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LE Prosthetic Gait Assessment & Deviation
M. Jason Highsmith, DPT, CP
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Outline Review basic, “normal” gait TT TF
Generalizations (Prognosis & Demographics) Proper alignment Deviations TF Generalizations
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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
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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
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Flexion Flexion Flexion Extension Flexion HS FF MS HO TO
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TT Gait Assessment Consider all 3 planes Desired is:
Flexion moment throughout stance Slight varus Slight toe out
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Alignment Considerations
Linear Angular Transverse 7
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Gait Deviation Definitions
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Gait Deviation Definitions
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Gait Deviation Definitions
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Properly Aligned Observe: All Planes Frontal: Toe out Slight Varus
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Properly Aligned Observe Sagittal: Slight Flexion Moment
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Normal Gait
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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
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Extension Moment
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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
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Flexion Moment
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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
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Valgus Moment
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Valgus Moment Prosthetic Cause Amputee Cause Foot Too Outset
Components Too ABDucted Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 20
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Varus Moment
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Varus Moment Prosthetic Cause Amputee Cause Foot Too Inset
Components Too ADDucted Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 22
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Drop Off
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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
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External Foot Rotation
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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
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Long Prosthesis
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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
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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
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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
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Vaulting
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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
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Wide Gait
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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
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TT Gait Deviations Conclusions
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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
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KD/TFA Components significantly effect gait Prognoses highly variable
View from all planes Anatomic/pathologic contributions? Component contributions? Socket contributions?
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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
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Things to Consider… Which knee is most stable?
What foot characteristics are most/least desirable with TF prostheses?
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Gait Deviation Definition
Toe Lever Arm Heel Lever Arm Socket Flexion 40
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Gait Deviation Definitions
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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
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Normal Gait
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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
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Toe Drag
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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
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Vaulting
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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
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Hip Hiking
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Hip Hiking Prosthetic Cause Amputee Cause Too Long Poor suspension
Excessive knee stability Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 50
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Circumduction
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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
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Internal Rotation of the Prosthesis
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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
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Internal Rotation of Toe
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Internal Rotation of the Toe
Prosthetic Cause Toe in Too far Amputee Cause Bad Gait Habits, Strength, Short Residual Limb 56
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Lateral Whip
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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
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External Rotation of the Prosthesis
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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
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External Rotation of the Toe
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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
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Medial Whip
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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
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Knee Flexion Moment (Knee Buckles)
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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
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Trendeleburg Gait
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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
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ABDuction Gait 69
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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
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Heel Rise
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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
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Lateral Shift
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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
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Long Prosthetic Step
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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
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Short Prosthetic Step
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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
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TF Gait Deviations Conclusions
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