697 Week 11 Monday Flashcards: Gait deviations

Inpatient Stay vs Outpatient Course

Inpatient Stay- Designed for individuals who are ready to roll. Well healed, have been mobile at

home, prosthesis fit and preliminarily adjusted

● Typically a 5-7-day rehab admission with goal to establish a wearing schedule, provide gait

training and education/instruction on donning/doffing as well as adjusting fit during the day;

opposite sessions for gait training and prosthetic/skin checks, patient should be stretching

and strengthening

Outpatient Course - Sometimes a better option for individuals predicted to take longer to achieve

tolerance for prosthetic weight bearing; more health problems, etc. OR who may need more

interventions to prepare for prosthetic ambulation (flexibility, strengthening, etc)

Things to do during every day of an inpatient stay

Liners Purpose

Interface Protection: Liners serve as a protective

barrier between the residual limb and the prosthetic

socket. They help prevent friction, pressure points,

● Cushioning: Liners often have padding to provide

cushioning, which helps distribute pressure evenly

Liners:

and skin irritation.

across the residual limb.

● Volume Management: Liners can help manage

volume fluctuations in the residual limb due to

changes in swelling, muscle atrophy, or weight loss/gain. This is especially important during the

initial fitting stages and over time as the residual

limb adapts.

● Socket Suspension: Some liners are designed with

features to aid in suspension, helping to hold the prosthetic limb inside the socket

Socks purpose

Volume Adjustment: Prosthetic socks come in different

thicknesses or ply, allowing users to adjust the fit of their

prosthetic limb by adding or removing layers. This is

Socks:

particularly useful for accommodating volume changes

throughout the day or during various activities.

● Moisture Management: Socks made from moisture-

wicking materials help keep the residual limb dry,

reducing the risk of skin breakdown and discomfort

caused by sweat.

● Comfort and Protection: Similar to liners, socks provide

additional cushioning and protection against friction

and pressure points.

● Alignment Correction: In some cases, socks may be

strategically layered to correct minor alignment issues

or to fine-tune the fit of the prosthetic limb.

Establishing a wearing schedule

• Initial phase: start wearing for short periods (1-2 hours) and gradually increase time in prosthesis every day as comfort allows

• After initial time, try to get them to wear it as long as possible to get used to it

• Continue to gradually increase the wear time over weeks and months, but allow the residual limb adequate time to adjust

• Make sure the patient has follow up appointments scheduled with the prosthetist to address concerns and make adjustments if needed

TKA Line

Trochanter: This point corresponds to the greater trochanter of the

femur. In prosthetics, the alignment of the socket and the prosthetic

knee component should be aligned with the trochanter to ensure

proper weight distribution and stability.

Knee: The knee joint of the prosthesis should be aligned with the

anatomical knee joint of the user. Proper alignment ensures natural

movement and stability during walking and other activities.

Ankle: The ankle joint of the prosthesis should also be aligned with

the anatomical ankle joint to facilitate smooth and efficient gait

mechanics. Proper alignment reduces stress on the residual limb and

other joints, improving overall comfort and function.

A/P View

The A/P view provides a frontal perspective, looking at the

prosthesis from the front and/or back of the user.

● In this view, prosthetists assess the alignment of the

prosthetic components in terms of their position

relative to the user's midline and symmetry between

the left and right sides.

● Proper alignment in the A/P view ensures that the

prosthetic components are positioned centrally and

symmetrically with respect to the user's body,

optimizing balance and stability.

Sagittal View

The sagittal view provides a side perspective,

looking at the prosthesis from the side of the user.

● In this view, prosthetists assess the alignment

of the prosthetic components in terms of their

position relative to the user's anatomical joint

axes, such as the knee and ankle.

● Proper alignment in the sagittal view ensures

that the prosthetic components are positioned

in line with the user's natural joint axes, allowing

for smooth and efficient movement during

walking and other activities.

Circumduction TFA description and potential causes

Description: The individual swings the prosthetic limb in a lateral arc during the swing phase rather than lifting it straight through.

Causes:

Anatomic: abduction contracture, poor knee control

Prosthetic: long prosthesis, excessive stiffness of knee unit, inadequate suspension, small socket, excessive plantarflexion

Circumduction TFA Implications and interventions:

Increased Energy Expenditure- Excessive lateral movement requires more effort, leading to fatigue and decreased endurance over time.

Higher Risk of Secondary Musculoskeletal Issues - Hip hiking and trunk compensation may lead to low back pain, hip pain, or joint overuse injuries on the intact side.  Increased stress on the ipsilateral hip flexors and abductors due to abnormal movement patterns.

Reduced Gait Efficiency and Speed - The extra movement makes walking less fluid and slower, which can limit mobility and daily activity performance.

Increased Fall Risk - The lateral movement disrupts balance and stability, especially in crowded or uneven environments.
Toe clearance issues can result in tripping or stumbling.

Potential Prosthetic Fit and Alignment Problems - May indicate excessive prosthetic length, insufficient knee flexion, or inadequate suspension, requiring prosthetist evaluation.

Prosthetic Adjustments: Ensure proper length, knee flexion settings, and suspension fit.

Gait Training: Emphasize hip and knee flexion strategies to encourage a more natural swing phase.

Strengthening & Flexibility: Improve hip flexor and core strength while addressing tight hip abductors and weak knee flexors.

Cueing & Feedback: Use verbal, tactile, or visual feedback to reinforce proper gait mechanics.

TFA rotation of foot on heel strike Description and cause

Description: The prosthetic foot rotates when it lands on the ground, as opposed to landing and falling in the sagittal plane

Cause: Anatomic: hip rotator weakness/contracture, femoral retroversion

Prosthetic: stiff heel cushion, foot is malaligned to shank

TFA rotation of foot on heel strike implications and treatment

Implication: Excess energy expenditure, further risk of developing or reinforcing a contracture at the hip

Treatment: Anatomic: work on ROM and strengthening for the hip, especially for rotators 

Prosthetic: adjust rotation of prosthetic foot, and swapping out the cushion for more compliance

TTA Contralateral early heel description and cause

Description: Contralateral or early heel rise or vaulting allows for clearance of the prosthetic with decreased hip/or knee flexion. Compensation for a prosthesis that is too long, inadequate suspension, or a learned gait pattern

Cause: Prosthetics: prosthesis that is too long, inadequate suspension, decreased weight acceptance through the prosthetic 

Anatomic: learned gait pattern, decreased strength of hip flexors on prosthetic side

TTA contralateral early heel rise implications and treatments

Implications: Decreased stance time on prosthetic limb, decreased gait speed

Treatment: Prosthetic: Adjust the suspension

Anatomical: Strengthen hip flexors and trunk

TTA lateral trunk description + cause

Description: The patient would have a lean toward the side with the TransTibial Amputation

Cause: Short prosthesis, poor fit

TTA Lateral trunk implication + treatment

Implication: increased energy expenditure and fall risk

Treatment: Increase Prosthetic length

Medial/lateral knee instability description + cause

Description: The patient would have wobbling & instability in medial to lateral movements

Cause: Weakness of the hip flexors, prosthetic sizing issues, abd/add mm weakness

Medial/lateral knee instability implication + treatment

Implication: Pt will have reduced ROM, Decreased mobility, & hyper focused in order to reduce instability

Causes: Banded hip flxn, ball squeezes, hip abd,, and fixing the prosthetic sizing.

TFA Excessively forced hip flexion during terminal swing description + cause

Description: The individual increases anterior sagittal plane movement of the prosthetic limb at the hip.

Cause: Reduced knee friction 

Taut extension aid (too strong of an extension moment because of it being too tight)

TFA Excessively forced hip flexion during terminal swing implication + treatment

Implications: increased energy expenditure

Treatment: fix the knee friction

TTA Excessive knee flexion during stance phase description + cause

Description: The individual uses an increased bent knee when putting weight on it

Cause: Increased ankle dorsiflexion, socket flexion, and posterior foot placement

Weak knee

TTA Excessive knee flexion during stance phase implication + treatment:

Implications: increased energy expenditure

treatment: Cane training

Tactile feedback gait training between // bars

T-band knee stability w/ perturbations (progress into different gait phases)

Eccentric knee extension

TFA Vaulting Description + causes

Description: The individual will raise the contralateral heel off of the ground.

Cause: Long prosthesis, inadequate suspension, inadequate knee friction, excessive plantarflexion, small socket (anatomical) walking speed exceeding that for which friction in sliding knee unit was adjusted

TFA Vaulting Implication + Treatment

Implication: Increased energy expenditure, imbalance/increased pressure during heel strike,

Treatment: Prosthetic adjustments to ensure proper limb length, socket fit, knee flexion, and foot alignment are essential. Gait training to promote symmetrical and efficient gait mechanics.

TTA knee hyperextension causes

Description is self explanatory

may be due to insufficient socket flexion, weak knee extensors, anterior foot placement, or inappropriate prosthetic foot

TTA knee hyperextension implication + treatment

1. Increased instability during gait and balance, excessive knee joint stress, and increased energy expenditure

2. Gait training, reassessing TTA fit, and ankle prosthesis positioning

TFA Lordosis description + causes

Description: 

Lordosis: Terminal stance

Excessive B hip flexion, lumbar lordosis, anterior pelvic tilt

Causes:

Prosthetic: poor posterior brim support, inadequate socket flexion 

MSK: Weak hip extension, hip flexion contracture, very short residual limb

TFA Lordosis implication + treatment

Clinical Implication: 

Spinal pain, poor postural

and reactive balance, further contractures

Interventions: PPT, hip flexor stretch, hip extensor strengthening, fix prosthetic

TTA Premature Heel rise description + cause

TTA Premature Heel rise implication + treatment

TTA abnormal limb rotation description + cause

Abnormal limb rotation (excessive internal or external rotation of the prosthetic limb during swing)

Insufficient suspension, and misalignment of suspension components (improper placement or fit of suspension straps or cuffs can lead to rotation). Outshooting to evade foot drop: If the individual has weak ankle dorsiflexion (foot drop), they may excessively rotate the limb to help clear the foot during the swing phase.

TTA abnormal limb rotation Implication + treatment

TFA Uneven step length description + cause

TFA Uneven step length implications + treatment

TTA foot slap description + cause

7A. Description:

Foot slap of the prosthetic limb occurs when the foot plantarflexes too quickly and strikes the ground with a loud slap

7A. Potential cause:

Anatomical:

- Eccentric quad weakness causing excessive knee flexion

- Flexion contracture of the knee or hamstring tightness

TTA foot slap treatment + implication

7A. Clinical implication:

- increased energy expenditure 

- imbalance

-  Msk implication: high risk of knee joint complications with instability, pain or weakness

- decreased aerobic capacity

7A. Interventions:

- eccentric quad strength/endurance

- Hamstring strength/endurance

- stretching into knee extension and HHS: prone with ankle weight

- gait training with adjustments to heel cushion, socket set more into extension or posteriorly

TFA medial or lateral heel whip description + cause

7B)

(Medial) 

- The heel of the prosthetic limb moves towards midline after toe-off (during swing phases) and forces the knee laterally

(Lateral) 

- The heel of the prosthetic limb moves laterally after toe-off (during swing phases) and forces the knee medially

TFA medial or lateral heel whip implication + treatment

TTA ER in late stage description + causes

Description: External rotation in late stage: Suble outward turning of the leg and foot as the body prepares to move forward in the late phase

Causes: Contralateral muscle imbalances proximally, tight ER rotators ipsilaterally.

TTA ER in late stage implication + treatment

Implication: Lack of stability w excessive movements (running, walking over objects or compliant surfaces)

Treatment: Strengthen IRs of hip, external cueing w/facilitatory techniques to reduce ER.

TFA Wide stance description + causes

Spread out legs, wide BOS

tight abductors, long prosthesis, abduction contracture

TFA Wide stance treatment + implication

Implication: decreased foot clearance, limited hip flexion, slow gait speed, less energy efficiency due to slow speed

Treatment: Stretching abductors, reducing prosthetic length, and socket adjustments to limit abduction. 

TTA Hip ER during heel strike description + causes

TTA Hip ER during heel strike Implication + treatment

TFA Foot slap description and causes

TFA foot slap implication + treatment

TTA toe drag description + cause

Caused by inadequate suspension of the prosthesis, a prosthesis that is too long, or lower-limb weakness in the hip abductors or ankle plantar flexors on the contralateral side.

TTA toe drag implication + treatment

Implication: tripping and falling

Strengthen contra plantar flexors and hip abd, adjust prosthetic

TFA Uneven Heel rise description + cause

Description: Heel rise during terminal stance, refers to an asymmetry in the amount or timing of heel lift during double support

Cause: too much friction, taut extension aid

TFA Uneven heel rise implication + treatment

1. Increase energy expenditure, circumduction. Uneven heel rise disrupts the symmetry of gait and can indicate problems with knee control and weight transfer

2. Decrease knee flexion, kt tape for hip extensors. Prosthetic adjustments, gait training to promote symmetrical weight transfer.