Efficient
was how Johnson defined the perfect gait. This is a word that comes up in dog-show judging, too, in which each entrant’s gait is examined, usually at a trot. Many of the breed standards for gait are a version of Johnson’s definition: “tireless and totally efficient” (malamute); “balanced, harmonious, sure, powerful, and unhindered” (rottweiler). Sometimes the descriptions range into the more lyrical: the “steady motion of a well-lubricated machine” (German shepherd); “true, precise, and not slurring” (Irish water spaniel); even “a perfect balance between power and elegance” (Rhodesian ridgeback). Despite the preponderance of potential patients among the pedestrians passing us, Johnson pointed out plenty of balanced, precise—
perfect
—walking. On a hilly street, two men, diametrically opposed in style, approached us going downhill. One man was heavyset, wearing a loose cotton jumpsuit and cradling a sports drink in one hand. His whitening dreadlocks were pulled into a cap. The other was slim and shorn, wearing a shiny gray suit and a bright pink shirt. The first walked loosely and evenly, his knees bending to comfortably
absorb each step, his pelvis rotating and his arms swinging smoothly. The gray suit was perfectly aligned in his steps: his ears over his shoulders, his shoulders over his hips.

Each, Johnson said, was a version of the ideal walker: their gaits had few asymmetries, were smooth and loose, and wasted no energy doing anything but going forward. From an evolutionary perspective, efficiency is the key. Our ancestors may have been easily outrun by any potential predator—we are not a particularly fast species—but we have endurance: those proto-humans who could keep running won their lives. And they could do that if their gait was efficient.

The gray suit lapel flapped in the breeze as its wearer jaywalked a diagonal across the middle of the street. The man in the jumpsuit ducked under a scaffolding. Neither was felled by predators on this day.

 • • • 

In Philadelphia, Lorber and I turned left onto Chestnut Street. Occasional raindrops were becoming less occasional. I had been back in this city exactly one day and was struck by how it was at once familiar and unfamiliar. Against a backdrop of urban design, shops, and citizens on the whole quite similar to those of my current city, the differences stood out as bas-relief. The sidewalks were narrower, befitting a place slightly older than my neighborhood. Buildings were on the whole shorter, allowing me to feel towering at five feet nine. The urban horizon was farther away: from some streets I could see to the next street, or to the next neighborhood, quite unlike the blindered, cavernous view one gets on a New York City street. Alleys interrupted long blocks, providing peeks onto the backsides of businesses. Peering down one alley, I wondered what kind of superhighway this was for one of John Hadidian’s urban species.

I also recognized what I thought of as a “Philadelphia look”: people with features reminiscent of my now-deceased grandmother, Johanna, who lived here for all of her eighty-six years. I can remember meeting her in a darkened restaurant on Chestnut Street for clam chowder. We sat in a hushed booth with velvet pillows, and she crumbled soda crackers into her soup bowl. And now I seemed to see people who resembled her, in the softness of her skin, the shape of her eyes, the pride in her walk. I could almost hear the jangles of the bracelets she wore on her arm. I asked Lorber, also a native of this city, if he knew this “look.” He responded with a blank expression. Apparently the look was simply a nostalgic concoction of my own head.

We picked up our pace as the rain did, and began discussing the kind of shelter we might soon seek.

“That woman,” Lorber interjected, his voice not changing tone from the previous sentence, “may have a genetic disorder.”

“What?” My mind was still attending to the rain and my eyes were still looking at awnings.

“On the XY chromosome. The way her ears were set low, her short stature, and what was called ‘webbing’ under the face, that’s indication of this disorder.”

I looked behind us. There had been a woman; on reflection, I had indeed noticed that someone had walked by. Now she was retreating and soon disappeared around the corner from which we had come. She was broad and brunette. That was all I had noticed. Lorber, meantime, had seen a genetic deformity on her twenty-third chromosome.

I was amazed. In a vague, theoretical sense, I of course knew that we all wear our genes on our faces, bodies, and sleeves. My blue-eyedness is not a function of anything that I have done over my life: it was preordained once the sperm hit the egg. Still, eye colors seem categorically different from the kind of global
diagnosis that Lorber was willing and able to make. This deformity would not only have physical ramifications, but behavioral ones. Seeing that woman’s face, he was also seeing her probable behavior.

Lorber was confident but appropriately circumspect about his on-the-fly diagnosis. After all, he was not able to use some of the most useful and overlooked elements of an introduction to a new patient: simply hearing the patient tell her own history, revealing details classified as “non-contributory,” such as her profession, family life, and daily habits. Symptoms need a backstory.