LE Prosthetic Gait Assessment & Deviation

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

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

3. 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

4. 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

5. Flexion Flexion Flexion Extension Flexion HS FF MS HO TO

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

7. Alignment Considerations • Linear • Angular • Transverse 7

8. Gait Deviation Definitions

9. Gait Deviation Definitions

10. Gait Deviation Definitions

11. Properly Aligned • Observe: • All Planes • Frontal: • Toe out • Slight Varus

12. Properly Aligned • Observe • Sagittal: • Slight Flexion Moment

13. Normal Gait

14. 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

15. Extension Moment

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

17. Flexion Moment

18. Flexion Moment • Prosthetic 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

19. Valgus Moment

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

21. Varus Moment

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

23. Drop Off

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. External Foot Rotation

26. 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

27. Long Prosthesis

28. 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

29. 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

30. Lateral Shift • Prosthetic 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

31. Vaulting

32. Vaulting • Prosthetic 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

33. Wide Gait

34. Wide Gait • Prosthetic 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

35. TT Gait Deviations Conclusions 35

36. 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

37. KD/TFA • Components significantly effect gait • Prognoses highly variable • View from all planes • Anatomic/pathologic contributions? • Component contributions? • Socket contributions?

38. 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

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

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

41. Gait Deviation Definitions

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. Normal Gait

44. 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

45. Toe Drag

46. Toe Drag • Prosthetic 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

47. Vaulting

48. Vaulting • Prosthetic 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

49. Hip Hiking

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