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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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Presentation Transcript
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
slide5

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

slide46

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 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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