Transcript LE Prosthetic Gait Assessment & Deviation

LE Prosthetic Gait
Assessment & Deviation
M. Jason Highsmith, DPT, CP
Outline
• Review basic, “normal” gait
• TT
– Generalizations (Prognosis & Demographics)
– Proper alignment
– Deviations
• TF
– Generalizations
– Proper alignment
– Deviations
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
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
Flexion
Flexion
HS
Flexion
FF
MS
Extension
HO
Flexion
TO
TT Gait Assessment
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1.
2.
3.
Consider all 3 planes
Desired is:
Flexion moment throughout stance
Slight varus
Slight toe out
Alignment Considerations
• Linear
• Angular
• Transverse
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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
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Observe:
All Planes
Frontal:
Toe out
Slight Varus
Properly Aligned
• Observe
• Sagittal:
• Slight Flexion Moment
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
Extension Moment
Extension Moment
• Prosthetic Cause
– Heel Too Soft
– Foot Too far Anterior
– Foot Too Plantarflexed
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• Amputee Cause
– Shoe Heel Height Too low
– Shoe Heel Height Too low
– Bad Gait Habits, Strength, Short Residual Limb
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Flexion Moment
Flexion Moment
• Prosthetic Cause
– Heel Too Firm
– Foot Too far Posterior
– Foot Too Dorsiflex
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• Amputee Cause
– Shoe Heel Height Too high
– Bad Gait Habits, Strength, Short Residual Limb
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Valgus Moment
Valgus Moment
• Prosthetic Cause
– Foot Too Outset
– Components Too ABDucted
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
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Varus Moment
Varus Moment
• Prosthetic Cause
– Foot Too Inset
– Components Too ADDucted
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
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Drop Off
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Drop Off
• Prosthetic Cause
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Short toe lever
Excessive socket flexion
Excessive dorsiflexion
Incorrect foot type
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Internal Rotation of hip at toe off/hip flexion
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External Foot Rotation
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External Foot Rotation
• Observations
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–
–
–
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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
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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
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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
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Lateral Shift
• Prosthetic Cause
– Foot Too far Inset
– Insufficient components
– Short Prosthesis
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ABDuction
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
Inadequate balance
– Weak Knee
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– Narrow Gait Base
Vaulting
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Vaulting
• Prosthetic Cause
– Long Prosthesis
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– 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
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Wide Gait
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Wide Gait
• Prosthetic Cause
– Prosthetic foot Too
– Excessive components
ABDuction
far Outset
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• 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
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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
KD/TFA
• Components significantly effect gait
• Prognoses highly variable
• View from all planes
• Anatomic/pathologic contributions?
• Component contributions?
• Socket contributions?
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
Things to Consider…
• Which knee is most stable?
• What foot characteristics are most/least
desirable with TF prostheses?
Gait Deviation Definition
• Toe Lever Arm
• Heel Lever Arm
• Socket Flexion
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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
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Toe Drag
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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
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Vaulting
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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
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Hip Hiking
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Hip Hiking
• Prosthetic Cause
– Too Long
– Poor suspension
– Excessive knee stability
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
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Circumduction
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Circumduction
• Prosthetic 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
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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
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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
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Lateral Whip
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Lateral Whip
• Prosthetic 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
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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
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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
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Medial Whip
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Medial Whip
• Prosthetic 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
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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
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Trendeleburg Gait
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Trendelenburg Gait
• Prosthetic 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
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ABDuction Gait
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ABDuction Gait
• Prosthetic Cause
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–
–
–
Prosthesis Too Long
Medial wall Too High
Insufficient femoral stability
Induces medial whip
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– ABDuction contracture
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Heel Rise
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Heel Rise
• Prosthetic Cause
– Inadequate extension aid
– Insufficient knee friction
– Improper knee selection
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Excessive use of hip flexors to initiate swing phase,
overpowering knee unit
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Lateral Shift
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Lateral Shift
• Prosthetic Cause
– Prosthetic foot Too far Inset
– Excessive socket ADDuction
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Weak hip ABDuction
– Narrow gait base
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Long Prosthetic Step
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Long Prosthetic Step
• Prosthetic Cause
– Excessive Plantarflexion of foot
– Excessive component extension
– Long toe lever arm
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb Flexion
contracture
– Patient Insecurity
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– Pain on sound side
Short Prosthetic Step
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Short Prosthetic Step
• Prosthetic Cause
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Socket pain
Weak extension aid
Unstable knee
Excessive Dorsiflexion
Poor suspension
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• Amputee Cause
–
–
–
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Bad Gait Habits, Strength, Short Residual Limb
Patient insecurity
Weak hip muscles
Poor balance
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TF Gait Deviations Conclusions
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