Gait Alignment/Deviations TF

1. Pelvic Rotation

2. Pelvic tilt

3. Knee and hip flexion

4. Knee and ankle interaction

5. Lateral pelvic displacement

Determinants of gait

“Symptom”

What is observed

“Cause”

Patient/prosthetic gait problem

Goal in gait assessment

Attempt to match normal gait

What methods of assessment are available and which ones are clinically applicable?

1. Sound - use multiple senses

2. Feedback from patient

3. Force plates/sensors

4. Outcome measures - speed, time, TUG

   1. Slow motion video capture - looking for specific phases of gait

Weak knee extensors results in

Foot slap at IC

Locked ankle results in

Knee buckling to allow HRF to move posteriorly

Where do you start making adjustments during static and dynamic alignment?

SOCKET

What do TF patients typically lose relating to gait?

Trunk rotation/arm swing

Applying force to ASIS, shifting weight into hand, allowing loading of the prosthesis

Transverse pelvic rotation

What does loading the prosthesis toe help with?

Weight distribution - helping with initiating knee extension and give them energy return

When would giving a patient stance flexion be justifiable?

When shock absorption is needed at IC

Name the different stance phase deviations

1. Foot slap

2. Foot rotation

3. Knee instability

4. Lateral trunk bending

5. Abducted gait

6. Delayed progression

7. Drop off

8. Unequal step length

9. Excessive lordosis

In someone who is not an amputee, when would foot slap occur?

If they have a weak tibialis anterior

Rapid plantarflexion to foot flat

Foot slap

Prosthetic causes for foot slap occurring

Prosthetic heel/bumper is too soft (articulated ankle)

When would a patient like having the foot slap deviation?

To provide stability in early stance, allowing the GRF to go anterior relative to the knee quicker for increased stability

Too hard of heel - long toe lever - locked ankle in an orthosis all lead to what?

Rapid knee flexion

External foot rotation in early stance - heel hits and instead of knee flexion the foot will rotate

Foot rotation

If you notice foot rotation at toe off, what could be the issue?

They can have too stiff of a toe lever

Prosthetic causes for foot rotation to occur

Prosthetic heel/bumper too firm

Shoe heel too firm

Socket rotation due to insufficient modification

Uncontrolled knee flexion in early stance - different than stance flexion

Knee instability

Causes for knee instability occurring from the patient

Weak hip extensors

Causes for knee instability because of the prosthetic

Insufficient socket flexion

Knee unit too far anterior

Foot in too much DF

Prosthetic heel (or shoe) too firm

Shoe heel height

Should the socket ever be extended?

NO

Bending toward prosthesis/affected side in stance

Lateral trunk bending

Patient causes for lateral trunk bending to occur

Short residual limb

Weak hip abductors - as this deviation takes weight off of the gluteus medius

Prosthetic causes for lateral trunk bending to occur

Px too short

Femur not stabilized laterally - could be that the lateral wall was not shaped, wide M-L dimension, insufficient socket adduction

Pain - ramus pressure or distal-lateral femur pressure

Prosthesis held away from midline (>4” BOS from the medial border of the heel)

Abducted gait

Patient causes for abducted gait to occur

Weak or contracted abductors

Poor balance, insecurity

Prosthetic causes for abducted gait

Prosthesis too long

Lateral wall not shaped

Pain in the ramus or distal-lateral femur pressure

If the patient is experiencing abducted gait, where should you start?

Try to fix first with a translation plate

Sensation of “walking uphill” during terminal stance

Delayed progression

Prosthetic causes for delayed progression

Toe lever too long - excessive PF or the foot too far anterior

Foot too far anterior

Foot category too high (too stiff)

Sensation of “stepping in a hole” during terminal stance

Drop off

Prosthetic causes for drop off

Toe lever too short - foot too DF or socket too far anterior to knee/foot

How could drop off also appear as in gait?

Knee flexing too early in the gait cycle

What can cause unequal step length?

Patient cause - new patient, poor balance, insecurity

Prosthetic cause - insufficient socket flexion (same ideas as if the socket was extended, not giving the patient enough ROM), painful socket

Long prosthetic step, short sound side step

Unequal step length

How can you fix unequal step length?

Alignment and gait training

Pelvic motion used to increase step length

Excessive lordosid

What does excessive lordosis compensate for?

Weak hip extensors/abdominals

Patient causes for excessive lordosis

Weak hip abductors/abdominals

Hip flexion contracture

Prosthetic causes for excessive lordosis

Insufficient socket flexion

List the swing phase deviations

1. Medial/lateral whip

2. Uneven heel rise

3. Circumduction

4. Vaulting

5. Terminal impact

Foot moves in a medial or lateral arc - observe direction of heel in early swing

Medial/lateral whip

What direction will the trunk swing toward in a medial/lateral whip?

Swing toward the Affected side

Patient causes for a medial/lateral whip

Weak musculature or improper donning

Prosthetic causes for medial/lateral whip

Knee axis in excessive rotation

Socket fit - too tight/too loose

Medial whip

External rotation - hip stays toward midline

Lateral whip

Internal rotation - hip stays in midline

Name differences between medial/lateral whip and circumduction

Hip stays in normal midline for a whip while in circumduction it does not.

Circumduction - at the hip

Whip - at the knee

Heel rises too high and too quickly from initial to mid swing - opposite can also occur

Uneven heel rise

Patient causes for uneven heel rise

Forceful hip flexion

Prosthetic causes for uneven heel rise

Incorrect flexion resistance - friction/valve setting, programming (MPK)

Hip moves in a lateral arc (abduction and flexion) to provide clearance

Circumduction

Patient causes for circumduction

Lack of confidence to flex the knee

Prosthetic causes for circumduction

Prosthesis too stable (or locked knee)

Excessive extension bias (as many knees come with an extension assist)

Excessive resistance to flexion

Inadequate suspension

Prosthesis too long - limb position to the socket

What side will the trunk lean toward when patient circumducts?

Opposite/unaffected side

Excessive PF to provide clearance

Vaulting

Patient causes for vaulting

Habit

Prosthetic causes for vaulting

Px too stable

Excessive extension bias

Excessive resistance to flexion

Inadequate suspension

Prosthesis too long - needing extra clearance

Full extension forcefully achieved prior to IC (“clunk”)

Terminal impact

Patient causes for terminal impact

Habit/preference

Prosthetic causes for terminal impact

Insufficient knee friction

Excessive extension assist

Footwear - heel height and durometer

Limb volume - shrinking/swelling of residual limb, sock ply management

Improper donning - rotation

Patient fatigue

Patient motivation

Other considerations for gait deviations