Checkout Procedures for Below-Knee
and for A b o v e - K n e e
Artificial
Limbs
By MARSHALL A. GRAHAM, M.S. and HERBERT E. KRAMER
Editor's
Note:
T h e s e two articles o n c h e c k o u t p r o c e d u r e s o r i g i n a l l y ap­
p e a r e d in the Journal of the Association for Physical and Mental
Rehabilitation,
m i s s i o n . In a n s w e r to o u r request, H e n r y C . Feller. C . P . , V i c e President o f
the J. E. H a n g e r C o . , W a s h i n g t o n . D.C., cp,,emted
as fallows o n the out­
lines:
" T h e outlines are c o m p r e h e n s i v e a n d a m p l y c o v e r the f u n c t i o n s that s h o u l d
b e c h e c k e d f o r a p r o p e r l y adjusted prosthesis. N o d o u b t a test o f the specific
s u g g e s t i o n s will b e n e c e s s a r y a n d e x p e r i e n c e o v e r a p e r i o d o f time will dis­
c l o s e any r e q u i r e d m o d i f i c a t i o n s .
" T h i s o r a similar c h e c k o u t p r o c e d u r e is
o f i n e s t i m a b l e benefit to all c o n c e r n e d , b y
m e m b e r s o f the t e a m a n d others c o n c e r n e d ,
c l i n i c team, a satisfactorily f u n c t i o n i n g a n d
n e c e s s a r y , h o w e v e r , a n d will b e
c o - o r d i n a t i n g the efforts o f the
in attaining the o b j e c t i v e o f the
cosmetic prosthetic appliance."
PART I.
A Checkout Procedure for Below-Knee Artificial Limbs
T h e r e has b e e n a g r o w i n g trend in recent years to utilize the s e r v i c e s o f
a m p u t a t i o n c l i n i c s in the rehabilitation o f amputees. T h e s e c l i n i c s , w h o s e
personnel include p h y s i c i a n s , therapists, and prosthetists. h a v e r e s p o n s i b i l i t y
for the p h y s i c a l and prosthetic rehabilitation of the patient. T h e i r responsi­
bilities d o not end with the p r e s c r i p t i o n o f a prosthesis, but i n c l u d e an
e v a l u a t i o n o f the a d e q u a c y o f the prosthesis and training b e f o r e the patient
p r o c e e d s t o s u b s e q u e n t phases of the rehabilitation p r o g r a m . It is k n o w n
that an i n a d e q u a t e l i m b can result in i n s u r m o u n t a b l e t r a i n i n g p r o b l e m s and
c a n h i n d e r the p h y s i c a l , e m o t i o n a l , a n d v o c a t i o n a l adjustment
o f the
amputee.
R e c e n t l y , as part o f a n a t i o n w i d e research and e d u c a t i o n a l p r o g r a m in
u p p e r e x t r e m i t y prosthetics, a c h e c k o u t p r o c e d u r e for artificial a r m s was
d e v i s e d . T h e e m p h a s i s in prosthetic e d u c a t i o n has shifted f r o m the upper
extremities to the l o w e r e x t r e m i t i e s . N e w Y o r k University and the university
o f C a l i f o r n i a in c o o p e r a t i o n with the V e t e r a n s A d m i n i s t r a t i o n are d e v e l o p i n g
l o w e r extremities c o u r s e s c o o r d i n a t e d by the Prosthetic R e s e a r c h B o a r d o f
the N a t i o n a l Research C o u n c i l . T h e s e c o u r s e s for p h y s i c i a n s , prosthetists
a n d therapists, in a d d i t i o n to t e a c h i n g f a b r i c a t i o n , p r e s c r i p t i o n , a n d t r a i n i n g
will i n c l u d e t e c h n i q u e s o f e v a l u a t i o n o f l o w e r e x t r e m i t y prostheses.
T h e m a j o r p o r t i o n o f the u p p e r e x t r e m i t y p r o c e d u r e c o n s i s t e d o f a c h e c k
list o f q u e s t i o n s c o n c e r n e d w i t h m i n i m a l l y a c c e p t a b l e p r o s t h e t i c s t a n d a r d s .
If all the q u e s t i o n s w e r e a n s w e r a b l e in the affirmative, the p r o s t h e s i s w a s
c o n s i d e r e d t o b e a c c e p t a b l e . A n y q u e s t i o n s a n s w e r e d in the n e g a t i v e i m m e ­
diately p o i n t e d u p a d e f i c i e n c y in the prosthesis.
THE AUTHORS
Herbert E. Kramer suffered an above knee
amputation as a result of action with the
infantry in Germany during W o r l d W a r I I .
Following separation
from the Army he
worked f o r the Veterans
Administration's
Prosthetic Center in New York f o r several
years, training in the prosthetic field. He
joined the Staff of New York University's
Prosthetic Devices Study in 1 9 4 7 . Mr. Kramer
has been specializing in gait and perform­
ance analysis, prosthetic evaluation and am­
putee training.
I n addition he himself has
always been active in wearing and testing
A major concern during the six and onethe latest experimental devices f o r above
half years with the Prosthetic Devices Study
knee amputees.
Other activities have i n ­
has been the physical aspects o f amputation
exten­
and prosthetic use, which culminated in the cluded lecturing and demonstrating
development, with M r . Kramer, of the two sively to various medical meetings and other
numerous organizations. In 1 9 4 8 he was
articles on checkout procedures f o r belowknee and above-knee prostheses. He has awarded the Patriotic Civilian Service Certi­
ficate from the Department of the Army " f o r
also been a prosthetic consultant since 1 9 5 3
furthering the program of research and de­
to the Association f o r Physical and Mental
Rehabilitation. Since September 1 9 5 6 M r . velopment in artificial limbs." Recently his
interest has once again brought his endeavor
Graham has been employed as a Project
Director with Space Utilization Analysis, Inc. into the field of limb fitting.
Marshall A . Graham is an alumnus o f the
City College of New York and Springfield
College, Springfield, Massachusetts, where
he received the B . S . and M . S . Degrees with
a major in physical education techniques
applied to rehabilitation. He is now a doc­
toral candidate in this field at New York
University. After working as a corrective ther­
apist at the V. A . Hospital in Northport,
Long Island, M r . Graham joined the staff
of the Prosthetics Devices Study of New York
University.
I n v i e w o f t h e s u c c e s s o f t h e u p p e r e x t r e m i t y c h e c k o u t as an i n t e g r a l p a r t
of
clinic procedure and
as a result
of many
requests
therapists t h r o u g h o u t the c o u n t r y , the authors
from
physicians
h a v e attempted
c h e c k list b y w h i c h t h e a d e q u a c y o f a b e l o w - k n e e p r o s t h e s i s c a n b e
mined.
This
prosthesis
check
list
as p r e s e n t e d
pertains
in Fig.
1.
primarily
to
a
conventional
Although many
variations
and
to d e v e l o p a
deter­
below-knee
are
found,
a
c o n v e n t i o n a l b e l o w - k n e e artificial l i m b is u s u a l l y c o m p r i s e d o f a w o o d e n
foot
with toe-break;
(al­
an
ankle with p r o v i s i o n for dorsi and
plantar
flexion
t h o u g h s o m e also m a k e p r o v i s i o n f o r i n v e r s i o n a n d e v e r s i o n ) ; a w o o d , metal,
fiber
or
plastic shank;
a carved wood,
metal
or
molded
leather
socket;
metal side braces with single axis knee j o i n t s ;
and
corset.
In
a
fork
strap
stump, and
addition,
attached
many
to
the
below-knee
shank,
as
amputees
an
aid
to
wear
retaining
or
a leather
waist
the
plastic
thigh
belt w i t h
limb on
a leather c h e c k l a c e r t o c o n t r o l t h e k n e e j o i n t s in e x t e n s i o n .
a
the
Fig. 1
Legend
A. Foot
B.
Toe-break
C. Ankle joint and bushing
D. Front ankle bumper rubber or felt; acts
as dorsiflexion stop)
E. Rear ankle bumper
flexion)
(rubber;
for plantar
F. Anterior ankle articulation space (leather
covered)
G. Posterior ankle articulation space (leather
covered)
H. Shank
(shin)
I. A i r vent o f shank
J . Fork strap
K. Check lacer
L. Knee
joint
M. Knee joint extension stop
N. Knee joint cover
O. Thigh brace
P. Thigh corset
(leather covered)
(leather)
Q. Attachment strap or fork strap to waist
belt
In this article, e a c h italicized q u e s t i o n represents a p o i n t t o b e c h e c k e d
by the c l i n i c g r o u p . A b r i e f d i s c u s s i o n f o l l o w s the q u e s t i o n with o c c a s i o n a l
hints f o r c o r r e c t i o n o f a s u b p a r c o n d i t i o n . A w o r k sheet f o r c l i n i c use can
be easily d r a w n f r o m the i n f o r m a t i o n c o n t a i n e d in this article, s u p p l e m e n t e d
by the r e a d e r s e x p e r i e n c e . A s u g g e s t e d f o r m f o r the w o r k sheet has a short
u n d e r l i n e d s p a c e p r e c e d i n g each n u m b e r e d q u e s t i o n , s o that a c h e c k ( V ) o r
a " n o " m a y b e inserted as each item is c o v e r e d at the c l i n i c . T h e r e m e d y
for items that p r o v e to h a v e s h o r t c o m i n g s m a y b e o b v i o u s , in w h i c h c a s e
extensive d i s c u s s i o n b y the c l i n i c g r o u p is u n n e c e s s a r y . It is the opinion o f
the a u t h o r s that a c h e c k o u t p r o c e d u r e such as this c a n facilitate the c l i n i c
f u n c t i o n s b y m e t h o d i c a l l y e m p h a s i z i n g the m o s t i m p o r t a n t f a c t o r s in the
prosthesis.
T h e r e a d e r s h o u l d b e c o g n i z a n t o f the fact that this article c o n c e r n s itself
solely with the d e t e r m i n a t i o n o f p r o s t h e t i c a d e q u a c y . T h e entire area o f
f u n c t i o n a l a d e q u a c y o f the a m p u t e e w i t h this p r o s t h e s i s as a c o n c o m i t a n t o f
t r a i n i n g a n d p r a c t i c e , is d e s e r v i n g o f special treatment a n d is n o t c o v e r e d
in this article.
T h e c h e c k list w h i c h f o l l o w s h a s b e e n d i v i d e d i n t o f o u r a r e a s c o n s i d e r e d
t o b e o f m a j o r i m p o r t a n c e . T h e first area, q u a l i t y c o n t r o l , is c o n c e r n e d w i t h
e x a m i n a t i o n o f the p r o s t h e s i s b e f o r e it is w o r n b y the patient. T h e s e c o n d
a r e a is c o n c e r n e d with the prosthesis w o r n b y the a m p u t e e w h i l e standing.
T h e t h i r d a r e a is c o n c e r n e d with the posthesis w o r n b y the a m p u t e e w h i l e
sitting. T h e f o u r t h a n d last a r e a is related t o the prosthesis w o r n b y the
a m p u t e e w h i l e w a l k i n g . A n y s h o r t c o m i n g s o f the prosthesis s h o u l d b e c o r ­
r e c t e d a n d the l i m b r e c h e c k e d b y the c l i n i c p r i o r to the start o f t r a i n i n g .
A.
1. Is the color
QUALITY
of the leg satisfactory
2. Has the inside socket
and has a wood sealer
CONTROL
and
homogeneous?
surface
been completely
and smoothly
been applied to the entire
surface?
finished,
In a w o o d s o c k e t , a w o o d sealer w i l l p r e v e n t p e r s p i r a t i o n f r o m the stump
f r o m p e n e t r a t i n g the w o o d c a u s i n g r o u g h spots, r i s i n g o f the g r a i n , o r c r a c k ­
i n g o f the s o c k e t , a n y o f w h i c h c a n c a u s e s t u m p i r r i t a t i o n . A g o o d finish
will p e r m i t a d e q u a t e h y g i e n i c c a r e b y a l l o w i n g r e s i d u a l p e r s p i r a t i o n t o b e
r e m o v e d easily f r o m the s o c k e t s u r f a c e .
3. Has the socket
rim been adequately
flared
and all sharp
edges
smoothed?
A s h a r p i n s i d e e d g e o f the s o c k e t r i m c a n c a u s e d i s c o m f o r t a n d e v e n
l a c e r a t i o n o f the skin, e s p e c i a l l y in the c a s e o f o b e s e a m p u t e e s w h o s e skin
folds m a y o v e r l a p the s o c k e t .
4. Is there a protective
to prevent
catching
cover over the medial and
or tearing of
trousers?
lateral
knee
T h i s has b e e n a c o n t i n u i n g p r o b l e m f o r b e l o w - k n e e a m p u t e e s .
plastic c a p s are a v a i l a b l e f o r p l a c e m e n t o v e r the j o i n t h e a d s .
5. Do the
play?
knee
joints
articulate
smoothly
without
resistance
joint
heads
Leather
or
or
excessive
E x c e s s i v e resistance w i l l c a u s e u n d u e w e a r o n the j o i n t , s h o r t e n i n g the
m a i n t e n a n c e - f r e e p e r i o d o f w e a r . It w i l l also f o r c e the a m p u t e e t o exert
m o r e s t u m p effort t o e x t e n d the k n e e , resulting in m o r e r a p i d fatigue. A
l o o s e j o i n t c a n d a m a g e the b e a r i n g s o r , as a result o f u n d u e strain, c a u s e a
c r a c k e d j o i n t . R o u g h a c t i o n o f the j o i n t s m a y b e an i n d i c a t i o n o f c r a c k e d
o r w o r n b a l l b e a r i n g s , dirt, o r l a c k o f l u b r i c a t i o n . V e r y often, n o i s e will b e
a s s o c i a t e d with these c o n d i t i o n s .
6. Do both side
simultaneously?
braces
come
into
contact
with
the
knee
extension
stops
U n e v e n c o n t a c t o f the k n e e e x t e n s i o n stops will c a u s e internal o r external
r o t a t i o n o f the prosthesis e a c h t i m e the k n e e r e a c h e s full e x t e n s i o n in addi­
t i o n to c a u s i n g u n e v e n strain o n the j o i n t s .
If a c h e c k l a c e r is w o r n , u n e v e n setting o f the j o i n t s m a y at first b e o v e r ­
l o o k e d . U s u a l l y a c h e c k l a c e r is u s e d t o p r e v e n t the c l i c k i n g n o i s e that
o c c u r s as the p r o s t h e t i c k n e e r e a c h e s full e x t e n s i o n . H o w e v e r , as the leather
stretches, c o n t a c t o c c u r s at the k n e e stops a n d the d e l e t e r i o u s effect o f im­
p r o p e r l y set k n e e j o i n t s w i l l b e c o m e apparent. ( N o t e : it has b e e n the ex­
p e r i e n c e o f the a u t h o r s that c h e c k lacers c a n b e e l i m i n a t e d in m a n y b e l o w k n e e p r o s t h e s e s . G e n e r a l l y , a l a c e r s h o u l d b e i n c l u d e d o n artificial l i m b s
o n l y f o r patients with short s t u m p s a n d / o r with k n e e instability d u e t o w e a k
l i g a m e n t o u s structures. F o r o t h e r patients, e l i m i n a t i o n o f a j o i n t c l i c k c a n
b e a c c o m p l i s h e d b y filing t h e k n e e e x t e n s i o n s t o p s a n d / o r b y the a m p u t e e
r e s u m i n g c o n t r o l o f his k n e e s o as t o limit e x t e n s i o n b e f o r e t h e j o i n t s t o p s
make contact.)
7. Does the distance
between
constant
during full flexion
the medial
and lateral
and
extension?
thigh
braces
remain
Inconsistent s p a c i n g b e t w e e n t h e t h i g h p o r t i o n o f the s i d e b a r s d u r i n g
f l e x i o n and e x t e n s i o n is an i n d i c a t i o n o f m i s a l i g n m e n t o f the k n e e j o i n t
h e a d s . T h e j o i n t h e a d s s h o u l d b e p e r p e n d i c u l a r to an i m a g i n a r y line t h r o u g h
their c e n t e r s and parallel to the line o f p r o g r e s s i o n o f the p r o s t h e t i c s w i n g .
I m p r o p e r j o i n t a l i g n m e n t will tend t o distort the thigh c o r s e t and will in­
fluence the p r o s t h e t i c s w i n g w h i l e w a l k i n g . It c a n c o n t r i b u t e also t o uneven
w e a r o f the k n e e j o i n t s a n d b r e a k a g e o f t h e thigh p o r t i o n o f the s i d e bars.
8. Is the brace
than on the
and corset approximately
medial
side?
1 inch
higher
on the lateral
side
T h e h i g h e r lateral s h a p i n g o f the thigh c o r s e t will p r o v i d e a better s u p p o r t
f o r the m u s c l e s o f the h i p ( w h i c h c o n t r o l m o v e m e n t s o f t h e f e m u r ) to work
against, p r o v i d i n g lateral stability.
T h e a n a t o m i c a l structure o f the f e m u r c a u s e s the b o d y w e i g h t to lean
laterally d u r i n g the stance p h a s e . T h i s b e c o m e s e x a g g e r a t e d in a m p u t e e s with
the l o s s o f m u s c u l a r c o n t r o l at the base o f s u p p o r t ( f o o t a n d a n k l e ) .
9. Has the thigh corset
coated
for resistance
1 0 . Is there
of parts
been finished
in a workmanlike
to perspiration,
and sewn and
adequate
clearance
at the ankle
or catching of
socks?
manner,
i.e.
lined,
riveted
neatly?
articulation
to prevent
rubbing
T o o little c l e a r a n c e will c a u s e r u b b i n g o f the i n s i d e s u r f a c e o f the f o o t o n
the ankle b l o c k w h i c h will c a u s e n o i s e . T o o m u c h c l e a r a n c e w i l l a l l o w s o c k
m a t e r i a l t o c a t c h , c a u s i n g t e a r i n g a n d / o r restriction o f ankle m o v e m e n t .
1 1 . Has the artificial
foot
N e a t u p h o l s t e r y , with
of s o c k s . I n a d d i t i o n , if
tearing of socks. There
scuff the g r o u n d d u r i n g
1 2 . I f used,
range?
been
properly
upholstered
and
fitted
to the
shoe?
n o " s h a r p " seams will d o m u c h to prevent tearing
the f o o t is t o o small, s l i p p a g e o f the s h o e c a n c a u s e
also w i l l b e a t e n d e n c y f o r the heel o f the s h o e to
the prosthetic swing phase.
do the fork strap and/or
(Check
length and holes
check strap
on
straps.)
have
sufficient
adjustment
B. STANDING
1. Is the amputee secure while
and with heels
touching?
standing
on the prosthesis
with good
posture
T h e a m p u t e e s h o u l d feel that t h e p r o s t h e s i s w i l l r e m a i n d i r e c t l y u n d e r
h i m w h i l e h e is s t a n d i n g w i t h his w e i g h t e v e n l y d i s t r i b u t e d o n b o t h feet.
If h e feels that h e is b e i n g f o r c e d b a c k w a r d , the p r o s t h e t i c ankle m a y b e set
in t o o m u c h plantar flexion. If h e s e e m s t o b e t h r o w n f o r w a r d a n d there is
a t e n d e n c y f o r the k n e e o n the p r o s t h e t i c s i d e to b u c k l e , the ankle m a y b e
set in t o o m u c h d o r s i f l e x i o n . I f his w e i g h t is o n the o u t s i d e o f the f o o t , the
ankle is set in t o o m u c h i n v e r s i o n ; if his w e i g h t is o n the i n s i d e o f the f o o t ,
the ankle is in t o o m u c h e v e r s i o n .
2 . Is the amputee
comfortable
while standing
posture
and with heels
touching?
on the prosthesis
with
good
S p e c i a l attention s h o u l d b e d i r e c t e d t o e x c e s s i v e pressure in s u c h c o m m o n
areas o f s o c k e t d i s c o m f o r t a s :
a ) p o s t e r i o r and distal t o the h e a d o f the fibula
b ) tibial t u b e r o s i t y
c ) anterior, distal t i b i a
d ) anterior r i m o f the s o c k e t ( i n the area o f the patellar l i g a m e n t )
In a d d i t i o n , the a m p u t e e s h o u l d n o t e x p e r i e n c e a c h o k i n g sensation
the distal p o r t i o n o f the stump.
3. Is the artificial
leg the correct
about
length?
I n c o r r e c t length o f the prosthesis c a n b e d e t e r m i n e d b y visual e x a m i n a t i o n
o f the a n t e r i o r - s u p e r i o r iliac spines o r the s u p e r i o r i l i a c crests. T h e usual
m e t h o d o f this e x a m i n a t i o n is f o r the e x a m i n e r t o p l a c e h i s t h u m b s o n the
s p i n o u s p r o c e s s e s o r t o p l a c e the h a n d s o n the crests o f the i l l i u m , a n d b y
sight, j u d g e w h e t h e r o r n o t they are level.
If the h e i g h t is n o t c o r r e c t , the use o f p r e p a r e d flat w o o d e n slabs o f vary­
i n g thicknesses is helpful in d e t e r m i n i n g the a m o u n t o f c o r r e c t i o n necessary
t o attain the c o r r e c t p r o s t h e t i c length.
4 . Is the anterior rim of the socket properly
lateral movements
of the
patella?
contoured
to allow
medial
and
A n a r r o w o r h i g h anterior r i m o f the socket that restricts lateral m o v e ­
m e n t o f the patella will g e n e r a l l y f o r c e the patella u p w a r d c a u s i n g the
patellar l i g a m e n t t o b e stretched. T h e a m p u t e e w i l l e x p e r i e n c e d i s c o m f o r t
b e c a u s e o f j a r r i n g pressures o n the patellar l i g a m e n t at heel c o n t a c t .
5. Does the posterior
rim of the socket
formation
of popliteal
flesh
roll?
extend
high
enough
to prevent
the
E x p e r i e n c e has s h o w n that k e e p i n g the p o s t e r i o r wall o f the s o c k e t h i g h
e n o u g h t o e n c a s e the flesh o f the distal p o p l i t e a l r e g i o n r e d u c e s the t e n d e n c y
t o w a r d f o r m a t i o n o f a fleshy roll. A p o p l i t e a l flesh r o l l c a n present a difficult
fitting p r o b l e m and restrict knee
flexion.
6. Do the side braces
conform
closely
to the contour
of the knee
and
thigh?
W e l l - c o n t o u r e d s i d e b a r s that p r o v i d e a g r i p p i n g a c t i o n ( w i t h o u t u n d u e
p r e s s u r e ) in the s u p r a c o n d y l a r r e g i o n o f the thigh will m i n i m i z e the piston
a c t i o n o f the s o c k e t o n the stump, p r o v i d e s o m e lateral stability, a n d result
in a m o r e c o s m e t i c a l l y a c c e p t a b l e prosthesis.
7. Does the thigh corset
the corset
tension?
fit
snugly,
with adequate
adjustment
for
increasing
T h e r e s h o u l d b e an o p e n i n g o f a p p r o x i m a t e l y 1 t o l 1/2 i n c h e s b e t w e e n the
c o r s e t b o r d e r s . T h e adjustability o f the t h i g h c o r s e t is p a r t i c u l a r l y i m p o r t a n t
f o r patients w h o s e b o d y w e i g h t s fluctuate, a n d f o r recent a m p u t e e s w h e r e
c o n s i d e r a b l e a t r o p h y o f the t h i g h m a y b e anticipated. A t h i g h c o r s e t that
c a n n o t b e tightened will b e c o m e l o o s e with thigh a t r o p h y , d i s t u r b i n g the
c u s t o m a r y w e i g h t d i s t r i b u t i o n b e t w e e n the c o r s e t a n d s o c k e t .
8. Is the general
shape
of the prosthesis
cosmetically
acceptable?
T o b e c o s m e t i c a l l y a c c e p t a b l e , a b e l o w - k n e e prosthesis s h o u l d a p p r o x i m a t e
the shape a n d size o f the n o n - a m p u t a t e d shank, ankle, a n d f o o t .
C.
1. Is the
amputee
comfortable
SITTING
while
sitting?
T h i s q u e s t i o n is o f a g e n e r a l n a t u r e .
specifically c o v e r e d in q u e s t i o n s 2 t o 6.
2. Can the amputee sit with a minimum
prosthetic
foot flat, on the
floor?
The various comfort
of 90 degree
flexion
factors
and
with
are
his
It s h o u l d h e p o s s i b l e f o r an a m p u t e e to sit c o m f o r t a b l y in restricted areas,
s u c h as m o t i o n p i c t u r e theatres and b u s e s . In a d d i t i o n , restriction o f k n e e
flexion c a n c a u s e the a m p u t e e ' s prosthetic f o o l to e x t e n d b e f o r e h i m in a
c o s m e t i c a l l y u n a c c e p t a b l e m a n n e r . T h e r e is also t h e d a n g e r o f others trip­
p i n g o v e r an e x t e n d e d f o o t .
3. Has the socket
been properly
shaped to prevent
crowding
in the
ham­
string and popliteal
areas?
S y m p t o m s o f i m p r o p e r s o c k e t c o n t o u r are t i n g l i n g a n d n u m b n e s s o f t h e
s t u m p a n d / o r p r e s s u r e o f t h e s o c k e t r i m o n the m e d i a l ( s e m i m e m b r a n o s u s
a n d s e m i t e n d i n o s u s ) o r lateral ( b i c e p s f e m o r i s ) distal t e n d o n s . I f s u c h
s y m p t o m s b e c o m e e v i d e n t , relief is usually i n d i c a t e d at the m e d i a l a n d / o r
lateral aspects o f the p o s t e r i o r s o c k e t r i m . In a d d i t i o n , s o c k e t p r e s s u r e in
the p o p l i t e a l r e g i o n i n d i c a t e s that the a p e x o f the p o s t e r i o r s o c k e t r i m is t o o
high.
4. Has the corset
been properly
shaped to prevent
crowding
in the
ham­
string and popliteal
areas?
A n i m p r o p e r l y s h a p e d p o s t e r i o r distal t h i g h c o r s e t w i l l c a u s e b u n c h i n g
and i r r i t a t i o n o f flesh in t h e u p p e r p o r t i o n o f the p o p l i t e a l area. T h e distal
c o r s e t s h o u l d h a v e an o x - b o w s h a p e with a cut-out f o r t h e l i g a m e n t s h i g h
e n o u g h t o p r e v e n t restriction o f their n o r m a l f u n c t i o n .
5. Does the stump remain firmly situated
in the socket
while the
amputee
is
sitting?
T h e s t u m p s h o u l d n o t pull o u t o f the s o c k e t o r a w a y f r o m t h e a n t e r i o r
s o c k e t wall w h e n the a m p u t e e is seated w i t h knees flexed to a b o u t 9 0 d e g r e e s .
If the s t u m p tends t o pull o u t o f the s o c k e t , it is an i n d i c a t i o n that the
k n e e j o i n t s are p l a c e d h i g h e r than k n e e center a n d / o r the p o s t e r i o r r i m o f
the s o c k e t is t o o h i g h .
If the s t u m p t e n d s to p u l l a w a y f r o m the a n t e r i o r w a l l o f the s o c k e t ( g a p ­
p i n g ) , it is an i n d i c a t i o n that the k n e e j o i n t s h a v e b e e n p l a c e d t o o far
p o s t e r i o r l y . T h i s is often a c c o m p a n i e d b y e x c e s s i v e p r e s s u r e at the a n t e r i o r
distal t i b i a .
6. Are both knees reasonably
level while the amputee
is
sitting?
F o r the b e l o w - k n e e a m p u t e e , this is a f u n c t i o n o f the c o r r e c t l e n g t h o f the
shank o f the prosthesis as well as the c o r r e c t p o s i t i o n i n g o f the p r o s t h e t i c
knee joints.
D . WALKING
1. Is the amputee
comfortable
while walking?
(If not, specify
areas of
discomfort.)
S p e c i a l attention s h o u l d b e d i r e c t e d t o certain c o m m o n areas o f d i s c o m ­
fort a n d irritation ( s e e q u e s t i o n 2 u n d e r t h e h e a d i n g , S t a n d i n g ) :
a ) p o s t e r i o r a n d distal t o the h e a d o f the fibula
b ) tibial t u b e r o s i t y
c ) a n t e r i o r , distal t i b i a
d ) a n t e r i o r r i m o f the s o c k e t ( i n the area o f the subpatellar
ligament)
T h e a u t h o r s b e l i e v e that these areas are w o r t h y o f e m p h a s i s s i n c e d i s c o m ­
fort will b e c o m e m o s t e v i d e n t w h e n w a l k i n g . T h e a m p u t e e ' s c o m m e n t s
s h o u l d b e related t o a careful e x a m i n a t i o n o f the s t u m p at the c o n c l u s i o n o f
the w a l k i n g phase o f the c h e c k o u t p r o c e d u r e .
2. Is the amputee
secure
while
walking?
T h e a m p u t e e s h o u l d feel that the p r o s t h e s i s r e m a i n s directly u n d e r h i m
d u r i n g stance p h a s e with little o r n o t e n d e n c y to shift his b o d y w e i g h t
laterally o r m e d i a l l y . Lateral instability, usually a s s o c i a t e d w i t h a shifting
o f the e n t i r e prosthesis laterally as full weight is taken o n the artificial l i m b ,
m a y b e c o r r e c t e d b y i n c r e a s i n g the a m o u n t o f valgus ( k n o c k ) o f the pros­
thesis. T h i s is a c c o m p l i s h e d b y b e n d i n g the u p p e r p o r t i o n o f the s i d e b r a c e s .
D i s p l a c i n g the prosthetic foot laterally o n the shank is a n o t h e r way o f wid­
e n i n g the s u p p o r t base. T h e latter m e t h o d , a l t h o u g h m o r e difficult, will not
influence the p o s i t i o n i n g o f the s t u m p within the s o c k e t , w h e r e a s b e n d i n g
of the s i d e b a r s m a y result in s t u m p d i s c o m f o r t . C o n v e r s e l y , medial insta­
bility ( w h i c h is less p r e v a l e n t ) is c o r r e c t e d b y i n c r e a s i n g the varus ( b o w )
o f the prosthesis, o r d i s p l a c i n g the f o o t m e d i a l l y .
A n t e r i o r - p o s t e r i o r stability is p r i m a r i l y a function o f the foot-shank rela­
t i o n s h i p . General prosthetic p r a c t i c e has a l i g n e d the foot o n the shank at an
a n g l e o f slightly less than 9 0 d e g r e e s o f d o r s i f l e x i o n . E x c e s s i v e d o r s i f l e x i o n
will c a u s e the a m p u t e e to Ilex his k n e e prematurely While w a l k i n g , result­
ing in a " d i p p i n g " gait and g i v i n g the i m p r e s s i o n o f t o o short a prosthesis.
E x c e s s i v e plantar flexion will c a u s e difficulty in transferring weight o v e r the
ball o f the foot, resulting in an i r r e g u l a r gait and g i v i n g the i m p r e s s i o n o f
t o o l o n g a prosthesis.
3. Does
the prosthesis
T h e three m a j o r
plane are:
a)
b)
c)
swing
variations
in a straight
line
of
progression?
o f the s w i n g o f a prosthesis
in the
sagittal
medial whip
lateral w h i p
circumduction
A m e d i a l w h i p is c h a r a c t e r i z e d b y a m o v e m e n t o f the heel o f the prosthetic
f o o t m e d i a l l y a n d a r o t a t i o n o f the k n e e laterally, w h i c h c a n best b e o b s e r v e d
i m m e d i a t e l y after toe-off. T h e f o o t then rotates b a c k to its usual p o s i t i o n
either d u r i n g the r e m a i n d e r o f the s w i n g p h a s e ( c a u s i n g a "fish t a i l " e f f e c t ) ,
o r as the heel o f the prosthesis is c o n t a c t i n g the g r o u n d with the t o e r o t a t i n g
m e d i a l l y . A m e d i a l w h i p c a n usually b e c o r r e c t e d b y m o v i n g the u p p e r p o r ­
tion o f the m e d i a l s i d e b r a c e p o s t e r i o r l y o n the t h i g h lacer.
A lateral w h i p is the reverse o f a m e d i a l w h i p , with the heel o f the f o o t
m o v i n g laterally a n d the k n e e r o t a t i n g m e d i a l l y i m m e d i a t e l y after toe-off o f
the prosthesis. A lateral w h i p can usually b e c o r r e c t e d b y m o v i n g the u p p e r
p o r t i o n o f the m e d i a l s i d e b r a c e anteriorly o n the t h i g h lacer.
C i r c u m d u c t i o n is a m o v e m e n t o f the prosthesis in a lateral a r c f r o m a
straight l i n e o f p r o g r e s s i o n . C i r c u m d u c t i o n is s e l d o m seen w i t h b e l o w - k n e e
amputees, but if present c a n b e c a u s e d b y the a m p u t e e w a l k i n g with little
o r n o k n e e flexion and s o m o v i n g his p r o s t h e s i s o u t w a r d to i n s u r e that the
f o o t clears the g r o u n d .
4. Is the toe-out
5. Does
of the prosthetic
the amputee
walk
with
foot
the same
a reasonably
as that
narrow
of the normal
base
of
foot?
support?
In e v a l u a t i n g this item, e a c h a m p u t e e must b e c o n s i d e r e d as an i n d i v i d u a l .
T h e length o f his s t u m p a n d h i s g e n e r a l b o d y t y p e must b e taken into c o n -
s i d e r a t i o n . It is to b e e x p e c t e d , f o r instance, that an o b e s e p e r s o n will w a l k
w i t h greater natural a b d u c t i o n than o n e w h o is thin o r m u s c u l a r .
In o r d e r to i n c r e a s e lateral stability, it has been the p r a c t i c e to fit very
short b e l o w - k n e e stumps with a prosthesis set in e x a g g e r a t e d v a l g u s (the
prosthetic foot o u t s e t ) , w h i c h p r o d u c e s an effect o f a b d u c t i o n .
T h e r e is n o reason why the a v e r a g e b e l o w - k n e e a m p u t e e with n o special
physical o r p r o s t h e t i c c o m p l i c a t i o n cannot walk with his base o f s u p p o r t as
n a r r o w as that o f the n o n a m p u t e e . T h i s is usually between /2 and 2 inches.
1
6. While walking,
ground
during
is the plantar surface
stance
phase?
of the prosthetic
foot
flat
on
the
O b s e r v a t i o n o f the attitude o f the f o o t d u r i n g the p r o s t h e t i c stance p h a s e
will s h o w w h e t h e r the f o o t has b e e n p r o p e r l y a l i g n e d o n the shin. A n
e v e r t e d o r i n v e r t e d f o o t will c a u s e u n e v e n w e a r o f the sides o f the s o l e o f
the s h o e a n d m a y b e the c a u s e o f lateral instability. P l a n t a r a n d d o r s i f l e x i o n
have already been discussed (see question 2 under the heading
Walking).
7. Is the resistance
of the ankle to plantar
foot-slap
or external
rotation
immediately
flexion
after
properly
set to
heel
contact?
prevent
If there is t o o little resistance ( c a u s e d b y t o o soft a rear a n k l e b u m p e r )
the prosthetic foot will strike the floor t o o r a p i d l y after heel c o n t a c t , c a u s i n g
a s l a p p i n g n o i s e . T o o m u c h resistance ( c a u s e d b y a rear ankle b u m p e r that
is t o o h a r d ) will c a u s e the prosthetic f o o t to d e l a y striking the floor after
heel c o n t a c t . T h i s will a l l o w the natural rotation o f the leg t o externally
rotate the p r o s t h e t i c f o o t b e f o r e it is flat o n the floor. T h e d e l a y o f the
s o l e o f the f o o t in c o n t a c t i n g the floor is readily o b s e r v a b l e as the a m p u t e e
walks.
8. Is the "piston
walking?
action"
between
the
stump
and
socket
minimal
during
A n easy m e t h o d f o r d e t e r m i n i n g p i s t o n a c t i o n b e t w e e n the s t u m p a n d the
s o c k e t is b y o b s e r v a t i o n o f the a c t i o n o f the b a s e o f the patella as it m o v e s
a w a y f r o m a n d t o w a r d the a n t e r i o r s o c k e t r i m . A p e n c i l m a r k o n the s t u m p
s o c k c a n b e m o s t helpful in this o b s e r v a t i o n . T h e m o t i o n n o t i c e d w h e n the
k n e e is flexed s h o u l d b e i g n o r e d . It is after the k n e e is e x t e n d e d a n d w e i g h t
p l a c e d o n the prosthesis that the a m o u n t o f p u m p i n g c a n b e m o s t a c c u r a t e l y
d e t e r m i n e d . D i s p l a c e m e n t o f one-half t o three-quarter i n c h is n o t unusual.
O b v i o u s l y , it is d e s i r a b l e to h a v e little p i s t o n a c t i o n .
9. Does
the prosthesis
function
in a smooth,
noise-free
manner?
C o m m o n areas a n d s o u r c e s o f n o i s e a r e :
a ) the ankle j o i n t , w h i c h m a y r e q u i r e g r e a s i n g
b ) the s p a c e b e t w e e n the f o o t a n d ankle w h i c h m a y b e i n a d e q u a t e a n d
c a u s e r u b b i n g ( a h o m e r e m e d y is t o insert s o a p s c r a p i n g s into the
space)
c ) the k n e e j o i n t s , w h i c h m a y r e q u i r e g r e a s i n g
d ) c l i c k i n g o f the k n e e j o i n t e x t e n s i o n s t o p s , w h i c h is usually e l i m i n a t e d
b y the use o f a c h e c k l a c e r o r b y filing the s t o p s .
A t the c o n c l u s i o n o f the w a l k i n g p h a s e o f the c h e c k o u t p r o c e d u r e , the
a m p u t e e ' s s t u m p s h o u l d b e e x a m i n e d f o r a n y irritated o r d i s c o l o r e d areas,
with particular attention d i r e c t e d t o the c o m m o n areas o f d i s c o m f o r t pre­
v i o u s l y d e s c r i b e d . S o m e i n d i c a t i o n o f h o w w e i g h t is distributed o v e r the
s t u m p c a n b e o b t a i n e d b y the i m p r e s s i o n left b y the s t u m p s o c k o n the skin.
T h i s p a p e r has attempted t o delineate the areas c o n s i d e r e d b y the a u t h o r s
to b e o f m a j o r i m p o r t a n c e in d e t e r m i n i n g the p r o s t h e t i c a d e q u a c y o f a b e ­
l o w - k n e e artificial l i m b .
PART II.
A Checkout Procedure for Above-Knee Artificial Limbs
By MARSHALL A. GRAHAM, M.S. and HERBERT E. KRAMER
I n the p r e c e d i n g article t h e a u t h o r s p r e s e n t a p r o c e d u r e f o r
the a d e q u a c y o f b e l o w - k n e e prostheses.
evaluating
T h e problems of above-knee ampu­
tees are m o r e acute than are t h o s e o f b e l o w - k n e e c a s e s , p r i m a r i l y as a result
o f the g r e a t e r f u n c t i o n a l a n a t o m i c a l loss d u e to the h i g h e r a m p u t a t i o n site.
A c o n v e n t i o n a l a b o v e - k n e e prosthesis usually consists o f a w o o d f o o t with
a toe-break
( F i g . 1 ) ; an ankle with p r o v i s i o n f o r d o r s i a n d p l a n t a r
flexion
( a l t h o u g h s o m e also p r o v i d e i n v e r s i o n a n d e v e r s i o n ) ; a w o o d , m e t a l ,
or
plastic s h a n k ; a s i n g l e o r m u l t i p l e a x i s k n e e
tension)
(providing
flexion
fiber
a n d ex­
( F i g 2 ) ; a c a r v e d w o o d , metal, m o l d e d leather, o r plastic s o c k e t ;
a n d a p e l v i c belt with s i n g l e o r d o u b l e a x i s h i p j o i n t ( o r an air v a l v e , if a
s u c t i o n s o c k e t is u s e d ) .
theses.
(No.
O n e is
fitted
F i g . 3 presents t w o c o n v e n t i o n a l a b o v e - k n e e p r o s ­
w i t h a p e l v i c belt as the m a j o r
means of
1 ) , w h i l e the other utilizes the s u c t i o n s o c k e t p r i n c i p l e
suspension
(No. 2 ) .
In
a d d i t i o n , m a n y a b o v e - k n e e a m p u t e e s w e a r an e x t e n s i o n a i d in the f o r m o f
a k i c k strap, h i c k o r y l e v e r , w r a p s p r i n g , c o i l s p r i n g , o r c o m p r e s s i b l e r u b b e r
b u m p e r s t o h e l p in a c h i e v i n g knee e x t e n s i o n w h i l e w a l k i n g .
In past y e a r s there has b e e n great e m p h a s i s p l a c e d o n
the p r o b l e m s o f a b o v e - k n e e a m p u t e e s .
of
literature is a v a i l a b l e
finding
solutions to
B e c a u s e o f this, an i m p r e s s i v e array
c o n c e r n i n g the
fit, a l i g n m e n t ,
t r a i n i n g related t o a b o v e - k n e e prostheses.
biomechanics,
H o w e v e r , t o the w r i t e r s '
and
knowl­
e d g e , there has b e e n n o c o m p r e h e n s i v e c l i n i c a l p r o c e d u r e set forth b y w h i c h
th a d e q u a c y o f an a b o v e - k n e e prosthesis c o u l d b e d e t e r m i n e d .
It is the pur­
p o s e o f this p a p e r t o present s u c h a p r o c e d u r e .
As
in the article d e a l i n g w i t h b e l o w - k n e e prosthesis
c h e c k o u t , e a c h ital­
i c i z e d q u e s t i o n represents a p o i n t to b e c h e c k e d b y the c l i n i c g r o u p .
A brief
d i s c u s s i o n f o l l o w s the q u e s t i o n with o c c a s i o n a l hints f o r c o r r e c t i o n o f a sub­
standard condition.
the i n f o r m a t i o n
perience.
A w o r k sheet f o r c l i n i c use c a n easily b e d r a w n
c o n t a i n e d in this article, s u p p l e m e n t e d
from
b y the r e a d e r ' s ex­
A s u g g e s t e d f o r m f o r the w o r k sheet has a short u n d e r l i n e d
space
p r e c e d i n g e a c h n u m b e r e d q u e s t i o n , s o that a c h e c k ( \ / ) o r a " n o " m a y b e
inserted as e a c h item is c o v e r e d at the c l i n i c .
T h e r e m e d y f o r items that
p r o v e to h a v e s h o r t c o m i n g s m a y b e o b v i o u s , in w h i c h case e x t e n s i v e dis­
c u s s i o n b y the c l i n i c g r o u p is u n n e c e s s a r y .
T h e c h e c k list w h i c h f o l l o w s has b e e n d i v i d e d into f o u r areas c o n s i d e r e d
to b e of m a j o r importance.
T h e first area, q u a l i t y c o n t r o l , is c o n c e r n e d w i t h
e x a m i n a t i o n o f the prosthesis b e f o r e it is w o r n b y the patient. T h e prosthesis
is then e x a m i n e d as it is w o r n b y the a m p u t e e w h i l e s t a n d i n g , sitting
walking.
A n y s h o r t c o m i n g s o f the prosthesis
should b e corrected and
and
the
l i m b r e c h e c k e d b y the c l i n i c p r i o r t o the start o f t r a i n i n g , s i n c e it is k n o w n
that an i n a d e q u a t e l i m b c a n result in i n s u r m o u n t a b l e
t r a i n i n g p r o b l e m s and
c a n h i n d e r the p h y s i c a l , e m o t i o n a l , a n d v o c a t i o n a l a d j u s t m e n t o f the a m p u t e e .
Fig. I—Legend: A . Foot, B . Toe-break, C. Ankle joint and bushing, D. Front ankle
bumper (rubber or felt; acts as doriflexion s t o p ) , E. Rear ankle bumper (rubber; f o r
plantar f l e x i o n ) , F. Anterior ankle articulation space (leather covered), G. Posterior
ankle articulation space (leather covered).
A.
QUALITY CONTROL
( T o b e c h e c k e d w i t h the p r o s t h e s i s off the patient.)
1.
Is the
color
of the leg satisfactory
and
homogeneous?
2.
Has the inside socket
surface
been completely
i.e. a wood sealer covering
the entire
surface?
and
smoothly
finished,
In a w o o d s o c k e t , a sealer w i l l p r e v e n t p e r s p i r a t i o n f r o m the s t u m p
f r o m p e n e t r a t i n g the w o o d , c a u s i n g r o u g h s p o t s , r a i s i n g o f the g r a i n , o r
c r a c k i n g o f the s o c k e t , a n y o f w h i c h c a n b e the c a u s e o f s t u m p irrita­
t i o n . A g o o d finish will p e r m i t a d e q u a t e h y g i e n i c c a r e , a l l o w i n g resi­
d u a l p e r s p i r a t i o n f r o m the s o c k e t s u r f a c e t o b e easily r e m o v e d .
3.
Has the socket rim been adequately
flared,
and all sharp edges
removed?
A s h a r p i n s i d e e d g e o f the s o c k e t r i m c a n c a u s e d i s c o m f o r t a n d even
l a c e r a t i o n o f the skin, e s p e c i a l l y in the c a s e o f o b e s e a m p u t e e s w h o s e
skin f o l d s m a y o v e r l a p the s o c k e t r i m .
4.
Is a back
pad
attached
to the posterior
socket
wall?
W h e n the a m p u t e e seats h i m s e l f o n a h a r d s u r f a c e ,
t a c h e d t o the p o s t e r i o r s o c k e t w a l l will h e l p t o :
a back pad
a. R e d u c e the w e a r o n t r o u s e r s .
b . M u f f l e the s o u n d o f the s o c k e t c o n t a c t i n g the h a r d c h a i r
5.
If a pelvic joint is used, does the joint
sistance or excessive
lateral
play?
articulate
smoothly
at­
surface.
without
re­
E x c e s s i v e r e s i s t a n c e will c a u s e u n d u e w e a r o f the j o i n t , s h o r t e n i n g the
m a i n t e n a n c e - f r e e p e r i o d o f use. It w i l l also restrict h i p m o t i o n , necessi­
tating a d d e d effort b y the a m p u t e e .
A l o o s e j o i n t c a n c a u s e n o i s e a n d loss o f p r o s t h e t i c c o n t r o l ( b y lateral
m o v e m e n t o f the s o c k e t ) o r , as a result o f u n d u e strain c a n fracture
the h i p j o i n t .
6.
Is there proper
clearance
between
shank during
knee flexion and
the anterior
extension?
portion
of the knee
and
T o o little c l e a r a n c e will c a u s e r u b b i n g o f the s u r f a c e s between the
knee a n d the a n t e r i o r - p r o x i m a l shank, p r o d u c i n g n o i s e . T o o m u c h clear­
a n c e will a l l o w the trouser material to c a t c h , resulting in tearing a n d / o r
a restriction o f k n e e m o t i o n . C a t c h i n g o f the trouser is m o s t likely to
take p l a c e when rising f r o m a sitting p o s i t i o n o r w h e n w a l k i n g into the
wind.
7.
Is the knee
extension
stop
padded?
T h e k n e e e x t e n s i o n s t o p s h o u l d b e p a d d e d with felt, r u b b e r o r other
s h o c k a b s o r b e n t material. T h e p a d d i n g will h e l p muffle n o i s e c a u s e d b y
c o n t a c t b e t w e e n the k n e e s t o p a n d the s o c k e t , as well as t o r e d u c e the
i m p a c t at full e x t e n s i o n d u r i n g w a l k i n g .
8.
Can the prosthetic
knee be flexed a minimum
of 1 2 0 ° ?
W h e n sitting, a d e q u a t e k n e e flexion will p e r m i t p o s i t i o n i n g o f the
p r o s t h e t i c f o o t well u n d e r the c h a i r .
T h i s k n e e flexion r a n g e is also i m p o r t a n t t o a l l o w the a m p u t e e t o
kneel c o m f o r t a b l y , s i n c e l i m i t e d k n e e flexion will c a u s e the a m p u t e e t o
fall f o r w a r d a n d c a n c a u s e s t u m p d i s c o m f o r t .
A q u i c k m e t h o d f o r d e t e r m i n i n g if t h e p r o s t h e t i c k n e e a l l o w s suffi­
cient flexion is t o p l a c e the prosthesis in a k n e e l i n g p o s i t i o n o n a flat
s u r f a c e . W i t h the k n e e flexed t o its m a x i m u m , t h e l o n g i t u d i n a l axis o f
the s o c k e t s h o u l d b e p o s t e r i o r t o a v e r t i c a l l i n e t h r o u g h the k n e e axis.
9.
Is the posterior-distal
socket
supported
over the entire cut-out area of
the shank during maximum
knee
flexion?
T h i s is p a r t i c u l a r l y i m p o r t a n t w h e n the a m p u t e e kneels. If the p o s ­
terior-distal s o c k e t is n o t e v e n l y s u p p o r t e d o v e r the entire s h a n k cut-out
area, t h e r e is a strong p o s s i b i l i t y that the p o s t e r i o r p o r t i o n o f the shank
will splinter, c r a c k o r b e c o m e d e f o r m e d .
10.
Is there adequate
clearance
in the ankle articulation
to prevent
rubbing
of parts or catching of
socks?
T o o little c l e a r a n c e will c a u s e r u b b i n g o f the i n s i d e s u r f a c e o f the
f o o t o n the ankle b l o c k , w h i c h m a y p r o d u c e n o i s e . E x c e s s i v e c l e a r a n c e
will a l l o w the s o c k t o c a t c h , c a u s i n g t e a r i n g a n d / o r restriction o f ankle
movement.
11.
Has the artificial foot been properly
upholstered
and fitted to the
shoe?
Neat u p h o l s t e r y w i t h n o s h a r p p r o t r u s i o n s o r e d g e s will d o m u c h to
prevent tearing o f socks.
If the f o o t is t o o small, s l i p p a g e o f the s h o e c a n c a u s e s o c k d a m a g e ,
or a t e n d e n c y f o r the heel o f the s h o e to scuff the g r o u n d d u r i n g the
p r o s t h e t i c s w i n g p h a s e . N a t u r a l l y , if the f o o t is t o o l a r g e the a m p u t e e
will find it difficult t o c h a n g e s h o e s o r s o c k s o n his prosthesis.
12.
If a kick
decreasing
strap is used,
tension?
13.
In a suction
socket,
is there
can the valve
adequate
body
adjustment
be threaded
for
easily
increasing
or
in and out of
the valve
seat?
It is i m p o r t a n t that the t h r e a d s o f the v a l v e seat b e free o f g l u e o r
dirt, as i m p r o p e r seating o f the v a l v e b o d y m a y c a u s e l o s s o f s u c t i o n
a n d / o r "anti-social" noises.
Fig. I I — H . Knee friction adjustment screw, I. Knee bolt (single a x i s ) , J . Knee control roller,
K. Knee control strap, L. W i l l o w or Bass wood construction, M. Rawhide over wood (painted).
Fig. III
N. Shank (Shin)
O. Knee extension stop
P. Cut out o f knee (per­
mits knee flexion)
Q. Knee
R. Suction socket valve
opening
S. Kick strap adjustment
buckle
SS. Kick strap
T . Suction socket
T T . Conventional, pelvic
belt socket
U. A i r vent opening
V. Knee control strap
W . Back pad
X. Pelvic joint
Y. Pelvic band
Z. Pelvic belt
B.
STANDING
(prosthesis o n )
1.
Is the amputee secure while standing
with good posture and with
heels
together?
W h e n the a m p u t e e stands w i t h g o o d p o s t u r e and heels t o g e t h e r ,
there s h o u l d he n o t e n d e n c y f o r the p r o s t h e t i c k n e e to b u c k l e . A l t h o u g h
the s l u m p is e x t e n d e d to the rear, pressure s h o u l d not b e n e c e s s a r y to
maintain knee stability. A s a further c h e c k , h a v e the a m p u t e e b a l a n c e
m o m e n t a r i l y on the prosthesis, with the s o u n d foot off the g r o u n d , to
b e sure the p r o s t h e t i c k n e e d o e s n o t b u c k l e . ( T h e fact that the a m p u t e e
c a n n o t b a l a n c e himself on the p r o s t h e s i s f o r any a p p r e c i a b l e t i m e d o e s
not i n d i c a t e a p r o s t h e t i c s h o r t c o m i n g , but m a y b e d u e to i n a d e q u a t e
training.)
I n c r e a s e d k n e e stability f o r the a m p u t e e c a n b e a c c o m p l i s h e d m o s t
e x p e d i t i o u s l y either b y ( a ) i n c r e a s i n g k n e e e x t e n s i o n b y a d j u s t i n g the
k n e e e x t e n s i o n stop o r ( b ) setting the f o o t in a d d i t i o n a l p l a n t a r
flexion.
T h e s e adjustments s h o u l d b e m a d e c o n s e r v a t i v e l y o r they m a y create
such p r o b l e m s as:
a. H y p e r - e x t e n s i o n o f the prosthetie k n e e w h i c h c a n result in in­
c r e a s e d l u m b a r l o r d o s i s w h e n the p r o s t h e s i s is in stance phase.
In a d d i t i o n , it will f o r c e t h e a m p u t e e t o use g r e a t e r s t u m p effort to
initiate k n e e flexion while w a l k i n g , c a u s i n g fatigue a n d / o r p o o r
a p p e a r a n c e o f gait ( e x c e s s i v e r e a r w a r d heel rise at t o e - o f f ) .
b . E x c e s s i v e plantar flexion o f the ankle w h i c h may c a u s e the am­
putee to c o m p l a i n o f a sensation o f w a l k i n g " u p a h i l l " as he trans­
fers his weight o v e r the ball o f the p r o s t h e t i c f o o t , resulting in the
feeling that the p r o s t h e s i s is t o o l o n g . In o r d e r to c o m p e n s a t e for
this apparent increase in length the a m p u t e e may d e v e l o p such p o o r
w a l k i n g habits as rising e x c e s s i v e l y o n the hall o f the n o r m a l f o o t
d u r i n g the s w i n g phase o f the prosthesis ( v a u l t i n g ) o r w a l k i n g
w i t h an a b d u c t e d o r c i r c u m d u c t e d gait.
If the t w o p r o s t h e t i c adjustments m e n t i o n e d a b o v e are not suc­
cessful, it m a y b e n e c e s s a r y t o sever the s o c k e t f r o m the k n e e b l o c k
a n d set it m o r e a n t e r i o r to the k n e e a x i s . It is r o u t i n e prosthetic
p r a c t i c e t o fit a m p u t e e s w i t h m e d i u m o r s h o r t s t u m p s w i t h the k n e e
b o l t p o s t e r i o r to a r e f e r e n c e line b e t w e e n the greater t r o c h a n t e r o f
the f e m u r a n d the ankle a x i s . In c o n t r a s t , a well-trained a m p u t e e
w i t h a l o n g e r , w e l l - d e v e l o p e d s t u m p c a n tolerate the k n e e axis
c l o s e r to the t r o c h a n t e r i c - a n k l e a x i s line, as an a m p u t e e o f this type
can m o r e readily control prosthetic knee
flexion.
2.
Is the amputee comfortable
while standing
on the prosthesis
with
good
posture and heels close
together?
T h e a b o v e - k n e e a m p u t e e b e a r s w e i g h t p r i m a r i l y at t h e :
a. Ischial t u b e r o s i t y
b . Gluteus m a x i m u s r e g i o n
W e i g h t - b e a r i n g is a v o i d e d a s m u c h as p o s s i b l e in the a d d u c t o r ,
f e m o r a l triangle a n d r a m u s r e g i o n s o f the Stump. S o m e w e i g h t is b o r n e
o v e r a m a j o r p o r t i o n o f the r e m a i n i n g area o f the s t u m p , e x t e n d i n g to
a p p r o x i m a t e l y 1 1/2 inches o f the end. T h e distal s t u m p s h o u l d b e rela­
tively free o f w e i g h t , s i n c e it is g e n e r a l l y m o r e sensitive in this area.
3.
Is the artificial
leg the correct
length?
T h e a d e q u a c y o f the length o f the prosthesis c a n b e d e t e r m i n e d b y
visual e x a m i n a t i o n o f the a n t e r i o r - s u p e r i o r i l i a c spines. T h e usual p r o ­
c e d u r e is f o r the e x a m i n e r t o p l a c e his t h u m b s o n these s p i n o u s p r o c ­
esses a n d b y sight j u d g e w h e t h e r o r n o t they are level.
If the height a p p e a r s unsatisfactory, the use o f p r e p a r e d flat w o o d e n
slabs o f v a r y i n g thicknesses
a n d 1/2") is v e r y helpful in de­
t e r m i n i n g the a m o u n t o f alteration n e c e s s a r y t o c o r r e c t the length o f
the prosthesis.
(1/8", 1/4"
4.
Is the anterior-medial
area of the socket
wall properly
contoured
to
avoid excessive
pressure
in the femoral
triangle
region?
T o o tight a fit in the f e m o r a l t r i a n g l e ( S c a r p a ' s t r i a n g l e ) r e g i o n will
usually c a u s e an " a c h i n g s e n s a t i o n . " T o o l o w a fit in the f e m o r a l tri­
a n g l e will c a u s e the d e v e l o p m e n t o f a flesh r o l l w h i c h m a y present seri­
o u s fitting p r o b l e m s .
T h e n e e d f o r a p r o p e r l y c o n t o u r e d s o c k e t in this area is c r i t i c a l , s i n c e
e d e m a o f the s t u m p is often a s s o c i a t e d w i t h restriction o f t h e l y m p h a t i c
and v e n o u s return, d u e to l o c a l i z e d restriction in the f e m o r a l t r i a n g l e
as well as the distal r e g i o n s o f the s t u m p .
5.
Is the medial socket
of an adductor
flesh
the
pubis?
wall the
roll and
correct
height
(b) excessive
to prevent
fa)
pressure
on the
formation
ramus of
A low medial wall may n o t initially c a u s e the a m p u t e e any appre­
c i a b l e d i s c o m f o r t . H o w e v e r , with time, an a d d u c t o r roll will d e v e l o p
w h i c h will not only hinder the amputee's gait ( a s he will tend to walk
with the prosthesis in a b d u c t i o n to a v o i d friction a n d p r e s s u r e ) b u t will
also c a u s e fitting difficulties. It is felt that the m e d i a l wall should he
n o m o r e than 1/4 i n c h l o w e r than the level o f the ischial seat o f the
socket.
I d e a l l y , the r a m u s s h o u l d b e l o c a t e d i n s i d e the m e d i a l s o c k e t wall
w h i c h s h o u l d b e s o s h a p e d as to m i n i m i z e p r e s s u r e d u r i n g weightbearing.
6.
Is the ischial
socket?
tuberosity
properly
situated
on the
ischial
support
of
the
P r e s e n t k n o w l e d g e o f a b o v e - k n e e p r o s t h e s e s indicates a quadrilaterally
s h a p e d s o c k e t with a definite flat p o r t i o n o n the p o s t e r i o r - m e d i a l r i m ,
w h i c h b e c o m e s the m a j o r w e i g h t - b e a r i n g area o f the s o c k e t ( f o r place­
ment o f the ischial t u b e r o s i t y o f the p e l v i s ) . I f the i s c h i u m s h o u l d slip
off this s o c k e t s u p p o r t area, the a m p u t e e will e x p e r i e n c e a c u t e d i s c o m ­
fort. I m p r o p e r p l a c e m e n t o f the ischial t u b e r o s i t y o n the s o c k e t r i m
( t u b e r o s i t y i n s i d e the s o c k e t ) is an i n d i c a t i o n that the d i s t a n c e b e t w e e n
the a n t e r i o r and p o s t e r i o r s o c k e t walls is t o o great, p r o v i d i n g insuffi­
cient c o u n t e r p r e s s u r e a l o n g the a n t e r i o r s o c k e t w a l l f o r stabilizing the
ischial t u b e r o s i t y o n its seat. T h i s d i s t a n c e b e t w e e n the a n t e r i o r a n d
p o s t e r i o r s o c k e t walls represents a critical m e a s u r e m e n t o f the a m p u t e e ' s
s t u m p ( t h e d i s t a n c e b e t w e e n the a d d u c t o r l o n g u s t e n d o n a n d the ischial
t u b e r o s i t y ) . P r e s e n t e x p e r t o p i n i o n is that the ischial t u b e r o s i t y s h o u l d
b e l o c a t e d one-half i n c h p o s t e r i o r t o the i n n e r s u r f a c e o f the rear wall
and o n e i n c h f r o m the inner m e d i a l s o c k e t wall. T h e r e f o r e , the anteriorp o s t e r i o r d i m e n s i o n s o f the i n n e r s o c k e t w a l l s s h o u l d b e one-half i n c h
less t h a n the a d d u c t o r l o n g u s - i s c h i a l t u b e r o s i t y
measurement.
T o d e t e r m i n e w h e t h e r the ischial t u b e r o s i t y is p r o p e r l y p o s i t i o n e d o n
the s o c k e t . have the a m p u t e e r e m o v e his w e i g h t f r o m the prosthesis,
place a finger ( with the palm up ) o n the ischial t u b e r o s i t y a n d a l l o w
the a m p u t e e t o re-apply his weight t o the s o c k e t . I n cases w h e r e l o c a ­
tion o f the ischial t u b e r o s i t y is difficult ( m u s c u l a r a n d / o r o b e s e pa­
tients ) . it m a y b e necessary to h a v e the patient b e n d f o r w a r d in o r d e r
to p r o p e r l y locate the bony p r o m i n e n c e a n d then h a v e h i m straighten
u p as b e r e a p p l i e s weight to the prosthesis.
It is further s u g g e s t e d that the c l i n i c i a n m a r k the l o c a t i o n o f the
ischial s u p p o r t o n the s o c k e t b e f o r e r e m o v i n g his finger. T h i s m a r k
will a l l o w l o c a t i o n o f the ischial s u p p o r t with the prosthesis off the
patient.
7.
Is the distal
slump
free
of
tension?
T o c h e c k the t e n s i o n o f the skin at the e n d o f the stump, insert a
finger t h r o u g h the v a l v e o p e n i n g o f the s u c t i o n s o c k e t o r t h r o u g h the
air vent o p e n i n g o f a c o n v e n t i o n a l socket and palpate the s l u m p while
the a m p u t e e alternates his w e i g h t o n and off the prosthesis. T h i s pro­
c e d u r e will also tell the relative p o s i t i o n o f the s t u m p within the s o c k e t
and g i v e i n f o r m a t i o n a b o u t the p u m p i n g a c t i o n taking p l a c e b e t w e e n
the s t u m p a n d s o c k e t .
E x c e s s i v e tension o n the distal s t u m p w i l l c a u s e an u n c o m f o r t a b l e
p u l l i n g sensation that is often e x a g g e r a t e d w h e n scar tissue is in this
area.
8.
Is there adequate
socket
puts full weight on the
space distal
prosthesis?
to the
stump
while
the
amputee
T h e r e s h o u l d b e a p p r o x i m a t e l y 2 i n c h e s o f s o c k e t s p a c e distal to the
s t u m p t o r e d u c e the p o s s i b i l i t y o f the e n d o f t h e s t u m p hitting the
b o t t o m o f the s o c k e t d u r i n g full w e i g h t - b e a r i n g o r if the s t u m p s h o u l d
slip t o o far into the s o c k e t .
L i m i t e d c l e a r a n c e in the s u c t i o n s o c k e t w i l l m e a n t o o small an air
s p a c e w h i c h may c a u s e t o o g r e a t a fluctuation o f p o s i t i v e and n e g a t i v e
pressures d u r i n g use. T h e r e c o m m e n d e d s u c t i o n s o c k e t p r e s s u r e in the
past has b e e n o n e to t w o p o u n d s per s q u a r e inch f o r b o t h n e g a t i v e a n d
p o s i t i v e pressures.
H o w e v e r , t h i s s h o u l d n o t b e a hard and fast rule.
T h e r e have been reports of successful suction Socket wearers with s o c k e t
p r e s s u r e s as h i g h as f o u r to five p o u n d s p e r s q u a r e i n c h .
9.
On weight-bearing
wall?
does
the stump
stay
in contact
with the lateral
socket
O n w e i g h t - b e a r i n g the lateral s t u m p s h o u l d b e in firm c o n t a c t w i t h
the s o c k e t w a l l in o r d e r t o a f f o r d m a x i m u m lateral s u p p o r t f o r the
a m p u t e e . T h i s c a n b e d e t e r m i n e d best b y a s k i n g the a m p u t e e if the
lateral wall g i v e s s u p p o r t w i t h o u t p a i n o r d i s c o m f o r t .
In the suction t y p e socket, the lateral fit b e c o m e s more, c r i t i c a l . T h e r e
s h o u l d b e n o g a p b e t w e e n the lateral r i m o f the s o c k e t and the a m p u t e e ' s
s t u m p , as this will c a u s e b r e a k a g e o f the s u c t i o n seal a l l o w i n g air t o
enter o r e s c a p e f r o m the s o c k e t with a c c o m p a n y i n g " a n t i - s o c i a l n o i s e . "
10.
I f a pelvic belt is used, does it accurately fit the contours
of the
body?
T h e p e l v i c belt s h o u l d pass b e t w e e n the iliac crest a n d the greater
t r o c h a n t e r a n d n o t e x e r t e x c e s s i v e p r e s s u r e o n the
anterior-superior
iliac s p i n e . A well fitting p e l v i c b a n d a n d j o i n t w i l l d o m u c h t o o v e r ­
c o m e e x c e s s i v e p u m p i n g a c t i o n b e t w e e n the s t u m p a n d s o c k e t w h i l e walk­
i n g . E x c e s s i v e p u m p i n g a c t i o n c a n c a u s e skin i r r i t a t i o n s o f the s t u m p
a n d m a y f o r c e the a m p u t e e t o w a l k with a gait c h a r a c t e r i z e d b y vault­
ing, abduction o r c i r c u m d u c t i o n .
11.
If a pelvic belt with hip joint is used, is the head of the joint
located
on or anterior
to the greater
trochanter?
T h e p e l v i c j o i n t s h o u l d b e attached to the s o c k e t o n o r slightly an­
t e r i o r t o the g r e a t e r t r o c h a n t e r a n d parallel t o the line o f p r o g r e s s i o n
f o r best f u n c t i o n w h i l e w a l k i n g a n d c o m f o r t w h i l e sitting. P i n c h i n g o f
the flesh in this a r e a is n o t u n c o m m o n w i t h an i m p r o p e r l y l o c a t e d
p e l v i c j o i n t . ( A l s o , s e e SITTING, q u e s t i o n s 4 a n d 5 ) .
12.
I f a Silesian
belt is used, are the attachments
properly
located?
T h e lateral a t t a c h m e n t o f the Silesian b a n d a g e s h o u l d b e at a p o i n t
a b o u t 1/4 i n c h p o s t e r i o r t o the g r e a t e r t r o c h a n t e r .
T h e a n t e r i o r attachment s h o u l d b e at o r n e a r a p o i n t f o r m e d b y the
intersection o f :
a. a h o r i z o n t a l l i n e at the level o f the ischial seat
b . a vertical l i n e d o w n the m i d d l e o f the s o c k e t
C.
1.
SITTING
Can the amputee
sit comfortably
with his hip flexed
to 90
degrees?
P a r t i c u l a r attention s h o u l d b e d i r e c t e d t o t h e a n t e r i o r s o c k e t r i m
while the a m p u t e e is seated w i t h the h i p a n d k n e e flexed t o 9 0 d e g r e e s .
W i t h the s u c t i o n s o c k e t , t o o h i g h an anterior wall m a y push against the
b o n y p r o m i n e n c e o f the pelvis, d i s p l a c i n g the s o c k e t . T h e r e is usually
n o d i s c o m f o r t with t o o low an a n t e r i o r wall of a s u c t i o n socket, a l t h o u g h
this is c o n d u c i v e to the d e v e l o p m e n t o f an anterior flesh roll.
W i t h the pelvic belt leg. t o o h i g h an anterior w a l l c a n c a u s e p r e s s u r e
and pain w h e r e it strikes the p e l v i s and can restrict h i p flexion. T o o
l o w an anterior r i m m a y c a u s e c r o w d i n g and p i n c h i n g o f t h e flesh o f
the a n t e r i o r p r o x i m a l s l u m p .
A n a d d i t i o n a l c h e c k o f the c o r r e c t height o f the a n t e r i o r socket wall
is to h a v e the a m p u t e e b e n d f o r w a r d and t o u c h his feel while sitting.
2.
Is the prosthetic
knee the correct
height and length in proportion
to the
sound
knee?
T h e p r o s t h e t i c k n e e presents an o b j e c t i o n a b l e a p p e a r a n c e if it e x t e n d s
b e y o n d o r is h i g h e r than the s o u n d k n e e w h i l e the a m p u t e e is sitting.
Either o f these c o n d i t i o n s i n d i c a t e s that the p r o s t h e t i c k n e e a x i s d o e s
n o t c o i n c i d e with the center o f r o t a t i o n o f the s o u n d k n e e .
If the p r o s t h e t i c k n e e e x t e n d s t o o far ( k n e e center t o o l o w a n d s o c k e t
t o o l o n g ) the p r o s t h e t i c f o o t m a y not reach the floor. If the p r o s t h e t i c
knee is t o o h i g h ( k n e e center t o o h i g h ) the a m p u t e e may h a v e difficulty
when sitting at a desk o r table o r when d r i v i n g a c a r .
A n a m p u t e e with a l o n g - a b o v e - k n e e s t u m p ( s u p r a - c o n d y l a r o r
l o w e r than the s o u n d k n e e in o r d e r t o a l l o w f o r fitting with a c o n v e n ­
tional a b o v e - k n e e prothesis. T h i s is especially true o f a s u c t i o n s o c k e t ,
d u e to the need f o r an air s p a c e .
3.
Does the knee remain flexed while the amputee
is
seated?
If an e x t e n s i o n a i d has t o o m u c h t e n s i o n , it will tend t o e x t e n d the
prosthetic k n e e w h e n the f o o t is lifted f r o m the floor. T h i s c o n d i t i o n
is m o r e prevalent with amputees w h o d o n o t utilize k n e e f r i c t i o n .
4.
Can the amputee
sit without
the prosthesis
internally
or
externally
rotating?
T h e o u t e r p o s t e r i o r s o c k e t wall s h o u l d b e relatively flat, s o that t h e
p o s t h e t i c shank r e m a i n s vertical w h e n in c o n t a c t w i t h a h a r d surface.
A n o t h e r c a u s e o f m e d i a l o r lateral r o t a t i o n o f the p r o s t h e s i s w h i l e
sitting is i m p r o p e r p l a c e m e n t o f the p e l v i c j o i n t . If the j o i n t head is
p l a c e d t o o far a n t e r i o r l y ( a n d m e d i a l l y rotated to the line o f p r o g r e s ­
s i o n ) the thigh p o r t i o n o f the p r o s t h e s i s will r o t a t e internally a n d the
shin will a b d u c t . If the j o i n t head is p l a c e d t o o far p o s t e r i o r l y , the
thigh p o r t i o n o f the prosthesis will rotate externally and the shank will
a d d u c t . A s previously m e n t i o n e d , the r e c o m m e n d e d p l a c e m e n t o f the
pelvic j o i n t is o n o r slightly a n t e r i o r to the g r e a t e r trochanter.
5.
Does the prosthesis
remain in good abduction-adduction
alignment?
W h i l e sitting, the a m p u t e e s h o u l d b e a b l e t o m a i n t a i n c o m f o r t a b l y
the t h i g h p o r t i o n o f the p r o s t h e s i s parallel t o the t h i g h o f h i s n o n amputated l i m b .
A l t h o u g h a d d u c t i o n is not usually e n c o u n t e r e d , a b d u c t i o n o f the thigh
is q u i t e c o m m o n . T h e a m p u t e e m a y a b d u c t the prosthesis t o relieve
p r e s s u r e in the a d d u c t o r o r f e m o r a l t r i a n g l e r e g i o n s o f the s t u m p .
A s e c o n d c a u s e m a y b e that the p e l v i c j o i n t assembly d o e s not c l o s e l y
follow the a n a t o m i c a l c o n t o u r s o f the h i p and thigh w h i l e sitting. T h e r e
s h o u l d not b e a large g a p between the j o i n t a n d the b o d y , a n d the j o i n t
a s s e m b l y s h o u l d not b e in a b d u c t i o n in relation t o the b o d y parts.
Pressure o r g a p p i n g o f the p e l v i c b a n d c a n also c a u s e a b d u c t i o n .
Gritti-Stoke
6.
Does
the
lateral
wall
remain
in contact
with
the
slump?
G a p p i n g at the lateral wall o f the socket while the a m p u t e e sits is a n
i n d i c a t i o n that the socket fit o r a l i g n m e n t is i m p r o p e r . T h e s o c k e t s h o u l d
fit snugly around the
entire s t u m p p e r i p h e r y . G a p p i n g is usually asso­
c i a t e d with pressures at the lateral-distal a n d / o r the m e d i a l - p r o x i m a l
s t u m p and can often he attributed t o p o o r s h a p i n g o f the s o c k e t . In
a d d i t i o n , there is a p r o b l e m o f air loss for the s u c t i o n s o c k e t w e a r e r .
7.
Is the
slump
ischial support
discomfort?
area
of the
socket
properly
contoured
to
prevent
A s h a r p b u r n i n g sensation in the ischial t u b e r o s i t y a r e a is an i n d i c a ­
t i o n o f insufficient relief f o r the h a m s t r i n g m u s c l e t e n d o n s as they are
stretched o v e r the i s c h i a l s u p p o r t r e g i o n o f t h e s o c k e t . T h e b u r n i n g
sensation is the result o f p r e s s u r e o n the stretched t e n d o n s as well as
f r i c t i o n . T h e usual p r o c e d u r e is t o relieve the ischial s u p p o r t r e g i o n
w i t h i n the s o c k e t b y s l o p i n g the s o c k e t in this a r e a o r b y c h a n n e l i n g
the s o c k e t to a l l o w sufficient r o o m f o r the t e n d o n s o f the h a m s t r i n g
m u s c l e s . T h i s b u r n i n g sensation is usually n o t i c e d after several m o m e n t s
o f sitting.
8.
With the suction
ting without
any
socket, can the amputee
reapply
disturbing
"suction
noises"?
his
weight
after
sit­
Ask the a m p u t e e to stand, putting his weight on the p r o s t h e s i s . A
flatulating noise o c c u r r i n g when weight is re-applied, is an i n d i c a t i o n
that air has re-entered the s o c k e t ( c o m m o n l y at the lateral s o c k e t wall ) .
A c o n d i t i o n o f this t y p e can b e very e m b a r r a s s i n g t o the w e a r e r a n d
if n o t c o r r e c t e d , m a y result in the r e j e c t i o n o f the s u c t i o n s o c k e t . A
h i g h , w e l l - c o n t o u r e d s o c k e t fit a c r o s s the lateral wall will prevent this
type of noise.
D.
1.
Is the amputee
discomfort.
comfortable
WALKING
while
walking?
If
not,
specify
areas
of
A r e a s o f d i s c o m f o r t o f the s t u m p , w h i c h m a y n o t b e a p r o b l e m w h i l e
sitting o r e v e n s t a n d i n g , b e c o m e acute w h i l e w a l k i n g , d u e t o the c o n ­
stantly c h a n g i n g d i s t r i b u t i o n o f w e i g h t in the s o c k e t .
S p e c i a l attention s h o u l d b e d i r e c t e d to the f o l l o w i n g r e g i o n s in w h i c h
d i s c o m f o r t and i r r i t a t i o n are c o m m o n l y f o u n d :
a.
b.
c.
d.
e.
Ischial tuberosity
R a m u s o f the p u b i s
Proximal adductor region
Femoral triangle (Scarpa's
Distal lateral r e g i o n
triangle)
E v e r y effort s h o u l d b e m a d e t o p r o v i d e the a m p u t e e w i t h a c o m f o r t ­
able s o c k e t , s i n c e his adaptability t o t r a i n i n g a n d his s u b s e q u e n t per­
formance depends heavily upon being comfortable.
2.
Is the
amputee
secure
while
walking?
P r o s t h e t i c instability o f the a b o v e - k n e e a m p u t e e c o n s i s t s b a s i c a l l y o f
t w o t y p e s : ( a ) b u c k l i n g at the k n e e a n d ( b ) lateral instability.
(a)
Buckling
at the knee is the m o r e d a n g e r o u s o f these t w o b a l a n c e
p r o b l e m s s i n c e i n a d v e r t e n t flexion o f the p r o s t h e t i c k n e e , o c c u r ­
r i n g w h e n the prosthesis is w e i g h t - b e a r i n g ( s t a n c e p h a s e ) can
c a u s e falling.
knee are:
(1.)
T h r e e c o m m o n c a u s e s o f an i n s e c u r e
prosthetic
F a u l t y a n t e r i o r - p o s t e r i o r a l i g n m e n t o f the k n e e .
T h e center of
r o t a t i o n o f t h e k n e e is t o o far a n t e r i o r t o a r e f e r e n c e l i n e b e t w e e n
the greater t r o c h a n t e r a n d t h e p r o s t h e t i c ankle axis ( s e e q u e s t i o n
1, STANDING).
(2.)
T o o h a r d a r e a r ankle b u m p e r ( p l a n t a r flexion b u m p e r ) . T o o
h a r d a r e a r ankle b u m p e r resists plantar flexion at the t i m e o f
heel c o n t a c t c a u s i n g the f o r w a r d m o m e n t u m o f t h e b o d y t o b e
a p p l i e d t o t h e k n e e resulting in a t e n d e n c y t o b u c k l e . T h i s c a n
b e o v e r c o m e t o s o m e extent b y e x c e s s i v e r e a r w a r d s t u m p pressure.
(3.)
E x c e s s i v e d o r s i - f l e x i o n o f the p r o s t h e t i c ankle. G e n e r a l p r o s t h e t i c
p r a c t i c e is t o align t h e f o o t o n the shin at an a n g l e o f 9 0 d e g r e e s
o r slightly greater ( p l a n t a r
flexion).
Excessive dorsi-flexion will
p l a c e the k n e e a x i s t o o far a n t e r i o r t o the g r e a t e r t r o c h a n t e r - a n k l e
a x i s line, s o that w h e n the a m p u t e e transfers his w e i g h t t o the
p r o s t h e s i s , the k n e e w i l l t e n d t o b u c k l e .
If the p r o s t h e t i c k n e e is unstable, t h e a m p u t e e m a y i n c o r p o r a t e vari­
o u s c o m p e n s a t o r y m o v e m e n t s in h i s g a i t pattern t o o v e r c o m e t h e diffi­
culties h e m a y b e e x p e r i e n c i n g . T h e f o u r m o s t c o m m o n o b s e r v a b l e
compensatory movements are:
(a)
forcefully Hexing the p r o s t h e t i c k n e e a n d then a b r u p t l y e x t e n d i n g
it with a w h i p - l i k e m o t i o n
( b ) o v e r e x t e n d i n g the prosthesis, d e l i b e r a t e l y t a k i n g a l o n g p r o s t h e t i c
step a n d then e x a g g e r a t i n g t h e h a r d i m p a c t at heel c o n t a c t
(c) w a l k i n g with a s l o w , halting gait and with " d o u b l e k n e e a c t i o n " ; the
p r o s t h e t i c k n e e d o e s not maintain full e x t e n s i o n as t h e w e i g h t is
transferred t o the p r o s t h e s i s after heel c o n t a c t and the a m p u t e e
( d ) l o r d o s i s — t h e a m p u t e e uses e x t e n s o r m u s c l e s o f the b a c k as a sub­
stitute f o r w e a k h i p e x t e n s o r s t o h e l p m a i n t a i n k n e e e x t e n s i o n ,
( b ) Lateral instability—The
a m p u t e e s h o u l d feel that the prosthesis
r e m a i n s d i r e c t l y u n d e r h i m d u r i n g stance p h a s e w i t h little o r n o ten­
d e n c y t o shift his b o d y w e i g h t laterally. Lateral instability is usually
a s s o c i a t e d with a shifting o f t h e entire p r o s t h e s i s laterally as full w e i g h t
is taken o n the artificial l i m b . T h e t w o b a s i c c a u s e s o f this i n n c o r r e c t in­
stability are i m p r o p e r medial-lateral a l i g n m e n t o f the p r o s t h e s i s and
inadequate training.
I m p r o p e r a l i g n m e n t m a y b e c o r r e c t e d b y i n c r e a s i n g the w i d t h o f the
w a l k i n g b a s e . T h e s u g g e s t e d w a y o f d o i n g this is t o d i s p l a c e t h e knees h a n k - f o o t o f the p r o s t h e s i s laterally in relation t o t h e s o c k e t . T h i s
p r o c e d u r e w i d e n s the b a s e o f s u p p o r t w i t h o u t i n f l u e n c i n g t h e p o s i t i o n
o f the s t u m p w i t h i n t h e s o c k e t .
A s e c o n d c a u s e o f lateral instability is i n a d e q u a t e t r a i n i n g .
A n am­
putee s h o u l d b e t r a i n e d in b a l a n c i n g , s o that h e is a b l e t o utilize the
h i p a b d u c t o r s o n t h e a m p u t a t e d s i d e f o r m a i n t a i n i n g a stable p o s i t i o n .
A s in k n e e stability, the a m p u t e e m a y c o m p e n s a t e in his g a i t pattern
f o r the f e e l i n g o f lateral i n s e c u r i t y b y w a l k i n g with an a b d u c t e d gait o r
w i t h c o n s i d e r a b l e lateral b e n d i n g o f the trunk o v e r the prosthesis.
3.
Does
the amputee
walk
with
a reasonably
narrow
base
of
support?
In e v a l u a t i n g this f a c t o r , e a c h a m p u t e e must b e c o n s i d e r e d as an
i n d i v i d u a l . T h e length o f his s t u m p a n d his g e n e r a l b o d y t y p e m u s t b e
re-ext
taken into c o n s i d e r a t i o n . It is t o b e e x p e c t e d , f o r instance, that an
o b e s e , e n d o m o r p h i c t y p e o f i n d i v i d u a l w i l l naturally w a l k with g r e a t e r
a b d u c t i o n t h a n w o u l d a thin o r m u s c u l a r p e r s o n .
I n a d d i t i o n , in o r d e r t o i n c r e a s e lateral stability, it has b e e n the
p r a c t i c e to fit v e r y s h o r t - a b o v e - k n e e s t u m p s w i t h a prosthesis set i n e x ­
aggerated valgus (the prosthetic foot o u t s e t ) , w h i c h p r o d u c e s a wider
base o f support.
O c c a s i o n a l l y with a p e l v i c belt w e a r e r , a b d u c t i o n c a n b e c a u s e d b y
the j o i n t b e i n g in a b d u c t i o n .
A n o t h e r c a u s e o f a b d u c t e d gait is p a i n o r pressure in the a b d u c t o r
o r ramus r e g i o n o f the s o c k e t . T h e a m p u t e e a b d u c t s his s t u m p a n d
t h e r e f o r e , the prosthesis, in o r d e r to gain relief in these areas. In s u c h
cases, a b d u c t i o n is often a c c o m p a n i e d b y lateral b e n d i n g o f the trunk.
H o w e v e r , t h e r e is n o r e a s o n w h y the a v e r a g e a b o v e - k n e e a m p u t e e ,
with no physical o r prosthetic complications, cannot walk with his base
o f s u p p o r t as n a r r o w as that o f a n o n - a m p u t e e . T h i s is usually be­
t w e e n 1/2 a n d 2 i n c h e s d i s t a n c e b e t w e e n the inner b o r d e r s o f the s h o e s .
4.
Does
the prosthesis
swing
in a straight
line of
progression?
T h e three m a j o r v a r i a t i o n s o f the s w i n g p h a s e o f a prosthesis in the
sagittal p l a n e a r e :
a. a m e d i a l w h i p
b . a lateral w h i p
c. c i r c u m d u c t i o n .
A m e d i a l w h i p is c h a r a c t e r i z e d b y a m o v e m e n t o f the heel o f the
prosthetic foot medially
and a rotation o f the k n e e laterally, n o t i c e d
immediately after toe-off. T h e f o o t then rotates b a c k t o its usual p o s i ­
tion either d u r i n g the r e m a i n d e r o f the s w i n g phase ( c a u s i n g a "fish
tail" effect ) , o r returns to its o r i g i n a l p o s i t i o n b y the toe rotating m e ­
dially immediately after the heel o f the prosthesis c o n t a c t s the g r o u n d .
A m e d i a l w h i p is c o r r e c t e d by the prosthetist rotating the p r o s t h e t i c
k n e e m e d i a l l y . In a d d i t i o n to a l i g n m e n t factors, a m e d i a l w h i p m a y
b e c a u s e d b y t o o tight a socket in the area o f the adductor
longus m u s c l e
and t e n d o n .
A lateral w h i p is the direct reverse o f a m e d i a l w h i p , with the heel
of the foot m o v i n g laterally and the knee rotating medially immediately
after toe-off o f the prosthesis. A lateral w h i p is c o r r e c t e d b y the pros­
thelist rotating the prosthetic k n e e laterally. A w h i p o f this t y p e m a y
b e c a u s e d b y t o o tight a s o c k e t fit in the area o f the gluteus
maximus.
C i r c u m d u c t i o n is a m o v e m e n t o f the prosthesis in a lateral a r c dur­
i n g its s w i n g phase. It c a n b e c a u s e d b y t o o l o n g a p r o s t h e s i s , o r b y
the a m p u t e e w a l k i n g with little o r n o k n e e flexion a n d s o m o v i n g his
prosthesis o u t w a r d in o r d e r t o assure the f o o t c l e a r i n g the g r o u n d .
5. Is the resistance
of the rear ankle
bumper
adequate
to prevent
foot-slap?
T o o little resistance o f the p r o s t h e t i c ankle t o plantar flexion is
c a u s e d b y t o o soft a rear ankle b u m p e r . T h e plantar s u r f a c e o f the
p r o s t h e t i c f o o t t h e r e f o r e strikes the floor t o o r a p i d l y a n d with an a u d i b l e
" s l a p , " as the b o d y w e i g h t is a p p l i e d t o the prosthesis after heel c o n t a c t .
6.
Is the resistance of the rear ankle
nal rotation of the
foot?
bumper
low enough
to prevent
exter­
T o o m u c h resistance o f the p r o s t h e t i c ankle to plantar flexion is
c a u s e d b y t o o h a r d a rear ankle b u m p e r . T h e p l a n t a r surface o f the
p r o s t h e t i c f o o t is t h e r e f o r e r e t a r d e d f r o m striking the floor after heel
c o n t a c t , a l l o w i n g the natural r o t a t i o n o f the leg a n d b o d y t o rotate ex­
ternally the p r o s t h e t i c f o o t b e f o r e it is flat o n the floor. T h e d e l a y o f
the sole o f the f o o t in c o n t a c t i n g the floor is r e a d i l y o b s e r v a b l e as the
a m p u t e e walks.
7.
Is the
normal
toe-out
foot?
of
the
prosthetic
8. Is the friction at the knee adequate
prosthetic
swings?
foot
reasonably
to control
close
the forward
to
that
and
of
the
rearward
T h e c o r r e c t setting o f k n e e f r i c t i o n m e c h a n i s m w i l l d o m u c h t o
e l i m i n a t e the t w o m a j o r s w i n g p h a s e gait d e v i a t i o n s c a u s e d b y p r o s t h e t i c
i n a d e q u a c y , i.e., e x c e s s i v e r e a r w a r d p r o s t h e t i c heel rise a n d v i o l e n t i m ­
p a c t at full k n e e e x t e n s i o n .
A t the t i m e o f toe-off, the a m p u t e e flexes his h i p , m o v i n g his
and s o c k e t f o r w a r d . W i t h o u t f r i c t i o n , the s h a n k o f the prosthesis
t e n d e n c y t o r e m a i n at rest o r t o m o v e in a d i r e c t i o n o p p o s i t e that
stump ( N e w t o n ' s L a w s o f M o t i o n ) d e p e n d i n g o n the f o r c e a n d
of h i p flexion. T h e result is e x c e s s i v e r e a r w a r d heel rise o f the
thetic f o o t after toe-off.
stump
has a
o f the
speed
pros­
T h i s e x c e s s i v e heel rise c a u s e s , in turn, a t i m e l a g in the e x t e n s i o n
o f the p r o s t h e t i c knee. T h e a m p u t e e finds it n e c e s s a r y t o w a i t f o r the
knee t o b e c o m e e x t e n d e d , a n d s o , f o r the prosthesis t o b e c o m e w e i g h t b e a r i n g . T h i s w a i t i n g m a y c a u s e p o o r gait characteristics s u c h as
vaulting
( r i s i n g o n the t o e o f the n o r m a l f o o t w h i l e the prosthesis is
in the s w i n g p h a s e ) o r e r r a t i c a c c e l e r a t i o n ( a s u r g i n g o f the entire
b o d y with e a c h n o n - p r o s t h e t i c s t e p ) .
A d d i n g f r i c t i o n to the k n e e creates a m o r e direct r e l a t i o n s h i p b e t w e e n
the p r o s t h e t i c t h i g h a n d shank ( c o n s i d e r the e x t r e m e situation o f e n o u g h
f r i c t i o n to l o c k the k n e e in e x t e n s i o n ) a n d s o the r e a r w a r d m o t i o n o f
the shank a n d f o o t is m i n i m i z e d . C o r r e c t adjustment will p r o d u c e
e q u a l heel rise f o r b o t h the p r o s t h e t i c a n d natural l e g s . ( I n the natural
leg, r e a r w a r d heel rise is c o n t r o l l e d b y a c t i o n o f the q u a d r i c e p s f e m o r i s
muscles.)
A f t e r knee flexion is c o m p l e t e d , a prosthesis with n o f r i c t i o n at the
knee e x h i b i t s the characteristics o f a p e n d u l u m . T h e s h a n k a n d f o o t
start the f o r w a r d s w i n g a n d g r a d u a l l y i n c r e a s e their s p e e d b y m e a n s
of g r a v i t y , but strike the k n e e e x t e n s i o n s t o p b e f o r e they are a l l o w e d
to decelerate naturally ( b y m e a n s o f g r a v i t y ) .
I n the h u m a n b o d y , a g r a d u a l d e c e l e r a t i o n o f the shank is a c c o m ­
p l i s h e d b y the h a m s t r i n g m u s c l e s o f the t h i g h . F r i c t i o n a p p l i e d t o the
p r o s t h e t i c k n e e acts f o r the s a m e p u r p o s e as the h a m s t r i n g s a l t h o u g h
n o t in the s a m e m a n n e r . T h e f r i c t i o n f o u n d in m o s t c o n v e n t i o n a l p r o s ­
thesis is o f a c o n s t a n t t y p e ( i . e . , acts t h r o u g h o u t the s w i n g p h a s e r a n g e
of the k n e e ) , w h e r e a s the h u m a n m u s c l e s act w i t h p r o g r e s s i v e l y greater
strength, c r e a t i n g w h a t h a s b e c o m e k n o w n as terminal
deceleration.
( S e v e r a l prostheses still in e x p e r i m e n t a l stages p r o v i d e a v a r i a b l e t y p e
o f f r i c t i o n that m o r e c l o s e l y a p p r o x i m a t e s m u s c l e f u n c t i o n s . )
A l s o , b e c a u s e o f the e x c e s s i v e r e a r w a r d heel rise a n d i m p a c t at full
k n e e e x t e n s i o n c a u s e d b y l a c k o f f r i c t i o n e s p e c i a l l y d u r i n g fast w a l k i n g ,
the a m p u t e e is f o r c e d t o restrict his w a l k i n g s p e e d . T h e a d d i t i o n o f
f r i c t i o n at the k n e e m a k e s it easier f o r the a m p u t e e t o w a l k faster with
better p r o s t h e t i c c o n t r o l a n d better a p p e a r a n c e .
F r i c t i o n s h o u l d b e adjusted f o r the a m p u t e e ' s n o r m a l w a l k i n g s p e e d .
H o w e v e r , it s h o u l d n o t b e s o great as to r e q u i r e an u n d u e a m o u n t o f
s t u m p effort to fully e x t e n d the p r o s t h e t i c knee. H i g h f r i c t i o n m a y also
tend to c a u s e the f o o t to " h a n g u p " at the e n d o f the r e a r w a r d m o t i o n .
It is the o p i n i o n o f the a u t h o r s that w i t h present c o m m e r c i a l l y avail­
able p r o s t h e t i c d e v i c e s , k n e e c o n t r o l c a n b e a c h i e v e d w i t h a fairly h i g h
d e g r e e o f f r i c t i o n a n d the a d d i t i o n o f a k n e e e x t e n s i o n a i d (see ques­
tion 9 b e l o w ) .
9.
10.
I f a knee extension
mechanism
is used, is it properly
adjusted?
T h e p r i m a r y f u n c t i o n s o f an e x t e n s i o n a i d a r e : a ) to m i n i m i z e ex­
c e s s i v e r e a r w a r d heel rise, a n d b ) to assist g r a v i t y in initiating the
k n e e e x t e n s i o n m o v e m e n t . A s the knee flexes, the e x t e n s i o n a i d ( b e it
in the f o r m o f a kick-strap, h i c k o r y lever, w r a p spring, c o i l s p r i n g , o r
c o m p r e s s i b l e b u m p e r ) is p l a c e d p r o g r e s s i v e l y o n i n c r e a s i n g t e n s i o n until
the t e n s i o n o v e r r i d e s the f o r c e o f inertia that is c a u s i n g the prosthetic
heel rise r e a r w a r d .
T h e n , d u e to its tensed c o n d i t i o n , the e x t e n s i o n a i d acts to h e l p grav­
ity initiate a n d c a r r y out the k n e e e x t e n s i o n m o v e m e n t ( f o r w a r d s w i n g
phase).
H o w e v e r , the e x t e n s i o n m e c h a n i s m s h o u l d n o t b e s o tight that it
limits knee flexion a n d causes scuffing o f the p r o s t h e t i c t o e . T o o tight an
adjustment will also tend to b r i n g the shank into full e x t e n s i o n with t o o
m u c h f o r c e , resulting in a j a r r i n g i m p a c t o n the stump. A s p r e v i o u s l y
m e n t i o n e d , there must b e a p r o p e r b a l a n c e o f f o r c e s b e t w e e n the ex­
tension aid and the k n e e friction.
At the conclusion
of this phase of the checkout,
have the amputee
re­
move his prosthesis
and examine
the stump for any irritated
or dis­
colored
areas, which might indicate need for further
prosthetic
service.
In the p r e c e d i n g p a g e s the a u t h o r s h a v e attempted to present in c o n ­
c i s e f o r m the h i g h l i g h t s o f a c h e c k o u t p r o c e d u r e f o r a b o v e - k n e e artificial
l i m b s . T h i s c h e c k o u t is a p p l i c a b l e to b o t h s u c t i o n s o c k e t a n d p e l v i c
belt t y p e s o f prostheses b y s i m p l y o m i t t i n g the f e w q u e s t i o n s that d o
not a p p l y in either c a s e .
The authors wish to thank members of the
Prosthetic Devices Study Staff f o r their review
of this article.
WHAT'S NEWS
T h e D.W.
Dorrance
Co. a n d the A. J. Hosmer Corp. h a v e h a d to e x p a n d
their q u a r t e r s in San J o s e , C a l i f o r n i a , as a result o f i n c r e a s e d d e m a n d f o r
their services.
T h e H o s m e r C o r p o r a t i o n has a n e w b u i l d i n g u n d e r c o n s t r u c t i o n , w h i c h
will b e o p e n A p r i l 1. It is just a f o u r m i n u t e s ' w a l k u p C o l e m a n A v e n u e
f r o m the present D o r r a n c e structure. M a i l f o r the H o s m e r C o r p o r a t i o n
s h o u l d b e a d d r e s s e d t o P . O . B o x 1 5 2 , San J o s e , C a l i f o r n i a .
T h e m o v e will m a k e it p o s s i b l e f o r the D . W . D o r r a n c e C o . to r e - o r g a n i z e
their present plant a n d use the a d d i i t o n a l s p a c e v a c a t e d b y the H o s m e r
C o r p o r a t i o n . A l l m a i l f o r the D o r r a n c e C o m p a n y s h o u l d b e a d d r e s s e d to
748 C o l e m a n A v e n u e , San J o s e , C a l i f o r n i a ( n o l o n g e r use P o s t Office B o x
1128).
C o p i e s o f the n e w Construction
Manual for the Flexible
Soft Socket
for
Upper
Extremity
Protheses
are n o w available. P e r s o n s interested should
write to T h o m a s J. Canty, Captain, M C U S N , Chief, A m p u t e e S e r v i c e , U . S.
Naval Hospital, Oakland 14, California.