LE Prosthetic Gait Assessment & Deviation M. Jason Highsmith, DPT, CP

Outline Review basic, “normal” gait TT TF Generalizations (Prognosis & Demographics) Proper alignment Deviations TF Generalizations

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 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 Consider all 3 planes Desired is: Flexion moment throughout stance Slight varus Slight toe out

Alignment Considerations Linear Angular Transverse 7

Gait Deviation Definitions

Gait Deviation Definitions

Gait Deviation Definitions

Properly Aligned Observe: All Planes Frontal: Toe out Slight Varus

Properly Aligned Observe Sagittal: Slight Flexion Moment

Normal Gait

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 Prosthetic Cause Amputee Cause Heel Too Soft Foot Too far Anterior Foot Too Plantarflexed Amputee Cause Shoe Heel Height Too low Bad Gait Habits, Strength, Short Residual Limb 16

Flexion Moment

Flexion Moment Prosthetic Cause Amputee 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 Prosthetic Cause Amputee Cause Foot Too Outset Components Too ABDucted Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 20

Varus Moment

Varus Moment Prosthetic Cause Amputee Cause Foot Too Inset Components Too ADDucted Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 22

Drop Off

Drop Off Prosthetic Cause Amputee 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 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 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 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 Prosthetic Cause Amputee 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 Prosthetic Cause Amputee 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 Prosthetic Cause Amputee 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 35

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 Components significantly effect gait Prognoses highly variable View from all planes Anatomic/pathologic contributions? Component contributions? Socket contributions?

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… Which knee is most stable? What foot characteristics are most/least desirable with TF prostheses?

Gait Deviation Definition Toe Lever Arm Heel Lever Arm Socket Flexion 40

Gait Deviation Definitions

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 Gait

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 Prosthetic Cause Amputee 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

Vaulting

Vaulting Prosthetic Cause Amputee 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 Prosthetic Cause Amputee Cause Too Long Poor suspension Excessive knee stability Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 50

Circumduction

Circumduction Prosthetic Cause Amputee 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 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 the Toe Prosthetic Cause Toe in Too far Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 56

Lateral Whip

Lateral Whip Prosthetic Cause Amputee 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 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 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 Prosthetic Cause Amputee 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) 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

Trendelenburg Gait Prosthetic Cause Amputee 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 69

ABDuction Gait Prosthetic Cause Amputee 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 Prosthetic Cause Amputee 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 Shift

Lateral Shift Prosthetic Cause Amputee 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 Prosthetic Cause Amputee 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 Prosthetic Cause Amputee 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 79