1. ASSESSMENT CHAPTER 6

2. Physical assessment PHYSIOTHERAPY ASSESSMENT session 7-10-12 CHAPTER 6 PART 19-21-22

3. The more common TF gait deviations are as follows: 1) Lateral trunk bending 2) Rotation of the foot at heel strike 3) Terminal swing impact 4) Drop off 5) Medial whip 6) Lateral whip 7) Uneven heel rise 8) Knee instability 9) Vaulting 10) Abducted gait 11) Lumbar lordosis 12) Forward trunk 13) Uneven step length 14) Circumduction 15) Uneven timing 16) Foot slap 17) Uneven arm swing  Free knee gait only

4. 1) 1)Lateral trunk bending toward prosthetic side Definition: patient leans towards the prosthesis. Phase of gait cycle: Stance phase Assessment done from: Front or rear views CAUSES a) Prosthetic causes   Lateral wall of the socket may give insufficient support to the femur.   Prosthesis too short   Socket too ADD   Medial brim of the socket too hight or giving discomfort.

5. 1) 1)Lateral trunk bending toward prosthetic side b) Amputee causes   ABD contracture of the stump   Very short stump   Painful stump   Weak stump hip ABD.

6. 1) 1)Lateral trunk bending away from prosthetic side Definition: patient leans towards the sound leg. Phase of gait cycle: Stance phase Assessment done from: Front or rear views CAUSES a) Prosthetic causes   Prosthesis too long   Socket too ABD b) Amputee causes: /

7. 2) Rotation of foot at heel strike   Definition: Rotation usually outwards   Phase of gait cycle: Heel strike.   Assessment done from: Front view. CAUSES a) Prosthetic causes   Too hard plantar flexion resistance.   Socket too loose   Too much toe out.

8. 2) Rotation of foot at heel strike b) Amputee causes   Poor muscle control of the residual limb (ext + int. rot.)

9. 3) Terminal swing impact Definition : Knee reaches extension too quickly prior to heel strike. Phase of gait cycle: From Stance phase. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Incorrect adjustment of swing phase controls.

10. 3) Terminal swing impact b) Amputee causes   Stump forcibly flexes to produce full ext. of the knee to ensure safety.   Lack of confidence.   Bad habit (The patient uses the sound to indicate that the knee is ready for heel contact).

11. 4) Drop off Definition : There is a downwards movement of the body as weight is transferred forwards over the prosthetic foot. Phase of gait cycle: Stance phase. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Too soft dorsi flexion resistance in prosthetic foot   Incorrect alignment: Socket set too far forward to the foot.

12. 4) Drop off CAUSES b) Amputee causes: Wearing the Incorrect heel height of shoe.

13. 5) Medial whip Definition: Heel travels medially on initial flexion at beginning of swing phase. Phase of gait cycle: Swing phase. Assessment done from: Rear view. CAUSES a) Prosthetic causes   Excessive ext. rot. of prosthetic knee.   Socket may be too tight a fit or too loose   Incorrect alignment at toe off   Excessive valgus set into the prosthesis at knee level.

14. 5) Medial whip CAUSES b) Amputee causes   Bad habit (cause by residual limb discomfort or a problem in the remaining leg)   Patient may have donned the prosthesis in internal rotation.

15. 6) Lateral whip   Definition: Heel travels laterally on initial flexion at beginning of swing phase.   Phase of gait cycle: Swing phase.   Assessment done from: Rear view.   CAUSES   a) Prosthetic causes   Excessive int. rot. of prosthetic knee.   Socket may be too tight a fit or too loose   Incorrect alignment at toe off   Excessive varus set into the prosthesis at knee level.

16. 6) Lateral whip   CAUSES b) Amputee causes   Bad habit (cause by residual limb discomfort or a problem in the remaining leg).   Patient may have donned the prosthesis in internal rotation.

17. 7) Uneven heel rise Definition : Heel of prosthesis rises upwards excessively when knee flexes at beginning of swing phase. Phase of gait cycle: Swing phase. Assessment done from: Lateral view point or rear view. CAUSES a) a) Prosthetic causes   Prosthetic knee flexes too easily   Swing phase controls adjusted incorrectly.

18. 7) Uneven heel rise CAUSES b) Amputee causes   Too much hip flexor muscle power used to flex the prosthetic knee.

19. 8) Knee instability Phase of gait cycle: From heel contact to midstance. Assessment done from: Lateral view point.   CAUSES a) Prosthetic causes   The knee axis is placed anterior to the TKA (the line of the body weight falls behind the knee).   The socket is placed too far anteriorly   Lack of adequate socket flexion   heel support too hard   hip flexion contracture not accommodated in the socket.

20. 8) Knee instability b) Amputee causes : /

21. 9) Vaulting   Definition: The amputee rises up on the toe of the sound leg to swing the prosthesis through from toe off to heel strike.   Phase of gait cycle: Swing phase   Assessment done from: Rear view. CAUSES a) Prosthetic causes   Too long prosthesis   Inadequate suspension   Too much stability or friction in the knee mechanism.

22. 9) Vaulting CAUSES b) Amputee causes   Poor muscle control of hip flexion   Fear of catching the toe of the prosthesis   Very short stump.

23. 10) Abducted gait Definition: a gait base that is wider than 5 cm at mid stance. Phase of gait cycle: Swing phase. Assessment done from: Front or rear views. CAUSES a) Prosthetic causes   Prosthesis too long,   Medial brim of socket too high,   Lateral wall of socket giving insufficient support to femur,   (Rigid pelvic band alignment incorrect),   Prosthesis incorrectly aligned socket too ADD.

24. 10) Abducted gait b) Amputee causes   Contracture of the ABD (stump side)   ADD roll   Bad habit.

25. 11) Lumbar lordosis Definition : Patient creates an active lumbar lordosis. Phase of gait cycle: Stance phase. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Insufficient stability in knee mechanism,   Insufficient socket flexion,   Discomfort on ischial plate   Heel of shoe on prosthesis too high.

26. 11) Lumbar lordosis CAUSES b) Amputee causes   Hip flexion contracture   Weak hip extensors   Weak abdominal muscles   Attempt to move centre of gravity forwards to improve stability.

27. 12) Forward trunk Phase of gait cycle: Over several gait cycles. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Insufficient flexion build into socket   Socket discomfort   Insufficient stability in knee mechanism.

28. 12) Forward trunk   CAUSES b) Amputee causes   Weak hip extensors   Hip flexion contracture   Poor general posture   Kyphosed spine   Compensation, looking at feet, from walking with a frame or because of poor eyesight.

29. 13) Circumduction Definition: Semicircular swing of the prosthesis to the side. Phase of gait cycle: swing phase. Assessment done from: Rear view. CAUSES a) Prosthetic causes   Prosthesis too long   Inadequate suspension   Too much stability or too much friction in the knee mechanism.

30. 13) Circumduction b) Amputee causes   Muscle weakness   Lack of confidence in flexing the knee   ABD contracture of stump   Muscle imbalance: weak ADD of the residual limb and inability to hip hitch.

31. 14) Uneven timing Definition: Steps of unequal length usually characterized by a very short stance phase on the prosthesis. Phase of gait cycle: Few gait cycles. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Ill fitting socket causing discomfort

32. 14) Uneven timing b) Amputee causes   Lack of balance   Lack of confidence   Weak residual limb, trunk and sound leg muscle.   Bad habit   Pain on ischial tuberosity   Poor training.

33. 15) Uneven step length (prosthetic step too long) Definition: Phase of gait cycle: Few gait cycles. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Flexion contracture not accomodated prosthetically.   Prosthesis too long.

34. 15) Uneven step length (prosthetic step too long) b) Amputee causes   Inability to extend the hip over prosthesis during stance phase due to hip flexion contracture and weakness of hip and back ext.   Lack of confidence,   Bad habit (ie: if initial gait rehabilitation was using a frame).

35. 15) Uneven step length (prosthetic step too short) Definition: Phase of gait cycle: Few gait cycles. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Socket too flexed   Ill fitting socket causing discomfort

36. 15) Uneven step length (prosthetic step too short) b) Amputee causes   Lack of confidence   Pain   Patient feels insecure with the knee mechanism.

37. 16) Foot slap Definition: Prosthetic forefoot audibly slaps down onto floor at heel strike. Phase of gait cycle: Stance phase. Assessment done from: Lateral view point. CAUSES a) Prosthetic causes   Plantar flexion resistance too soft (heel too soft)   heel lever arm that is too short.

38. 16) Foot slap b) Amputee causes   Driving prosthetic heel into ground excessively because of fear of instability of the knee.   Wearing incorrect shoe.

39. 17) Uneven arm swing Definition: The arm on the prosthetic side is usually held stiff to that side of the body. There is no natural swing. Phase of gait cycle: terminal stance. Assessment done from: Rear view. CAUSES a) Prosthetic causes   Ill fitting socket causing discomfort.   Socket too flexed   Flexion contracture not accomodated prosthetically.   Prosthesis too long.

40. 17) Uneven arm swing b) Amputee causes   Lack of balance   Lack of confidence   Pain   Patient feels insecure with the knee mechanism.   Inability to extend the hip over prosthesis during stance phase due to hip flexion contracture and weakness of hip and back ext.   Bad habit (ie: if initial gait rehabilitation was using a frame)   Poor training.

41. References  Bella J. May, AMPUTATIONS AND PROSTHETICS, F.A Davis Company, 2nd edition, 1996, p: 171-172, 187-193.  B. Engstrom - C. Van de Ven, THERAPY FOR AMPUTEES, 3rd edition, Livingstone,1999, p: 137-140.