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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
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


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





Properly aligned
Properly Aligned

  • Observe:

  • All Planes

  • Frontal:

  • Toe out

  • Slight Varus


Properly aligned1
Properly Aligned

  • Observe

  • Sagittal:

  • Slight Flexion Moment



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 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 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 moment1
Valgus Moment

  • Prosthetic Cause

    • Foot Too Outset

    • Components Too ABDucted

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

20



Varus moment1
Varus Moment

  • Prosthetic Cause

    • Foot Too Inset

    • Components Too ADDucted

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

22



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 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 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



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 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



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 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



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

  • 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



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 hiking1
Hip Hiking

  • Prosthetic Cause

    • Too Long

    • Poor suspension

    • Excessive knee stability

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

50



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 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 the toe
Internal Rotation of the Toe

  • Prosthetic Cause

    • Toe in Too far

  • Amputee Cause

    • Bad Gait Habits, Strength, Short Residual Limb

56



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 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 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 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



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 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 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 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 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 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



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