Le prosthetic gait assessment deviation
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LE Prosthetic Gait Assessment & Deviation. M. Jason Highsmith, DPT, CP. Outline. Review basic, “normal” gait TT Generalizations (Prognosis & Demographics) Proper alignment Deviations TF Generalizations Proper alignment Deviations. Prognosis. Trans-tibial prosthesis users-

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LE Prosthetic Gait Assessment & Deviation

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Le prosthetic gait assessment deviation

LE Prosthetic Gait Assessment & Deviation

  • M. Jason Highsmith, DPT, CP


Outline

Outline

  • Review basic, “normal” gait

  • TT

    • Generalizations (Prognosis & Demographics)

    • Proper alignment

    • Deviations

  • TF

    • Generalizations

    • Proper alignment

    • Deviations


Prognosis

Prognosis

  • Trans-tibial prosthesis users-

    • In the absence of severe comorbidities

  • Tend to have prognoses favoring pre-morbid activity

  • It is reasonable to expect return to most activities


Demographics

Demographics

  • When toe amputation is not considered:

  • Trans-tibial amputation is most represented level of limb loss:

    • 45% trans-tibial followed closely by

    • 40% trans-femoral then steep drop to

    • <10% below elbow (UE) at 3rd most represented level


Le prosthetic gait assessment deviation

Flexion

Flexion

Flexion

Extension

Flexion

HS

FF

MS

HO

TO


Tt gait assessment

TT Gait Assessment

  • Consider all 3 planes

  • Desired is:

  • Flexion moment throughout stance

  • Slight varus

  • Slight toe out


Alignment considerations

Alignment Considerations

  • Linear

  • Angular

  • Transverse

7


Gait deviation definitions

Gait Deviation Definitions


Gait deviation definitions1

Gait Deviation Definitions


Gait deviation definitions2

Gait Deviation Definitions


Properly aligned

Properly Aligned

  • Observe:

  • All Planes

  • Frontal:

  • Toe out

  • Slight Varus


Properly aligned1

Properly Aligned

  • Observe

  • Sagittal:

  • Slight Flexion Moment


Normal gait

Normal Gait


Deviations

Deviations

  • Normal Gait

  • Extension Moment

  • Flexion Moment

  • Varus Moment

  • Valgus Moment

  • Drop Off

  • External Foot Rotation

  • Long Prosthesis

  • Short Prosthesis

  • Lateral Shift

  • Vaulting

  • Wide Gait


Extension moment

Extension Moment


Extension moment1

Extension Moment

  • Prosthetic Cause

    • Heel Too Soft

    • Foot Too far Anterior

    • Foot Too Plantarflexed

  • Amputee Cause

    • Shoe Heel Height Too low

    • Shoe Heel Height Too low

    • Bad Gait Habits, Strength, Short Residual Limb

16


Flexion moment

Flexion Moment


Flexion moment1

Flexion Moment

  • Prosthetic Cause

    • Heel Too Firm

    • Foot Too far Posterior

    • Foot Too Dorsiflex

  • Amputee Cause

    • Shoe Heel Height Too high

    • Bad Gait Habits, Strength, Short Residual Limb

18


Valgus moment

Valgus Moment


Valgus moment1

Valgus Moment

  • Prosthetic Cause

    • Foot Too Outset

    • Components Too ABDucted

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

20


Varus moment

Varus Moment


Varus moment1

Varus Moment

  • Prosthetic Cause

    • Foot Too Inset

    • Components Too ADDucted

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

22


Drop off

Drop Off


Drop off1

Drop Off

  • Prosthetic Cause

    • Short toe lever

    • Excessive socket flexion

    • Excessive dorsiflexion

    • Incorrect foot type

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Internal Rotation of hip at toe off/hip flexion

24


External foot rotation

External Foot Rotation


External foot rotation1

External Foot Rotation

  • Observations

    • Patient wants foot to match sound side

    • Internal rotation of knee at toe off

    • Induce “medial whip”

    • Drop off at end of stance phase

    • Low back pain

    • Skin irritation due to rotational stress in socket

26


Long prosthesis

Long Prosthesis


Long prosthesis1

Long Prosthesis

  • Observations

    • Patient reports lower back pain

    • Patient reports they feel like they are walking up a hill

    • Noticeable rise and drop of shoulder on the effected side

    • Hesitation in gait timing from prosthetic mid-stance to sound side heel strike

28


Short prosthesis

Short Prosthesis

  • Observations

    • Patient reports lower back pain

    • Patient reports they feel like they are stepping into a hole

    • Noticeable rise and drop of the shoulder on the sound side

    • Uneven arm motion to accommodate uneven stride length

    • Appears like the patient may be vaulting

29


Lateral shift

Lateral Shift

  • Prosthetic Cause

    • Foot Too far Inset

    • Insufficient components ABDuction

    • Short Prosthesis

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb Inadequate balance

    • Weak Knee

    • Narrow Gait Base

30


Vaulting

Vaulting


Vaulting1

Vaulting

  • Prosthetic Cause

    • Long Prosthesis

    • Poor Suspension

    • Excessive Plantarflexion of foot

    • Excessive knee resistance or stability

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb Inadequate balance

    • Fear of catching the toe

    • Weak hip flexors of residual limb

    • Improper initiation of hip flexors on residual limb

32


Wide gait

Wide Gait


Wide gait1

Wide Gait

  • Prosthetic Cause

    • Prosthetic foot Too far Outset

    • Excessive components ABDuction

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb Inadequate balance

    • Insecurity, wants to widen base in attempt to increase stability

    • Weak ML knee control

34


Tt gait deviations conclusions

TT Gait Deviations Conclusions

35


Transfemoral demographics

TransFemoral Demographics

  • When toe amputation is not considered:

  • Trans-femoral amputation is 2nd most represented level of limb loss:

    • 45% trans-tibial followed closely by

    • 40% trans-femoral then steep drop to

    • <10% below elbow (UE) at 3rd most represented level


Kd tfa

KD/TFA

  • Components significantly effect gait

  • Prognoses highly variable

  • View from all planes

  • Anatomic/pathologic contributions?

  • Component contributions?

  • Socket contributions?


Trans femoral

Trans-Femoral

  • Ideas about grouping deviations:

  • Some deviations result from length problems

    • (or perceived length problems)

    • E.g. vaulting, hip hiking, toe drag

  • Some are transverse plane problems

    • E.g. IR/ER socket, toe in/out, whips

  • Some are strictly patient related

    • E.g. Uneven timing, Trendelenburg, Vaulting

  • Some are strictly component/alignment related

    • E.g. knee instability, excess toe in/out, whips

  • Some are much more dangerous than others

  • Quite a few overlap categories


Things to consider

Things to Consider…

  • Which knee is most stable?

  • What foot characteristics are most/least desirable with TF prostheses?


Gait deviation definition

Gait Deviation Definition

  • Toe Lever Arm

  • Heel Lever Arm

  • Socket Flexion

40


Gait deviation definitions3

Gait Deviation Definitions


Gait deviation definitions4

Gait Deviation Definitions

TKA

Trochanter/ knee/ ankle

Stationary alignment line to identify the relative alignment between the center of interface weight line, center of axis of the knee and the axis of the foot


Normal gait1

Normal Gait


Deviations1

Deviations

  • Toe Drag

  • Vaulting

  • Hip Hiking

  • Circumduction

  • Internal Rotation of the Prosthesis

  • Internal Rotation of the Toe

  • External Rotation of the Prosthesis

  • External Rotation of the Toe

  • Lateral Whip

  • Medial Whip

  • Knee Flexion Moment

  • Trendelenburg Gait

  • ABDuction Gait

  • Heel Rise

  • Lateral Shift

  • Long Prosthetic Step

  • Short Prosthetic Step

44


Toe drag

Toe Drag


Le prosthetic gait assessment deviation

Toe Drag

  • Prosthetic Cause

    • Too Long

    • Too much Plantarflexion

    • Poor suspension

    • Excessive knee flexion

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Weak hip extensors

    • Weak hip ABDuctors on sound side

    • Poor posture

46


Vaulting2

Vaulting


Vaulting3

Vaulting

  • Prosthetic Cause

    • Too Long

    • Knee friction incorrectly set

    • Poor suspension

    • Excessive Plantarflexion of the foot

    • Excessive knee resistance of stability

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Weak hip flexors on residual limb

    • Improper initiation of hip flexors on residual limb

48


Hip hiking

Hip Hiking


Hip hiking1

Hip Hiking

  • Prosthetic Cause

    • Too Long

    • Poor suspension

    • Excessive knee stability

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

50


Circumduction

Circumduction


Circumduction1

Circumduction

  • Prosthetic Cause

    • Too Long

    • Excessive knee stability

    • Excessive knee friction

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Lack of confidence in flexing the knee

    • ABDuction contracture

    • Weak hip flexors

52


Internal rotation of the prosthesis

Internal Rotation of the Prosthesis


Internal rotation of the prosthesis1

Internal Rotation of the Prosthesis

  • Prosthetic Cause

    • Poor fitting interface

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Prosthesis Donned incorrectly

    • Weak muscles

54


Internal rotation of toe

Internal Rotation of Toe


Internal rotation of the toe

Internal Rotation of the Toe

  • Prosthetic Cause

    • Toe in Too far

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

56


Lateral whip

Lateral Whip


Lateral whip1

Lateral Whip

  • Prosthetic Cause

    • Internal rotation of the knee

    • Loose socket

    • Mis-aligned toe break

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Socket not donn properly

    • Internal rotation of the hip at toe off/hip flexion

58


External rotation of the prosthesis

External Rotation of the Prosthesis


External rotation of the prosthesis1

External Rotation of the prosthesis

  • Prosthetic Cause

    • Prosthesis donned incorrectly

    • Poor fitting interface

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Weak muscles

60


External rotation of the toe

External Rotation of the Toe


External rotation of the toe1

External Rotation of the Toe

  • Prosthetic Cause

    • Toe Out Too far

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Improper donning of the prosthesis

62


Medial whip

Medial Whip


Medial whip1

Medial Whip

  • Prosthetic Cause

    • External rotation of the knee

    • Socket Too tight

    • Mis-aligned toe break

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Socket donn improperly

    • External rotation of the hip at toe off/hip flexion

64


Knee flexion moment knee buckles

Knee Flexion Moment(Knee Buckles)


Knee flexion moment knee buckles1

Knee Flexion Moment(Knee Buckles)

  • Prosthetic Cause

    • Knee Too anterior/socket Too Posterior

    • Excessive Dorsiflexion

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Weak hip extensors

    • Hip flexion contracture

    • Change in Heel height

66


Trendeleburg gait

Trendeleburg Gait


Trendelenburg gait

Trendelenburg Gait

  • Prosthetic Cause

    • Poor fitting interface

    • Short prosthesis

    • Foot Too far outset

    • Ineffective lateral socket containment

    • High medial wall

    • Aligned in ABDuction

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Congenital Defects

    • Weak muscles

68


Abduction gait

ABDuction Gait

69


Abduction gait1

ABDuction Gait

  • Prosthetic Cause

    • Prosthesis Too Long

    • Medial wall Too High

    • Insufficient femoral stability

    • Induces medial whip

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • ABDuction contracture

70


Heel rise

Heel Rise


Heel rise1

Heel Rise

  • Prosthetic Cause

    • Inadequate extension aid

    • Insufficient knee friction

    • Improper knee selection

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Excessive use of hip flexors to initiate swing phase, overpowering knee unit

72


Lateral shift1

Lateral Shift


Lateral shift2

Lateral Shift

  • Prosthetic Cause

    • Prosthetic foot Too far Inset

    • Excessive socket ADDuction

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Weak hip ABDuction

    • Narrow gait base

74


Long prosthetic step

Long Prosthetic Step


Long prosthetic step1

Long Prosthetic Step

  • Prosthetic Cause

    • Excessive Plantarflexion of foot

    • Excessive component extension

    • Long toe lever arm

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb Flexion contracture

    • Patient Insecurity

    • Pain on sound side

76


Short prosthetic step

Short Prosthetic Step


Short prosthetic step1

Short Prosthetic Step

  • Prosthetic Cause

    • Socket pain

    • Weak extension aid

    • Unstable knee

    • Excessive Dorsiflexion

    • Poor suspension

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

    • Patient insecurity

    • Weak hip muscles

    • Poor balance

78


Tf gait deviations conclusions

TF Gait Deviations Conclusions

79


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