Gait Deviations/ Troubleshooting Flashcards
What causes knee instability in a prosthesis?
Knee too anterior
Excessive resistance to PF
Shoe heel height increased
Insufficient socket flexion
Unequal step length
Painful socket
Unstable knee
Patient insecurity
Insufficient initial socket flexion to accommodate contracture
Foot slap
PF bumper or heel cushion to soft
Patient forces heel compression to ensure knee instability
Insufficient PF resistance in the px foot
How to correct knee instability in a prosthesis?
Reduce the degree of dorsiflexion or anterior translation of the socket over the foot.
What deviations occur at loading response?
External foot rotation Knee flexion is not smooth Knee flexion is abrupt and uncontrolled Knee remains extended; rides heel> midstance Pistoning
What gait deviations occur at mid stance?
Abducted gait
Lateral trunk bending
Toe rotation does not match sound side
What is external foot rotation caused by?
PF bumper or heel cushion too firm
Excessive toe out
Socket rotation -loose fit
Socket rotation- tight medial/posterior wall
Knee flexion is not smooth what is the cause
Weak quads
The knee remains extended and patient rides the heel through to midstance?
Foot too anterior Insufficient socket flexion Foot plantarflexed Sach heel too soft (if more than 3/8" comp) Heel on shoe too low Excessive use of knee extensors
Knee flexion is abrupt and uncontrolled?
Foot too posterior
Socket too flexed
Foot excessively dorsiflexed
Heel on shoe too high
Plantarflexion bumper or heel wedge too firm
Shoe does not allow heel cushion to compress sufficiently
What causes pistoning?
Patient dropping too deeply into socket
Suspension too loose
Not enough prosthetic socks
Poor modifications - not enough support under medial tibial flare or patellar tendon
Abducted gait
Pubic ramus pressure Pain at distal lateral femur Lateral wall not shaped to provide adequate femur support Prosthesis too long Excessive abduction built in Pelvic band too far from ilium Patient has weak/contracted abductors Patient insecurity
Lateral trunk bending
Prosthesis is too short Excessive outset Insufficient socket adduction Wide ML Lateral wall not shaped to provide adequate femur support Pubic Ramus pressure Pain at distal lateral femur
Toe rotation does not match sound side is caused by?
Improper foot rotation alignment
What gait deviations occur at terminal stance?
Pelvic rise
Drop off
Excessive lumbar lordosis
What causes pelvic rise (hill climbing) hip hiking
Toe lever too long
Prosthesis that is too long
Prosthetic knee with Insufficient friction
What causes drop off (excessive pelvic drop with forward progression
Toe lever too short
Keel or toe level is soft
Heel height is too high
What causes excessive lumbar lordosis?
Insufficient initial socket flexion
Improper shaped posterior wall causing painful ischium weight
Hip flexion contracture
What gait deviations occur at preswing?
Medial whip Lateral whip Socket drops pistoning Inadequate or delayed knee flexion Uneven heel rise
Medial whip
Knee axis is in external rotation
Socket donned in external rotation
Lateral whip
Knee axis in internal rotation
Socket donned in internal rotation
Socket drops (pistoning)
Inadequate suspension
Inadequate or delayed knee flexion
Excessive mechanical resistance to knee flexion
Prosthesis Aligned with too much stability
Uneven heel rise
Incorrect resistance to knee flexion
What gait deviations occur at initial contact?
Knee instability
Unequal step length
Foot slap
What gait deviations occur in terminal swing?
Excessive terminal impact
Unequal step length
Terminal impact
Caused by: Insufficient knee friction Extension bias too strong Warn or absent extension bumper Patient deliberately extends
Circumduction is caused?
Excessive mechanical resistance to knee flexion Aligned w/too much knee stability Prosthesis too long Medial brim pressures Inadequate suspensions
Vaulting
Prosthesis too long
Excessive mechanical resistance to knee flexion
Aligned in too much stability
Inadequate suspension
Patient is having pain or redness on distal end of RL and or redness on distal Patella
Not enough socks allows RL to “bottom out”
Patient is having redness on distal aspect of fibula head and distal patella is caused by?
Not enough socks allows RL to drop too far into socket
Patient is having redness on tibial tubercle and or proximal fibular head. May also show signs of verrucose hyperplasia why?
Too many socks being used causes lack of distal contact.
RL volume reduced and they are wearing proper ply but socks cause too much tightness proximally: adding padding posterior, medial tibial flare and lateral tibial flare (pre tibs) *reduce sock ply
Pressures on distal lateral and proximal medial is caused by?
Alignment issue:
Excessive varus
Excessive foot inset
Too much socket adduction
Discomfort on anterior proximal patella and posterior distal RL
Can occur @initial contact or preswing - initial swing
Patient switched to lower height shoe Foot too anterior (toe lever too long) Heel cushion or plantar flexion bumper too soft Plantarflexed foot Posterior leaning pylon Excessively extended socket
- All these can cause excessive extension in stance phase
Discomfort on anterior distal tibia and posterior proximal RL near hamstring tendons
Can occur @initial contact or preswing to initial swing
Patient switched to higher heel height Foot too posterior (toe lever short) Heel or plantarflexion bumper too firm Dorsi flexed foot Heel too short or soft Anterior leaning pylon Excessive socket flexion
*All of these can cause excessive flexion in stance
Patient is having all over redness or irritation
Could be improper hygiene or allergic
Proper sock ply is being used with proper alignment but there is irritation present over a bony prominence
Check for distal contact with clay or flexible steel probe. If RL is seated properly bony prominence needs to be relieved by heating, grinding, or distraction pads.
Patient complains of discomfort while ambulating but is comfortable while standing
Mostly pistoning:
Assess w patient weight bearing you hold prosthesis in place and have patient lift RL. If RL motion more than 1cm of patella than pistoning is occurring.
- -faulty suspension
- -loose socket fit
- -not enough socks
Pylon leans medially
Too much socket adduction
Foot outset
Pylon leans laterally
Not enough socket adduction
Foot inset
State one cause and one correction for:
Anterior distal and posterior pressure?
Cause: shoe change
Correction: heel wedge to correct height
State one cause and one correction for:
AK distal lateral pressure, socket fit good
Cause: too much adduction built into socket
Correction: remove adduction
State one cause and one correction for:
BK distal end pressure with blisters “I’m just pulling it on”
Cause: incorrect donning of liner causing void at distal end
Correction: re educate on rolling on Liner
State one cause and one correction for:
BK distal pressure cuff suspension- self adjust, tight, gained 20lbs, putty test?
Cause: lack of distal contact
Correction: remake socket
State one cause and one correction for:
Pediatric Symes: fib head, tibial tuberosity, lateral distal pressure
Caused: gained weight
Correction: remake socket
State one cause and one correction for:
Pediatric exoskeleton Symes - distal lateral pressure
Cause: bone spur
Correction: distraction pad until can remake socket
State one cause and one correction for:
AK medial brim pressure
Cause: weight loss
Correction: add socks
State one cause and one correction for:
BK redness on distal Patella and anterior distal tibia
Cause: patient is shrink
Correction: add sock
State one cause and one correction for:
Knee disarticulation- medial window. Medial pain and Proximal fit?
Cause: not enough socks
Correction: distraction pads
- alignment (too much abduction)
- check proximal stability
State one cause and one correction for:
BK redness on all bony landmarks. Traditional suction socket
Cause: pistoning
Correction:
Leak in suction - replace vacuum pump, check for leak in sleeve
State one cause and one correction for:
TR- patient could not open TD completely. Rubber hands
Cause: force vs excursion problem
Correction:
State one cause and one correction for:
TH TD opens prematurely
Cause: EFT too proximal
Correction: move EFT distal
If patient is having a problem with the prosthesis what questions must you ask to determine the cause?
Is it physical problems (ROM, weaknes)
Fit issues with the socket (volume)
Alignment issues with the prosthesis
What Are the causes if patient is unable to flex knee, difficult rolling over toe
Too rigid of toe lever (too plantarflexed)
Prosthetic knee is too stiff
Not fully shifting weight over knee, pelvic rotation
Not putting enough weight through the prosthesis
What Are the solutions/corrections if patient is unable to flex knee, difficult rolling over toe
Prosthesis alignment GRF
Gait training, trusting prosthesis
What are similar causes of circumduction, abducted, and hip hiking gait ?
Clearance of prosthesis- height and PF ankle
Pain
Insufficient suspension
Trouble bending knee
What are similar corrections of circumduction, abducted, and hip hiking gait ?
Check volume add/ remove sock
Check suspension
Gait training- weight through prosthesis
Foot placement BOS
What are the causes of toe dragging in a BK prosthesis?
Prosthesis height
Foot too PF
Suspension inadequate
Patient habit/inadequate knee flexion
How to correct toe dragging in a BK prosthesis?
Gait training (strengthen muscles) If patient has a liner/sleeve on over knee, increases stiffness - remind pt to intentionally flex their knee Alignment
What are possible causes of excessive varus thrust (BK)
Socket too loose in ML
Improper foot placement at unitized contact
Foot too inset
Foot “toed” in too much
What are some solutions to excessive varus thirst in a BK
Volume issue/ add socks
Gait training
Prosthetic alignment change (outset foot)
Rotate socket or change toe out
What are prosthetic causes of drop off?
Short toe lever
Excessive socket flexion
Excessive dorsiflexion
Incorrect foot type
What are amputee causes of drop off?
Bad gait habit, strength, short residual limb
Internal rotation of hip at toe off / hip flexion
Patient complains of feeling like they are walking uphill what is the cause?
A long prosthesis
Patient complains of feeling like they are stepping into a hole what is the cause?
A short prosthesis
What are some thing to do before messing with alignment?
Check fit of sock ply (try too many socks then decrease per ply)
Check AP dimension (use corset stays/probe or inside calipers)
Check ML dimension (use corset stays, probe or inside calipers)
If patient has AP dimension issues you correct by?
Add popliteal pad
Check patella tendon bar
Look for sock marks in the weight tolerant areas
Check popliteal shelf (make sure no impingement on hamstrings for comfort)
What happens if the posterior shelf is lowered excessively?
Lowering the shelf excessively will loose the AP and the limb will bottom out.
If patient has ML dimension issues you correct by?
Adding padding to medial or lateral walls and medial flare: be careful of fibular head
Within range of 1/4 to anatomical measurements
What happens if the length of the socket is too long?
No distal contact, patient may experience varicose hyperplasia (scaling or hardening of distal end)
How correct socket if the length of the socket is too long?
Apply foam pad to distal end to create total contact
Have patient wear Shrinker sock sung to reduce condition without wearing socket.
What happens if a patient has a knee flexion contracture?
They may need to be fit with a preparatory socket/ copolymer until the contracture is reduced by stretching through PT
What is bell clapping and how do you fix or check for it?
Socket would be loose distally allowing the limb to move in the AP direction without total contact.
BAby powder mAy be helpful tool to determine where the limb is not making contact with the socket
Use probe to check Area
Recheck measurements
Add pad on wallet hollow for TF
Add pad in the gastrocnemius and pretib areas for TT
Hammocking of socks- patient feels like they are bottoming out but are not actually at the bottom of the socket.
Test with ball of putty to see actual pressure
Check socks marks distally and proximal to distal cut bone
What is the solution for Hammocking of socks- patient feels like they are bottoming out but are not actually at the bottom of the socket.
Reduce sock ply
Heat relieves socket in specific area to decrease Hammocking effect
Compare current measurements to previous measurements.
How to correct pistoning if pt has too many layers of socks
Reduce to 3 or 5 ply Reduce ply fit with adding pads Check suspension May need to add pad to existing sc pad Check cuff strap Check fit of sleeve, corset or gel liner
How to determine the length of socket?
Check either mid patella tendon or medial Tibial plateau to distal end.
True or false too many (8-10) sock ply will raise the limb out the socket
True
Too many socks will cause pistoning and rotation of the socket
Solution : pad the weight tolerant Areas to reduce the ply fit or global reaction of the negative cast/model
