LE Prosthetic Gait Assessment & Deviation

LE Prosthetic Gait LE Prosthetic Gait Assessment & Assessment &

Deviation Deviation

M. Jason Highsmith, DPT, M. Jason Highsmith, DPT, CPCP

OutlineOutline

• Review basic, “normal” gaitReview basic, “normal” gait• TT TT

– Generalizations (Prognosis & Generalizations (Prognosis & Demographics)Demographics)

– Proper alignmentProper alignment– DeviationsDeviations

• TFTF– GeneralizationsGeneralizations– Proper alignmentProper alignment– DeviationsDeviations

PrognosisPrognosis

• Trans-tibial prosthesis users-Trans-tibial prosthesis users-– In the absence of severe comorbiditiesIn the absence of severe comorbidities

• Tend to have prognoses favoring Tend to have prognoses favoring pre-morbid activity pre-morbid activity

• It is reasonable to expect return to It is reasonable to expect return to most activities most activities

DemographicsDemographics

• When toe amputation is not When toe amputation is not considered:considered:

• Trans-tibial amputation is most Trans-tibial amputation is most represented level of limb loss:represented level of limb loss:– 45% trans-tibial followed closely by45% trans-tibial followed closely by– 40% trans-femoral then steep drop to40% trans-femoral then steep drop to– <10% below elbow (UE) at 3<10% below elbow (UE) at 3rdrd most most

represented levelrepresented level

HS FF MS HO TO

Flexion FlexionFlexion FlexionExtension

TT Gait AssessmentTT Gait Assessment

• Consider all 3 planesConsider all 3 planes• Desired is:Desired is:

1.1. Flexion moment throughout stanceFlexion moment throughout stance

2.2. Slight varusSlight varus

3.3. Slight toe outSlight toe out

Alignment Alignment ConsiderationsConsiderations

• LinearLinear• AngularAngular• TransverseTransverse

Gait Deviation Gait Deviation DefinitionsDefinitions

Properly AlignedProperly Aligned

• Observe:Observe:• All PlanesAll Planes• Frontal:Frontal:• Toe outToe out• Slight VarusSlight Varus

Properly AlignedProperly Aligned

• ObserveObserve• Sagittal:Sagittal:• Slight Flexion Slight Flexion

MomentMoment

Normal GaitNormal Gait

QuickTime™ and a decompressor

are needed to see this picture.

DeviationsDeviations

• Normal Gait Normal Gait

• Extension MomentExtension Moment

• Flexion MomentFlexion Moment

• Varus MomentVarus Moment

• Valgus MomentValgus Moment

• Drop OffDrop Off

• External Foot RotationExternal Foot Rotation

• Long ProsthesisLong Prosthesis

• Short ProsthesisShort Prosthesis

• Lateral ShiftLateral Shift

• VaultingVaulting

• Wide GaitWide Gait

Extension MomentExtension Moment

• Prosthetic CauseProsthetic Cause– Heel Too Soft Heel Too Soft – Foot Too far AnteriorFoot Too far Anterior– Foot Too PlantarflexedFoot Too Plantarflexed

• Amputee CauseAmputee Cause– Shoe Heel Height Too lowShoe Heel Height Too low– Shoe Heel Height Too lowShoe Heel Height Too low– Bad Gait Habits, Strength, Short Bad Gait Habits, Strength, Short

Residual LimbResidual Limb16

Flexion MomentFlexion Moment

• Prosthetic CauseProsthetic Cause– Heel Too FirmHeel Too Firm– Foot Too far PosteriorFoot Too far Posterior– Foot Too DorsiflexFoot Too Dorsiflex

• Amputee CauseAmputee Cause– Shoe Heel Height Too highShoe Heel Height Too high– Bad Gait Habits, Strength, Short Bad Gait Habits, Strength, Short

Residual LimbResidual Limb18

Valgus MomentValgus Moment

• Prosthetic CauseProsthetic Cause– Foot Too Outset Foot Too Outset – Components Too ABDuctedComponents Too ABDucted

• Amputee CauseAmputee Cause– Bad Gait Habits, Strength, Short Bad Gait Habits, Strength, Short

Residual LimbResidual Limb

Varus MomentVarus Moment

• Prosthetic CauseProsthetic Cause– Foot Too InsetFoot Too Inset– Components Too ADDuctedComponents Too ADDucted

Drop OffDrop Off

• Prosthetic Cause– Short toe lever– Excessive socket flexion Excessive socket flexion – Excessive dorsiflexionExcessive dorsiflexion– Incorrect foot typeIncorrect foot type

• Amputee Cause – Bad Gait Habits, Strength, Short Residual Bad Gait Habits, Strength, Short Residual

Limb Limb – Internal Rotation of hip at toe off/hip

flexion24

External Foot RotationExternal Foot Rotation

• ObservationsObservations– Patient wants foot to match sound sidePatient wants foot to match sound side– Internal rotation of knee at toe offInternal rotation of knee at toe off– Induce “medial whip”Induce “medial whip”– Drop off at end of stance phaseDrop off at end of stance phase– Low back painLow back pain– Skin irritation due to rotational stress Skin irritation due to rotational stress

in socketin socket

Long ProsthesisLong Prosthesis

• ObservationsObservations– Patient reports lower back painPatient reports lower back pain– Patient reports they feel like they are Patient reports they feel like they are

walking up a hillwalking up a hill– Noticeable rise and drop of shoulder on Noticeable rise and drop of shoulder on

the effected sidethe effected side– Hesitation in gait timing from Hesitation in gait timing from

prosthetic mid-stance to sound side prosthetic mid-stance to sound side heel strikeheel strike

Short ProsthesisShort Prosthesis

• ObservationsObservations– Patient reports lower back painPatient reports lower back pain– Patient reports they feel like they are Patient reports they feel like they are

stepping into a holestepping into a hole– Noticeable rise and drop of the shoulder Noticeable rise and drop of the shoulder

on the sound sideon the sound side– Uneven arm motion to accommodate Uneven arm motion to accommodate

uneven stride lengthuneven stride length– Appears like the patient may be vaultingAppears like the patient may be vaulting

Lateral ShiftLateral Shift

• Prosthetic CauseProsthetic Cause– Foot Too far InsetFoot Too far Inset– Insufficient components Insufficient components

ABDuctionABDuction– Short ProsthesisShort Prosthesis

• Amputee CauseAmputee Cause– Bad Gait Habits, Strength, Short Residual Bad Gait Habits, Strength, Short Residual

Limb Inadequate balanceLimb Inadequate balance– Weak KneeWeak Knee– Narrow Gait BaseNarrow Gait Base

VaultingVaulting

• Prosthetic CauseProsthetic Cause– Long ProsthesisLong Prosthesis

– Poor SuspensionPoor Suspension

– Excessive Plantarflexion of footExcessive Plantarflexion of foot

– Excessive knee resistance or stabilityExcessive knee resistance or stability

• Amputee CauseAmputee Cause– Bad Gait Habits, Strength, Short Residual Limb Bad Gait Habits, Strength, Short Residual Limb

Inadequate balanceInadequate balance

– Fear of catching the toeFear of catching the toe

– Weak hip flexors of residual limbWeak hip flexors of residual limb

– Improper initiation of hip flexors on residual limbImproper initiation of hip flexors on residual limb32

Wide GaitWide Gait

• Prosthetic CauseProsthetic Cause– Prosthetic foot Too Prosthetic foot Too

far Outsetfar Outset– Excessive components Excessive components

ABDuction ABDuction

• Amputee CauseAmputee Cause– Bad Gait Habits, Strength, Short Residual Limb Bad Gait Habits, Strength, Short Residual Limb

Inadequate balanceInadequate balance– Insecurity, wants to widen base in attempt to Insecurity, wants to widen base in attempt to

increase stabilityincrease stability– Weak ML knee controlWeak ML knee control

TT Gait Deviations TT Gait Deviations ConclusionsConclusions

TransFemoral TransFemoral DemographicsDemographics

• When toe amputation is not When toe amputation is not considered:considered:

• Trans-femoral amputation is 2Trans-femoral amputation is 2ndnd most represented level of limb loss:most represented level of limb loss:– 45% trans-tibial followed closely by45% trans-tibial followed closely by– 40%40% trans-femoral then steep drop to trans-femoral then steep drop to– <10% below elbow (UE) at 3<10% below elbow (UE) at 3rdrd most most

represented levelrepresented level

KD/TFAKD/TFA

• Components significantly effect gaitComponents significantly effect gait• Prognoses highly variablePrognoses highly variable

• View from all planesView from all planes

• Anatomic/pathologic contributions?Anatomic/pathologic contributions?• Component contributions?Component contributions?• Socket contributions?Socket contributions?

Trans-FemoralTrans-Femoral

Ideas about grouping deviations:Ideas about grouping deviations:• Some deviations result from length problems Some deviations result from length problems

– (or perceived length problems)(or perceived length problems)– E.g. vaulting, hip hiking, toe dragE.g. vaulting, hip hiking, toe drag

• Some are transverse plane problemsSome are transverse plane problems– E.g. IR/ER socket, toe in/out, whipsE.g. IR/ER socket, toe in/out, whips

• Some are strictly patient relatedSome are strictly patient related– E.g. Uneven timing, Trendelenburg, VaultingE.g. Uneven timing, Trendelenburg, Vaulting

• Some are strictly component/alignment relatedSome are strictly component/alignment related– E.g. knee instability, excess toe in/out, whipsE.g. knee instability, excess toe in/out, whips

• Some are much more dangerous than others Some are much more dangerous than others • Quite a few overlap categoriesQuite a few overlap categories

Things to Consider…Things to Consider…• Which knee is most stable?Which knee is most stable?

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

Gait Deviation DefinitionGait Deviation Definition

• Toe Lever ArmToe Lever Arm• Heel Lever ArmHeel Lever Arm• Socket FlexionSocket Flexion

Gait Deviation Gait Deviation DefinitionsDefinitions

TKATrochanter/ 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 GaitNormal Gait

DeviationsDeviations• Toe DragToe Drag

• VaultingVaulting

• Hip Hiking Hip Hiking

• CircumductionCircumduction

• Internal Rotation of the ProsthesisInternal Rotation of the Prosthesis

• Internal Rotation of the ToeInternal Rotation of the Toe

• External Rotation of the ProsthesisExternal Rotation of the Prosthesis

• External Rotation of the ToeExternal Rotation of the Toe

• Lateral WhipLateral Whip

• Medial WhipMedial Whip

• Knee Flexion MomentKnee Flexion Moment

• Trendelenburg GaitTrendelenburg Gait

• ABDuction GaitABDuction Gait

• Heel RiseHeel Rise

• Lateral ShiftLateral Shift

• Long Prosthetic StepLong Prosthetic Step

• Short Prosthetic StepShort Prosthetic Step

Toe DragToe Drag

• Prosthetic CauseProsthetic Cause– Too LongToo Long

– Too much PlantarflexionToo much Plantarflexion

– Poor suspensionPoor suspension

– Excessive knee flexionExcessive knee flexion

• Amputee CauseAmputee Cause– Bad Gait Habits, Strength, Short Residual LimbBad Gait Habits, Strength, Short Residual Limb

– Weak hip extensorsWeak hip extensors

– Weak hip ABDuctors on sound sideWeak hip ABDuctors on sound side

– Poor posturePoor posture

Toe DragToe Drag

VaultingVaulting

• Prosthetic CauseProsthetic Cause– Too LongToo Long

– Knee friction incorrectly setKnee friction incorrectly set

– Poor suspensionPoor suspension

– Excessive Plantarflexion of the footExcessive Plantarflexion of the foot

– Excessive knee resistance of stabilityExcessive knee resistance of stability

– Weak hip flexors on residual limbWeak hip flexors on residual limb

– Improper initiation of hip flexors on residual limbImproper initiation of hip flexors on residual limb

Hip HikingHip Hiking

• Prosthetic CauseProsthetic Cause– Too LongToo Long– Poor suspensionPoor suspension– Excessive knee stabilityExcessive knee stability

CircumductionCircumduction

Circumduction Circumduction

• Prosthetic CauseProsthetic Cause– Too LongToo Long– Excessive knee stabilityExcessive knee stability– Excessive knee frictionExcessive knee friction

• Amputee CauseAmputee Cause– Bad Gait Habits, Strength, Short Residual LimbBad Gait Habits, Strength, Short Residual Limb– Lack of confidence in flexing the kneeLack of confidence in flexing the knee– ABDuction contractureABDuction contracture– Weak hip flexorsWeak hip flexors

Internal Rotation of the Internal Rotation of the ProsthesisProsthesis

• Prosthetic CauseProsthetic Cause– Poor fitting interfacePoor fitting interface

Residual LimbResidual Limb– Prosthesis Donned incorrectlyProsthesis Donned incorrectly– Weak musclesWeak muscles

Internal Rotation of ToeInternal Rotation of Toe

Internal Rotation of the Internal Rotation of the ToeToe

• Prosthetic CauseProsthetic Cause– Toe in Too farToe in Too far

Lateral WhipLateral Whip

• Prosthetic CauseProsthetic Cause– Internal rotation of the kneeInternal rotation of the knee– Loose socketLoose socket– Mis-aligned toe breakMis-aligned toe break

LimbLimb– Socket not donn properlySocket not donn properly– Internal rotation of the hip at toe off/hip Internal rotation of the hip at toe off/hip

flexionflexion 58

External Rotation of the External Rotation of the ProsthesisProsthesis

External Rotation of the External Rotation of the prosthesisprosthesis

• Prosthetic CauseProsthetic Cause– Prosthesis donned incorrectlyProsthesis donned incorrectly– Poor fitting interfacePoor fitting interface

Residual LimbResidual Limb– Weak musclesWeak muscles

External Rotation of the External Rotation of the ToeToe

• Prosthetic CauseProsthetic Cause– Toe Out Too farToe Out Too far

Residual LimbResidual Limb– Improper donning of the prosthesisImproper donning of the prosthesis

Medial WhipMedial Whip

• Prosthetic CauseProsthetic Cause– External rotation of the kneeExternal rotation of the knee– Socket Too tightSocket Too tight– Mis-aligned toe breakMis-aligned toe break

LimbLimb– Socket donn improperlySocket donn improperly– External rotation of the hip at toe off/hip External rotation of the hip at toe off/hip

flexionflexion 64

Knee Flexion MomentKnee Flexion Moment(Knee Buckles)(Knee Buckles)

• Prosthetic CauseProsthetic Cause– Knee Too anterior/socket Too PosteriorKnee Too anterior/socket Too Posterior– Excessive DorsiflexionExcessive Dorsiflexion

LimbLimb– Weak hip extensorsWeak hip extensors– Hip flexion contractureHip flexion contracture– Change in Heel heightChange in Heel height

Trendeleburg GaitTrendeleburg Gait

Trendelenburg GaitTrendelenburg Gait

• Prosthetic CauseProsthetic Cause– Poor fitting interfacePoor fitting interface

– Short prosthesisShort prosthesis

– Foot Too far outsetFoot Too far outset

– Ineffective lateral socket containmentIneffective lateral socket containment

– High medial wallHigh medial wall

– Aligned in ABDuctionAligned in ABDuction

– Congenital DefectsCongenital Defects

– Weak musclesWeak muscles68

ABDuction GaitABDuction Gait

• Prosthetic CauseProsthetic Cause– Prosthesis Too LongProsthesis Too Long– Medial wall Too HighMedial wall Too High– Insufficient femoral stabilityInsufficient femoral stability– Induces medial whipInduces medial whip

Limb Limb – ABDuction contractureABDuction contracture

Heel RiseHeel Rise

• Prosthetic CauseProsthetic Cause– Inadequate extension aidInadequate extension aid– Insufficient knee frictionInsufficient knee friction– Improper knee selectionImproper knee selection

Residual Limb Residual Limb – Excessive use of hip flexors to initiate Excessive use of hip flexors to initiate

swing phase, overpowering knee unitswing phase, overpowering knee unit

• Prosthetic CauseProsthetic Cause– Prosthetic foot Too far InsetProsthetic foot Too far Inset– Excessive socket ADDuctionExcessive socket ADDuction

Residual Limb Residual Limb – Weak hip ABDuctionWeak hip ABDuction– Narrow gait baseNarrow gait base

Long Prosthetic StepLong Prosthetic Step

• Prosthetic CauseProsthetic Cause– Excessive Plantarflexion of footExcessive Plantarflexion of foot– Excessive component extensionExcessive component extension– Long toe lever armLong toe lever arm

Limb Flexion contractureLimb Flexion contracture– Patient InsecurityPatient Insecurity– Pain on sound sidePain on sound side 7

Short Prosthetic StepShort Prosthetic Step

• Prosthetic CauseProsthetic Cause– Socket painSocket pain– Weak extension aidWeak extension aid– Unstable kneeUnstable knee– Excessive DorsiflexionExcessive Dorsiflexion– Poor suspensionPoor suspension

• Amputee CauseAmputee Cause– Bad Gait Habits, Strength, Short Residual LimbBad Gait Habits, Strength, Short Residual Limb– Patient insecurityPatient insecurity– Weak hip musclesWeak hip muscles– Poor balancePoor balance 7

TF Gait Deviations TF Gait Deviations ConclusionsConclusions

LE Prosthetic Gait Assessment & Deviation

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Effects of prosthetic foot forefoot flexibility on gait of