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Uploaded byJoe Antony
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Gait deviations in Transtibial prosthesis users

The document discusses gait deviations in transtibial prosthesis users, covering areas such as initial contact, loading response, mid stance, terminal stance, preswing, and swing phase. It details potential deviations, their possible causes, and suggested solutions for each phase of gait. Terminology from the Rancho Los Amigos gait classification system is used throughout to facilitate understanding of the mechanics involved.

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GAIT DEVIATIONS IN TRANSTIBIAL PROSTHESIS USERS DR. JOE ANTONY PHYSICAL MEDICINE AND REHABILITATION KGMU
CONTENTS DR. JOE ANTONY 2 • BASICS OF GAIT • Ranchos los amigos gait terminology • Kinematics • Kinetics and muscle action • DEVIATIONS IN • Initial contact • loading response • Mid stance • Terminal stance • Preswing • Swing phase
RANCHOS LOS AMIGOS GAIT TERMINOLOGY Stance Phase Starting point End point Initial contact Foot comes in contact with ground Loading response Initial contact C/l foot leaves ground Mid stance C/l foot leaves ground I/l heel leave the ground Terminal stance I/l heel leave the ground C/l initial contact 3 DR. JOE ANTONY
RANCHOS LOS AMIGOS GAIT TERMINOLOGY Swing Phase Starting point End point Initial swing Foot leaving the ground I/l foot in alignment with C/l Ankle Mid swing I/l foot in alignment with C/l Ankle I/l tibia become vertical Terminal I/l tibia Initial 4 DR. JOE ANTONY
SAGITTAL PLANE KINEMATICS 5 DR. JOE ANTONY
Ground reaction force and its effect 6 DR. JOE ANTONY
KINETICS AND MUSCLE ACTION 7 DR. JOE ANTONY Initial contact and loading response Mid stance progression
8 DR. JOE ANTONY Terminal stance Preswing
INITIAL CONTACT • Initial contact with the heel • Normal toe out angle is kept at 5-10 degree, heel-to-toe progression through lateral border • Knee maintained in 5-10 flexion • Stride length equal to that of the 9 DR. JOE ANTONY
DEVIATIONS IN INITIAL CONTACT 1. Initial contact with forefoot 2. Knee fully extended 3. Knee excessively flexed 4. Unequal stride length 1 0 DR. JOE ANTONY
INITIAL CONTACT WITH FOREFOOT Causes Solution Excessive plantar flexion of prosthetic feet Realignment of feet Restricted ROM of extension ( knee flexion contracture) Exercises to improve ROM, adjust the socket to accommodate the contracture 1 1 DR. JOE ANTONY
KNEE FULLY EXTENDED Possible causes Solution Faulty suspension, does not maintain knee in 5-10 degrees flexion Correct suspension system Insufficient pre flexion of socket Increase flexion attitude of the socket Foot too anterior Slide foot posteriorly 1 2 DR. JOE ANTONY
KNEE EXCESSIVELY FLEXED (GREATER THAN 10DEGREES) Possible causes Solution Faulty suspension (maintain knee in greater than 10 degree flexion) Correct suspension system Flexion contracture Evaluate ROM then decide • Accommodate if less than 20 degree • Stretch the hamstrings • Surgical correction of deformity 1 3 DR. JOE ANTONY
UNEQUAL STRIDE LENGTH Shorter stride on sound side Shorter stride on prosthetic limb Lack of confidence in prosthesis- in new users Flexion deformity of knee joint Increased gait training Management of knee flexion deformity 1 4 DR. JOE ANTONY
LOADING RESPONSE • Smooth knee flexion to approximately 20 degrees • Approximately 3/8” heel compression • No piston action 1 5 DR. JOE ANTONY
DEVIATIONS IN LOADING RESPONSE • Abrupt knee flexion • Knee remains extended • Piston action 1 6 DR. JOE ANTONY
ABRUPT KNEE FLEXION Causes Solution Weak quadriceps Strengthening Foot too posterior Slide foot anteriorly Knee flexion deformity/socket too flexed/foot is dorsiflexed Reduce socket flexion Heel on shoe is too high Select correct shoe or change foot Cushion heel too firm (no compression) Evaluate amount of heel compression( may be less than 3/8”) and adjust Shoe does not Modify the shoe 1 7 DR. JOE ANTONY
KNEE REMAINS EXTENDED Causes Solutions Foot is too anterior Move foot posteriorly Insufficient socket flexion Increase socket flexion SACH heel too soft ( more than 3/8) Select firmer heel Heel on shoe too low Add heel Excessive use of Gait training 1 8 DR. JOE ANTONY
PISTON ACTION (>6mm) Causes Solution Suspension too loose Correct suspension Not enough prosthetic socks Add Socks Not enough support under medial tibial flare or patellar tendon Add appropriate pads or make new socket 1 9 DR. JOE ANTONY
MID STANCE • Pylon vertical • Socket displaced laterally by about ½” (duplicates varum moment at mid stance) • 2-4” between medial sides of feet (as swinging foot passes stance foot) 2 0 DR. JOE ANTONY
DEVIATIONS IN MID STANCE 1. Pylon leans medially 2. Pylon leans laterally 3. ½” varus moment not apparent 4. Varus moment excessive 5. Less than two inches between feet at mid stance 6. Greater than four inches between feet at mid 2 1 DR. JOE ANTONY
Gait deviation Causes Solutions Pylon leans medially Too much adduction in the socket Reduce socket adduction Foot may be outset Adjust the position of foot Pylon leans laterally Not enough adduction in the socket Increase socket adduction Foot may ne inset Adjust the position 2 2 DR. JOE ANTONY
Deviations Causes Solutions ½” varus moment not apparent (for some patients who cannot control varus force, this is desirable) Foot relatively outset Inset foot Varus moment excessive ( more than ½” Foot too inset Reduce foot inset Socket ML Reduce 2 3 DR. JOE ANTONY
Gait deviations Problems Solutions Less than 2 inches between feet at mid stance Foot Inset (narrow base gait) Reduce foot inset Greater than four inches between feet at midstance Foot too outset Reduce foot outset 2 4 DR. JOE ANTONY
LATERAL TRUNK BENDING TO PROSTHETIC SIDE Causes Solutions Prosthesis too short Evaluate and correct length Residual limb pain ( patient leans laterally to reduce the torque) Evaluate for residual limb pain Foot too outset Reduce foot outset 2 5 DR. JOE ANTONY
TERMINAL STANCE • Heel off should occur smoothly and effortlessly prior to initial contact on the sound side • Immediately after heel off the knee should to flex in preparation for toe off 2 6 DR. JOE ANTONY
DEVIATIONS IN TERMINAL STANCE 1. Heel-off occurs early 2. Heel-off is delayed 2 7 DR. JOE ANTONY
EARLY HEEL OFF Causes Solutions Excessive posterior position of the foot ( short toe lever arm) Move the foot anteriorly Foot excessively dorsiflexed ( socket in too much flexion) Reduce foot dorsiflexion 2 8 DR. JOE ANTONY
DELAYED HEEL OFF 2 9 DR. JOE ANTONY Causes Solutions Excessive anterior position of the foot ( long toe lever arm) Move the foot posterior Foot plantar flexed ( insufficient socket flexion) foot dorsiflexion
PRE SWING • Smooth transfer of body weight to the sound side • Socket remains adequately suspended as swing phase is initiated 3 0 DR. JOE ANTONY
DEVIATIONS IN PRE SWING 1. Drop off 2. Socket drops away from the residual limb 3 1 DR. JOE ANTONY
DROP OFF- Patient appears to fall too quickly to the sound side Causes Solutions Foot too posterior Slide foot posteriorly Foot too dorsiflexed (Excessive socket flexion) Reduce foot dorsiflexion 3 2 DR. JOE ANTONY
SOCKET DROPS OFF- Gaps between socket and stump Casuses Solution Suspension is too loose Readjust the suspension Not enough prosthetic socks Add socks 3 3 DR. JOE ANTONY
SWING PHASE • During initial swing the heel of the foot should accelerate smoothly with no tendency to “whip” medially or laterally • During mid swing the foot should swing through without touching the floor. The patient should not have to exert extra effort to assure clearance 3 4 DR. JOE ANTONY
DEVIATIONS IN SWING PHASE 1. Foot whips medially or laterally during initial swing 2. Prosthetic foot touches the floor during mid swing 3 5 DR. JOE ANTONY
FOOT WHIPS MEDIALLY OR LATERALLY DURING INITIAL SWING Causes Solution Cuff suspension not aligned evenly Reposition of suspension attachment Prosthetic socket is rotated medially or laterally with respect to line of progression Readjust the socket alignment 3 6 DR. JOE ANTONY
PROSTHETIC FOOT TOUCHES THE FLOOR DURING MIDSWING Causes Solution Prosthesis is too long Shorten prosthesis Suspension is too loose Tighten the suspension Limited knee flexion – By socket or suspension system Evaluate the degree flexion with prosthesis and eliminate limitations Muscle weakness or lack of gait training Strengthening of the knee flexors and gait training 3 7 DR. JOE ANTONY
3 8 DR. JOE ANTONY References • Braddoms textbook of PMR 21st edition • Orthotics and Prosthotics in rehabilitation, Kevin K chui, 4 th edition • Atlas of orthosis and assistive devices , 4th edition, AAOS THANK YOU