Prosthetic gait deviation

PROSTHETIC GAIT
AYAN GHOSAL
PGT,PMR

INTRODUCTION
Amputee gait pattern varies from normal gait pattern.
◦ There is increased energy expenditure.
◦ Transtibial: 25-40%
◦ Transfemoral: 68-100%
◦ Different muscle groups are used to create a smoother gait.
◦ There are compensation for prosthesis, muscle tightness or weakness, lack of
balance and fear.
◦ altered gait pattern result in complications, increase energy expenditure ,
non compliance.
◦ WE NEED GAIT ANALYSIS.

Gait analysis involves
Observation- From front and side and other axes
Three dimensional analysis of gait in gait lab.
 Identification of gait deviations
 Determination of the causes.

FEW DEFINITIONS
◦ GAIT CYCLE OR STRIDE : Activity that occurs between
the time one foot touches the floor & the time the
same foot touches the floor again.
◦ STRIDE LENGTH : Is the distance traveled during gait
cycle.
◦ STEP : one half of a stride. It takes two steps ( a rt. one
& a lt. one ) to complete a stride or gait cycle.
◦ CADENCE : Is the number of steps taken per minute, &
can vary greatly.
◦ STEP LENGTH : Is that distance between heel strike
of one foot & heel strike of the other foot.
11 July 2021 7

Transtibial gait
◦ During initial contact: Prolong heel strike, weight bearing through heel
before flat foot contact, delayed forefoot loading
◦ Knee flexion diminished at initial contact, overall max. flexion achieved
is reduced.
◦ During swing of sound limb :
Increased heel
rise of
prosthetic limb
to achieve
adequate step
length of
sound limb
elevation of
COG
greater
on sound
limb(130% vs
111%)
greater quads
contraction

◦ Toe off force of prosthetic limb diminished
◦ During stance energy generated by prosthetic limb is 50% of
normal
◦ Compensation by Increased trunk muscle energy expenditure.
◦ Hip extension ROM 50% to the opposite limb.
◦ Stance time on opposite limb increased than prosthetic limb

Transfemoral gait
◦ The gait cycle is affected by the quality of the surgery, the type and alignment of
the prosthesis, the condition of the stump and the length of the remaining
muscular structure and how well these are reattached.
◦ To prevent knee buckling during stance phase: fixed or free knee.
◦ With fixed knee: Hip hitching or hip hiking is needed to clear the prosthetic limb
during swing.
◦ With free knee , need to remain extended longer than stance phase: prolonged
heel strike- body move forward over pros limb as an unit – hip extensor as stabiliser
◦ During swing of free knee: hip flexor power similar to opposite side needed – for
the speed of hip flexion required, though the weight of prosthesis much less
◦ Stance time of sound side increased. Speed 30% slower

Scoring system for prosthetic
gait:
◦ Gait analysis can be done in 3d gait lab.
◦ Observational gait analysis: POGS scoring system:
◦ New scoring system with 4 subsections for trunk ,hip ,knee and foot-
ankle, and total16 different parameters.

1.Patients Factor :
 Range of motion
 Muscle strength
 Limb length
 Pain
 Decresed confidence
 Habitual/learned behaviour
2 .Prosthetic factor:
◦ 1.Socket design
◦ 2.Suspension
◦ 3.Foot and or knee selection
THESE ARE TO BE CORRECTED.
Causes are following types:

Basic principles:
◦ Gait is always different than normal.
◦ Some specific gait patterns in transfemoral and transtibial amputee.
◦ Asymmetry transfemoral > transtibial
◦ Altered trunk motion must be taken into account.
◦ Risk of falling.
◦ Level of amputation, type of prosthesis, knee and ankle jt. allignment
to be considered along with hip trunk core muscle strength and
stability

Transtibial
Gait
Deviations
17

Excessive knee flexion :
TOO FAR TOO HARD TOO HIGH
• Socket too far anteriorly displaced
• Too hard plantiflexor bar: inhibit
plantiflexion
• Too high heel of the foot.

Insufficient knee flexion:
TOO FAR TOO SOFT TOO LOW
• Socket is far posteriorly displaced
• Too soft plantiflexor bar
• Too low heel of foot

Lateral thrust
LIMO
• Foot too much inset leads to lateral
Thrust

Medial thrust:
LIMO
◦ Foot to much outset leads to
medial thrust

Transfemoral
Gait
Deviations
25

Abduction at stance
NORMALLY LATERAL WALL HIGHER
THAN MEDIAL
• When medial wall > Lateral, pain in
groin region
• When hip OA in prosthetic limb.
• Weak or contracted abductor
• Long prosthesis

Circumduction at swing
3 LONG SIP
◦ Long prosthesis
◦ Lesser knee flexion
◦ Lock knee
◦ Small socket
◦ Inadequate suspension
◦ Plantiflexed foot

Vaulting: Swing
◦ It is plantiflexion of normal limb to
swing the prosthetic limb.
◦ Cause: similar to circumduction
Hip Hiking: swing
◦ Cause: simlar

Lateral shift towards prosthetic
limb
• Short medial high lateral wall
• Short prosthesis
• Short amputed limb
• Weak abductor: Maintain
COG
• Abd contracture

Forward flexion
Exaggerated lordosis
HI, PW
• Hip flexion contracture
• Insufficient A-P wall
support
• Painful ischial
• Weak hip ext. abd. Or
abdominal mscls
USHA
• Unstable knee
• Short ambulation aid
• Hip flexion contracture

Medial/lateral whip at heel off
NORMALLY KNEE BOLT KEPT IN
SLIGHT EXT. ROTATION
◦ If more external rotated, medial
Whip of knee, heel laterally
◦ If not externally rotated, lateral
whip at knee, heel medially
◦ Mal-rotated shoe, socket.
Other cause(In suction socket)
◦ Flabby muscle causing femoral
rotation
◦ Tight socket

Foot rotation at
heel contact
Malrotated shoe
Stiff plantiflexion bumper
Too hard heel cushion
Foot slap:
early planter flexion
Soft plantiflexion bumper

High heel rise early swing
Normally heel rise is higher
than sound limb
◦ Higher heel rise if there is
◦ inadequate knee friction
◦ Slack knee extension aid
◦ There will be forced hip flexion
to keep knee extended at heel
strike

Terminal impact at late swing
◦ Knee friction:
◦ High at early swing
◦ Low at mid swing
◦ High at late/terminal swing
◦ When less knee friction or taut ext.
aid: patient forcefully extend knee
,giving hard impact at terminal swing

Both trastibial
and
transfemoral

Unequal step length:
prosthetic stance lesser than sound limb
Causes
◦ Pain or insecurity
◦ Insufficient friction at the
prosthetic knee or too loose an
extension aid.
◦ Hip flexion contracture
◦ Insufficient socket flexion
◦ If there is pendular socket
motion

Unequal arm swing(2ndary)
The arm on the prosthetic side is held close to the body
◦ Poor prosthetic fit
◦ Poor balance
◦ Fear
◦ Habit
Always due to other gait deviations and lack of training

◦ CHECKOUT:
Gait training may last from weeks to months.
The more proximal levels of amputation require
lengthier gait training.
STATIC
EVALUATION
DYNAMIC
EVALUATION
EVALUATION
OFF
PROSTHESIS
GAIT
TRAINING

Cont..
From even surface to unevensurface
Specific training of transfer ,knee stability.
Independent level of ambulation with or without
gait aid
Weight shifting and balance activity in parallel bar

Prosthetic gait deviation

Prosthetic gait deviation

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