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

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Presentation on theme: "LE Prosthetic Gait Assessment & Deviation M. Jason Highsmith, DPT, CP."— Presentation transcript:

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

2 Outline Review basic, “normal” gaitReview basic, “normal” gait TTTT –Generalizations (Prognosis & Demographics) –Proper alignment –Deviations TFTF –Generalizations –Proper alignment –Deviations

3 Prognosis Trans-tibial prosthesis users-Trans-tibial prosthesis users- –In the absence of severe comorbidities Tend to have prognoses favoring pre-morbid activityTend to have prognoses favoring pre-morbid activity It is reasonable to expect return to most activitiesIt is reasonable to expect return to most activities

4 Demographics When toe amputation is not considered:When toe amputation is not considered: Trans-tibial amputation is most represented level of limb loss: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 3 rd most represented level

5 HSFFMSHOTO Flexion Extension

6 TT Gait Assessment Consider all 3 planesConsider all 3 planes Desired is:Desired is: 1. Flexion moment throughout stance 2. Slight varus 3. Slight toe out

7 7 Alignment Considerations Alignment Considerations LinearLinear AngularAngular TransverseTransverse 7

8 8 Gait Deviation Definitions

9 9

10 10 Gait Deviation Definitions

11 Properly Aligned Observe:Observe: All PlanesAll Planes Frontal:Frontal: Toe outToe out Slight VarusSlight Varus

12 Properly Aligned ObserveObserve Sagittal:Sagittal: Slight Flexion MomentSlight Flexion Moment

13 13 Normal Gait

14 Deviations Normal GaitNormal 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

15 Extension Moment

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

17 Flexion Moment

18 18 Flexion Moment Prosthetic CauseProsthetic Cause –Heel Too Firm –Foot Too far Posterior –Foot Too Dorsiflex Amputee CauseAmputee Cause –Shoe Heel Height Too high –Bad Gait Habits, Strength, Short Residual Limb 18

19 Valgus Moment

20 20 Valgus Moment Prosthetic CauseProsthetic Cause –Foot Too Outset –Components Too ABDucted Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb 20

21 Varus Moment

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

23 23 Drop Off

24 24 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

25 25 External Foot Rotation

26 26 External Foot Rotation ObservationsObservations –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

27 27 Long Prosthesis

28 28 Long Prosthesis ObservationsObservations –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

29 29 Short Prosthesis ObservationsObservations –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

30 30 Lateral Shift Prosthetic CauseProsthetic Cause –Foot Too far Inset –Insufficient components ABDuction –Short Prosthesis Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb Inadequate balance –Weak Knee –Narrow Gait Base 30

31 31 Vaulting

32 32 Vaulting Prosthetic CauseProsthetic Cause –Long Prosthesis –Poor Suspension –Excessive Plantarflexion of foot –Excessive knee resistance or stability Amputee CauseAmputee 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

33 33 Wide Gait

34 34 Wide Gait Prosthetic CauseProsthetic Cause –Prosthetic foot Too far Outset –Excessive components ABDuction Amputee CauseAmputee 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

35 35 TT Gait Deviations Conclusions 35

36 TransFemoral Demographics When toe amputation is not considered:When toe amputation is not considered: Trans-femoral amputation is 2 nd most represented level of limb loss:Trans-femoral amputation is 2 nd most represented level of limb loss: –45% trans-tibial followed closely by 40% trans-femoral then steep drop to40% trans-femoral then steep drop to –<10% below elbow (UE) at 3 rd most represented level

37 KD/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?

38 Trans-Femoral Ideas about grouping deviations:Ideas about grouping deviations: Some deviations result from length problemsSome deviations result from length problems –(or perceived length problems) –E.g. vaulting, hip hiking, toe drag Some are transverse plane problemsSome are transverse plane problems –E.g. IR/ER socket, toe in/out, whips Some are strictly patient relatedSome are strictly patient related –E.g. Uneven timing, Trendelenburg, Vaulting Some are strictly component/alignment relatedSome are strictly component/alignment related –E.g. knee instability, excess toe in/out, whips Some are much more dangerous than othersSome are much more dangerous than others Quite a few overlap categoriesQuite a few overlap categories

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

40 40 Gait Deviation Definition Toe Lever ArmToe Lever Arm Heel Lever ArmHeel Lever Arm Socket FlexionSocket Flexion 40

41 41 Gait Deviation Definitions

42 42 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

43 43 Normal Gait

44 44 Deviations Toe DragToe Drag VaultingVaulting Hip HikingHip 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 44

45 45 Toe Drag

46 46 Prosthetic CauseProsthetic Cause –Too Long –Too much Plantarflexion –Poor suspension –Excessive knee flexion Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Weak hip extensors –Weak hip ABDuctors on sound side –Poor posture 46 Toe Drag

47 47 Vaulting

48 48 Vaulting Prosthetic CauseProsthetic Cause –Too Long –Knee friction incorrectly set –Poor suspension –Excessive Plantarflexion of the foot –Excessive knee resistance of stability Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Weak hip flexors on residual limb –Improper initiation of hip flexors on residual limb 48

49 49 Hip Hiking

50 50 Hip Hiking Prosthetic CauseProsthetic Cause –Too Long –Poor suspension –Excessive knee stability Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb 50

51 51 Circumduction

52 52 Circumduction Prosthetic CauseProsthetic Cause –Too Long –Excessive knee stability –Excessive knee friction Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Lack of confidence in flexing the knee –ABDuction contracture –Weak hip flexors 52

53 53 Internal Rotation of the Prosthesis

54 54 Internal Rotation of the Prosthesis Prosthetic CauseProsthetic Cause –Poor fitting interface Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Prosthesis Donned incorrectly –Weak muscles 54

55 55 Internal Rotation of Toe

56 56 Internal Rotation of the Toe Prosthetic CauseProsthetic Cause –Toe in Too far Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb 56

57 57 Lateral Whip

58 58 Lateral Whip Prosthetic CauseProsthetic Cause –Internal rotation of the knee –Loose socket –Mis-aligned toe break Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Socket not donn properly –Internal rotation of the hip at toe off/hip flexion 58

59 59 External Rotation of the Prosthesis

60 60 External Rotation of the prosthesis Prosthetic CauseProsthetic Cause –Prosthesis donned incorrectly –Poor fitting interface Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Weak muscles 60

61 61 External Rotation of the Toe

62 62 External Rotation of the Toe Prosthetic CauseProsthetic Cause –Toe Out Too far Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Improper donning of the prosthesis 62

63 63 Medial Whip

64 64 Medial Whip Prosthetic CauseProsthetic Cause –External rotation of the knee –Socket Too tight –Mis-aligned toe break Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Socket donn improperly –External rotation of the hip at toe off/hip flexion 64

65 65 Knee Flexion Moment (Knee Buckles)

66 66 Knee Flexion Moment (Knee Buckles) Prosthetic CauseProsthetic Cause –Knee Too anterior/socket Too Posterior –Excessive Dorsiflexion Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Weak hip extensors –Hip flexion contracture –Change in Heel height 66

67 67 Trendeleburg Gait

68 68 Trendelenburg Gait Prosthetic CauseProsthetic Cause –Poor fitting interface –Short prosthesis –Foot Too far outset –Ineffective lateral socket containment –High medial wall –Aligned in ABDuction Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Congenital Defects –Weak muscles 68

69 69 ABDuction Gait 69

70 70 ABDuction Gait Prosthetic CauseProsthetic Cause –Prosthesis Too Long –Medial wall Too High –Insufficient femoral stability –Induces medial whip Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –ABDuction contracture 70

71 71 Heel Rise

72 72 Heel Rise Prosthetic CauseProsthetic Cause –Inadequate extension aid –Insufficient knee friction –Improper knee selection Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Excessive use of hip flexors to initiate swing phase, overpowering knee unit 72

73 73 Lateral Shift

74 74 Lateral Shift Prosthetic CauseProsthetic Cause –Prosthetic foot Too far Inset –Excessive socket ADDuction Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Weak hip ABDuction –Narrow gait base 74

75 75 Long Prosthetic Step

76 76 Long Prosthetic Step Prosthetic CauseProsthetic Cause –Excessive Plantarflexion of foot –Excessive component extension –Long toe lever arm Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb Flexion contracture –Patient Insecurity –Pain on sound side 76

77 77 Short Prosthetic Step

78 78 Short Prosthetic Step Prosthetic CauseProsthetic Cause –Socket pain –Weak extension aid –Unstable knee –Excessive Dorsiflexion –Poor suspension Amputee CauseAmputee Cause –Bad Gait Habits, Strength, Short Residual Limb –Patient insecurity –Weak hip muscles –Poor balance 78

79 79 TF Gait Deviations Conclusions 79


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