Gait Deviations in Amputees Flashcards
2 causes for a medial whip during gait
Knee axis is at excessive external rotation.
Also occurs if prosthesis is donned in external rotation.
Cause of lateral whip during gait. Name phase of gait in which lateral whip occurs
Knee axis is at excessive internal rotation.
Heel moves laterally at beginning of swing phase.
Define lateral trunk bending, the phase of which it is seen during gait, and its causes
Significant leaning of torso towards prosthetic side. Occurs at midstance. Compensation reduces pressure on the lateral distal femur. Can occur when prosthetic foot is excessively outset and/or socket is abducted. May also be an antalgic gait due to a bone spur on the distal lateral femur. Weakened hip abductors is another cause.
Cause of knee instability and when it occurs during gait
Knee flexes uncontrollably at loading response. Typically occurs when socket is too far posterior to Trochanter-knee-ankle (TKA) line. May also occur in early stance phase when excessive resistance to plantar flexion is caused by a heel durometer or plantar flexion bumper that is too firm. Short lever arm of residual limb and weaknesses in hip extensors also attributed.
Cause of excessive heel rise and when it occurs during gait
Results from inadequate resistance to knee flexion. Heel moves abnormally high during initial swing. Delays swing phase and reduces gait velocity.
Causes of external rotation of foot at heel contact
Lateral movement of forefoot at beginning of stance phase. May result when heel durometer is too firm, insufficient space in socket for muscle expansion, or if socket is too tight in conjunction w/ loose soft tissue.
Cause of abducted gait
Results in a wide BOS. Common prosthetic cause= excessive pressure on ramus as it exits the socket medially.
Circumduction of leg
Occurs if knee flexion resistance is extreme, prosthesis is too long and/or extension assist is too strong. One may also circumduct due to pain from impingment of tissues at medial brim of prosthetic.
Cause of terminal impact
Inadequate resistance to knee extension causes audible “clunk” at terminal swing phase. Knee unit reaches full extension without resistance; will wear out the knee quickly over time.
Causes of unequal step length
Associated w/ excessive lumbar lordosis. Sound limb step length is shorter than prosthetic step length. Solution: flexing socket 5 deg assists w/ increasing step length.
Flexion contracture at hip = greater flexion needed at socket.
Negative affects of pistoning or bell-clapping
Translates into a decrease in control over prosthesis and it results in discomfort (blistering from shear forces).
Normal Gait knee flexes smoothly 8-10 d from heel contact to midstance. This helps to absorb shock and reduce energy requirements of gait. List potential causes of an extended knee w/ transtibial prosthesis:
- Too long of a lever arm
- Socket to far posterior over foot
- Insufficient knee flexion (socket or patient)
- Soft heel
- Inadequate training
- Weak quads
More causes of knee instability w/ transtibial prostheses which may shorten stance phase on prosthetic side:
- Socket too far forward over foot
- Heel is too hard
- Too much knee flexion (socket or patient)
- Higher heeled shoes
- Too short of toe lever
Results of excessive rise/drop of hip w/ transtibial prostheses.
Excessive Rise or Drop of the Hip
Causes:
Rise = Prosthesis is too long.
Drop = Prosthesis is too short.
What are the 3 things you need to observe when observing gait analysis?
- Sitting (static)
- Standing (static)
- Gait (dynamic)
What are the 3 areas you need to observe when evaluating a transtibial amputee in a general static position?
- Residual limb - Does the skin have any sores, abrasions, cuts, or other problems?
- Prosthesis - What is the overall/general condition of the prosthesis?
- Liner - Does it fit with the socket?
For a transtibial amputee (eval in general static position), what are the potential issues with their residual limb?
Some areas might not tolerate socket pressure and cause abrasions, cuts, sores, etc.
For a transtibial amputee (eval in general static position), what are potential issue with the condition of their prosthesis?
Any changes, broken components, wear and tear
For a transtibial amputee (eval in general static position), what are potential issues with their liner?
Improper fit that can cause pain, skin breakdown, and gait deviations
What is priority #1 when observing a transtibial amputee in static?
observe and check the skin to make sure it’s not broken
What are the three areas you need to observe when evaluating a transtibial amputee in sitting?
- Seated posture - Knees flex to 90 deg? feet flat on floor?
- Posterior Flaring - Pressure on HS when seated?
- Residual Limb Position - Stump rise out of socket when seated?
For a transtibial amputee (eval in sitting), what are potential issues with their overall seated posture?
If pressure on the knee or bony prominences, the pt may keep leg extended
For a transtibial amputee (eval in sitting), what are the potential issues with posterior flaring?
pt will keep leg extended or report pain if there is pressure applied to HS
For a transtibial amputee (eval in sitting), what are potential issues with residual limb position?
Socket may be too small or the pt may be wearing too many socks
When treating an amputee, what measurement should you take daily/every time you see them?
Circumferential measurements
What are the 11 things you need to observe when evaluating a transtibial amputee/prosthesis in standing?
- Pain on weight-bearing - how does the limb interface with socket at bony prominences? Redness? Blanching?
- Knee stability - socket aligned with 5-8 deg of hip flex?
- Equal leg length - ASIS, PSIS and iliac crest level?
- Base of Support - too wide? too narrow?
- Pylon - is it vertical?
- Shoe position on the floor - is foot fully on the floor?
- Brim pf socket - are there excessive rolls of tissue at the brim of the socket? or gaps?
- Amount of contact - too little/too much contact?
- Liner - is there a good interface?
- Suspension - does the leg move/distract from stump when NWB?
- Sleeve suspension - is the sleeve on the skin at least 2 inches above liner?
Is static alignment more important than functional alignment?
No - you may make static alignment not as optimal, so that functional alignment can be better
When a transtibial amputee has increased knee flexion, are they going to be more or less stable?
Too much flexion = more unstable
Too much extension = pain
For a transtibial amputee (eval in standing), what are potential issues with pain in weight-bearing?
Excessive pressure will cause skin integrity issues and gait deviations
For a transtibial amputee (eval in standing), what are potential issues with knee stability (flex/ext)?
- Too much socket flexion –> knee extension & anterior pressure
- Too little flexion –>end stump bearing
For a transtibial amputee (eval in standing), what are potential issues with unequal leg length?
- Long prosthesis –> hip hike, circumduction (vaulting on opposite leg)
- Short prosthesis –> trendelenberg and lateral curve at lumbar spine
For a transtibial amputee (eval in standing), when examining BOS what width range can potentially cause issues?
> 2-4 inches
What is standard bench alignment socket values?
5 deg flexion
5 deg adduction
Describe the alignment of prosthetic foot.
- the top is level int he frontal and sagittal plane
- the medial border is parallel to the line of progression
What are the 4 goals in prosthetic alignment?
- Facilitating heel strike at initial contact
- Provide adequate single limb stability during stance phase
- Creating smooth forward movement (rollover) during the transition from early to late stance phase
- Insuring adequate swing phase toe clearance
* Goals are reached through dynamic alignment*
Is the goal of an amputee to achieve “normal” gait?
No, but new tech allows pt to walk without obvious deviations
For a transtibial amputee (eval in standing), what are potential issues with misalignment of he pylon?
If not aligned = gait deviations
If pylon starts leaning lateral = valgus, medial pressure on the knee (lateral on the hip)
For a transtibial amputee (eval in standing), what are potential issues with bad show position on the floor?
The foot becomes plantarflexed or dorsiflexed
Walking on your toes = reduced pressure from shortened lever – decrease stance time
For a transtibial amputee (eval in standing), what are potential issues with the brim of the socket?
socket may be too tight, may be to small, or not molded right
For a transtibial amputee (eval in standing), what are potential issues with inadequate liner interface?
worn out liners = skin breakdown
For a transtibial amputee (eval in standing), what are potential issues with inadequate suspension?
too much movement = skin breakdown
For a transtibial amputee (eval in standing), what are potential issues with inadequate skin contact with sleeve and liner?
Will lead to pistoning
What are the 2 things you should observe in static in a transfemoral amputee/prosthesis?
- Socket Interior - smooth?
2. Component function - knee joint 5-8 deg of flex? good stability?
For a transfemoral amputee, what are potential issues with a socket interior that is not smooth?
skin breakdown, abrasions, sores
For a transfemoral amputee, what are potential issues with a inadequate knee flexion and/or good stability?
- too much flexion = instability
- too little flexion = hyperextension –> pain and worn out components
- problems in stance = FALLS
What are the 4 things you should observe in sitting in a transfemoral amputee/prosthesis?
- Fit of socket - secure in all positions?
- B shin & thigh length - knees level when sitting with them flexed to 90 deg?
- Burning/pinching - smooth,thin socket or liner layer on posterior wall?
- Reach shoes - can they lean forward and reach shoes?
For a transfemoral amputee, what are potential sitting issues with shin and thigh length?
A high prosthetic knee –> misaligned knee joint. & poor swing through
For a transfemoral amputee, what are potential sitting issues with a smooth posterior socket/liner?
If not smooth = sciatic nerve pressure and possibly pain
For a transfemoral amputee, what are potential sitting issues with pt not being able to reach his shoes?
Anterior wall may be blocking forward lean
What are the 4 things you should observe in standing in a transfemoral amputee/prosthesis?
- Socket fit - is pt comfy in socket?
- knee stability - knee in line or behind the trochanter to knee axis?
- Level of pelvis - ASIS, PSIS, iliac crest level?
- Base of Support - width should not be >2-4 inches
For a transfemoral amputee, what are potential standing issues with socket fit?
Gait deviations, non-compliance, skin breakdown
For a transfemoral amputee, what are potential standing issues with knee stability?
If knee is anterior to the line = instabiltiy
For a transfemoral amputee, what are potential standing issues with unlevel pelvis?
Gait deviations, possibly hip and LBP
In Transfemoral Amputations in Standing,, what are the standing observations?
- Socket contact with residual limb
- Adductor roll
- Pressur on pubic ramus
In transfemoral amputations what are things to assess?
- Good contact between socket and residual limb?
- adductor roll?
- Pressure on pubic ramus from socket?
What are potential issues for transfemoral amputation in standing?
If loose or tight–>skin breakdown, discomfort
Pain if adductor roll is over medial wall is pinched between socket and pubic ramus
Pain–>abducted gait
What are some dynamic observations you can make during a gait analysis
- Observe systematically (AP, ML, general to specific)
- Identify presence of deviations and determine cause
Describe foot slap
Characterized by rapid, and un-cosmetic PF movement immediately after Heel Contact
Result of Insufficient of PF resistance in prosthetic foot
An excessively soft PF Bumper enough but with an articulated ankle may produce this deviation
Describe Hyperextension of the Knee
Heel cushion which is too soft or keel or toe lever arm that is too long or too firm
Anatomically, hyperextension can be caused by laxity of the posterior capsule of knee or HS tendons.
May require the application of a supracondylar/suprapatellar PTB style socket
Careful attention to anterior proximal trim lines can limit hyperextension
TX: includes HS strengthening (Swiss ball, bridging, band exercises
Describe Pistoning of the Knee
Occurs when tibial moves vertically during alternating WB and NWB periods
Best seen in popliteal region as individual walks away
Seen when sockit is too large or suspension inadequate
Describe Excessive External Rotation
Characterized by lateral movement of forefoot at beginning of stance phase
Heel durometer is too firm
Describe excessive varus
Achieved by modest medial inset of prosthetic foot relative to socket
-Increased pressure on proximal medial and distal lateral regions of residual limb
Describe vaulting
Pronounced PF of sound ankle which elevates the COM to assist in clearance at the prosthetic limb during swing phase
Too long: vault over limb
Presence of excessive knee friction will cause same deviation as the individual attempts to clear forefoot of prosthesis
Describe Asymmetrical Shoulder Movement
May suggest LLD
Measure Asymmetry in ASIS, PSIS, and iliac crest
Tx: glute strength, pelvic tilts, core work, hip flexor strengthening
Describe possible reasons for a gait deviation during Mid-Stance in a transfemoral prosthesis
- “active lumbar lordosis”
- lack of initial socket flexion
- flexion contracture that the prosthesis cannot accommodate
- weak hip extensors
- weak abs
Describe a gait deviation during Terminal Stance in a transfemoral prosthesis
- drop off
- short toe lever arm
- decreased heel off
- if body weight doesn’t come over toe of prosthesis the heel will not come off and may lead to delayed knee flexion
Reasons for a circumducted gait deviations during the swing phase in a transfemoral prosthesis
- prosthesis is too long
- not enough knee flexion in prosthesis
- decreased patient confidence
- stance phase control knee may not be functioning
Reasons for vaulting gait deviations during the swing phase in a transfemoral prosthesis
- prosthesis is too long
- inadequate socket suspension
- excessive stability built into the knee/decreased knee
- inadequate gait training
Reasons for medial and/or lateral whip gait deviations during the swing phase in a transfemoral prosthesis
- Medial: excessive ER rotation of prosthetic knee
- Lateral: excessive IR rotation of prosthetic knee
- socket may be too small
Reasons for uneven arm swing and uneven step gait deviations during the swing phase in a transfemoral prosthesis
- these two things go together
- poor or inadequate gait training
- fear of putting weight through the prosthetic leg
What will you observe during the gait if the prosthetic foot is inset?
BOS is too narrow because prosthetic foot is aligned too close to the intact foot during midstance
What will you observe during the gait if the prosthetic foot is outset?
BOS is too wide because prosthetic foot is too far from the intact foot during midstance
What will you observe during the gait if the prosthetic foot is has a heel that is too hard?
- knee instability during weight acceptance because the heel doesn’t function to absorb any shock
- knee absorbs more force which results in some level of instability
What will you observe during the gait if the prosthetic foot is has a heel that is too soft?
- knee is extended during weight acceptance because heel absorbs too much force and patient will have to stiffen the leg/knee to prevent leg from buckling
What will you observe during the gait if the prosthetic foot is has to much ER?
- less efficient gait
- may reflect alignment of prosthesis or the intact hip
- may also reflect ER/torsion of tibia/fibular of residual limb
- very rarely will see foot aligned in too much IR
In a transtibial pylon what would you expect to see if there is a medial leaning pylon?
- wide BOS during midstance similar to the BOS you observe with an outset foot
In a transtibial pylon what would you expect to see if there is a lateral leaning pylon?
- narrow BOS during midstance similar to BOS with an inset foot
With a transtibial socket, what do you expect to see/happen when it is too far posterior to the prosthetic foot?
- behind prosthetic foot = long toe lever arm
- knee is extended during weight acceptance phase
- gait pattern may look stiff
With a transtibial socket, what do you expect to see/happen when it is too far anterior over prosthetic foot?
- ahead of prosthetic foot = short toe lever arm
- too much knee flexion during weight acceptance phase of gait (knee instability)
- observable during terminal stance
- promotes lack of confidence in prosthetic leg
With a transtibial socket, what do you expect to see/happen if it doesn’t allow for enough knee flexion?
- knee is extended rather than flexed during weight acceptance phase
- pt may feel like they are walking uphill
- gait may look stiff
With a transtibial socket, what do you expect to see/happen if it allows for too much knee flexion?
- knee will appear unstable during weight acceptance phase
- prosthetic leg/knee will buckle
With a transtibial socket, what do you expect to see/happen if the socket is too big?
- prosthetic leg will piston
- contribute to gait instability
- uneven step and stride lengths
What would you expect to see/happen if the prosthetic knee exhibits too much flexion (allows too much or aligned that way)?
- prosthetic leg will buckle from initial contact to midstance
- will look like knee/LE instability
What would you expect to see/happen if the prosthetic knee exhibits too much extension or doesn’t allow enough flexion(allows too much or aligned that way)?
- will function as if they are too long
- circumduction, vaulting or excessive pelvic rise/hip hike on side of prosthetic leg during swing phase
- may see abducted gait pattern or a wide BOS
What would you expect to see/happen if the prosthetic knee exhibits too much ER?
- medial whip of prosthetic leg during swing phase
What would you expect to see/happen if the prosthetic knee exhibits too much IR?
- lateral whip of prosthetic leg during swing
With a transfemoral socket, what do you expect to see/happen when it is too loose?
- ER foot or prosthetic leg that looks hard to control
- vaulting
- inadequate suspension of prosthesis
With a transfemoral socket, what do you expect to see/happen when it is too tight/small?
- excessive soft tissue or adductor roll during stance
- pt may complain of pain or burning sensation
- abducted gait to relieve medial pressure
- a whip may be present
With a transfemoral socket, what do you expect to see/happen when the socket doesn’t allow for initial hip flexion?
- may see “active lumbar lordosis”
- pt is hyperextending lumbar spine to keep COG within BOS
With a transfemoral socket, what do you expect to see/happen when the lateral wall of socket is not adducted enough or the medial wall is too tall?
- lateral trunk bending during midstance towards side of prosthetic leg
- may see abducted gait with a high medial wall to unload pressure on ramus
What do you expect to see/happen when there’s a short toes lever with a transfemoral prosthesis?
- pelvic drop off during terminal stance
What do you expect to see/happen if the prosthetic leg is too short?
- excessive pelvic drop off
- increase in lateral trunk bending towards the side of the prosthetic leg
