M. Jason Highsmith, DPT, CP

Outline
• Review basic, “normal” gait
• TT
– Generalizations (Prognosis & Demographics)
– Proper alignment
– Deviations
• TF
– Generalizations
– Proper alignment
– Deviations

Prognosis
• Trans-tibial prosthesis users-
– In the absence of severe comorbidities
• Tend to have prognoses favoring pre-morbid activity
• It is reasonable to expect return to most activities

Demographics
• When toe amputation is not considered:
• Trans-tibial amputation is most represented level of limb loss:
– 45% trans-tibial followed closely by
– 40% trans-femoral then steep drop to
– <10% below elbow (UE) at 3 rd most represented level

Flexion Flexion Flexion Extension Flexion
HS FF MS HO TO

TT Gait Assessment
1.
2.
• Consider all 3 planes
• Desired is:
Flexion moment throughout stance
3.
Slight varus
Slight toe out

Alignment Considerations
•
•
•

Gait Deviation Definitions
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Gait Deviation Definitions
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Gait Deviation Definitions
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• Observe:
• All Planes
• Frontal:
• Toe out
• Slight Varus
Properly Aligned

Properly Aligned
• Observe
• Sagittal:
• Slight Flexion Moment

Normal Gait
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• Normal Gait
• Extension Moment
• Flexion Moment
• Varus Moment
• Valgus Moment
• Drop Off
• External Foot Rotation
• Long Prosthesis
• Short Prosthesis
• Lateral Shift
• Vaulting
• Wide Gait
Deviations

Extension Moment

Extension Moment
• Prosthetic Cause
– Heel Too Soft
– Foot Too far Anterior
– Foot Too Plantarflexed
• Amputee Cause
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– Shoe Heel Height Too low
– Shoe Heel Height Too low
– Bad Gait Habits, Strength, Short Residual Limb

Flexion Moment

Flexion Moment
• Prosthetic Cause
– Heel Too Firm
– Foot Too far Posterior
– Foot Too Dorsiflex
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• Amputee Cause
– Shoe Heel Height Too high
– Bad Gait Habits, Strength, Short Residual Limb

Valgus Moment

Valgus Moment
• Prosthetic Cause
– Foot Too Outset
– Components Too ABDucted
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb

Varus Moment

Varus Moment
• Prosthetic Cause
– Foot Too Inset
– Components Too ADDucted
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb

Drop Off
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Drop Off
• Prosthetic Cause
– Short toe lever
– Excessive socket flexion
– Excessive dorsiflexion
– Incorrect foot type
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Internal Rotation of hip at toe off/hip flexion

External Foot Rotation
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External Foot Rotation
• Observations
– Patient wants foot to match sound side
– Internal rotation of knee at toe off
– Induce “medial whip”
– Drop off at end of stance phase
– Low back pain
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– Skin irritation due to rotational stress in socket

Long Prosthesis
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Long Prosthesis
• Observations
– Patient reports lower back pain
– Patient reports they feel like they are walking up a hill
– Noticeable rise and drop of shoulder on the effected side
– Hesitation in gait timing from prosthetic mid-stance
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Short Prosthesis
• Observations
– Patient reports lower back pain
– Patient reports they feel like they are stepping into a hole
– Noticeable rise and drop of the shoulder on the sound side
– Uneven arm motion to accommodate uneven stride length
– Appears like the patient may be vaulting
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Lateral Shift
• Prosthetic Cause
– Foot Too far Inset
QuickTime™ and a – Insufficient components ABDuction
– Short Prosthesis
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
Inadequate balance
– Weak Knee
– Narrow Gait Base

Vaulting
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Vaulting
• Prosthetic Cause
– Long Prosthesis
– Poor Suspension
– Excessive Plantarflexion of foot
– Excessive knee resistance or stability
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb Inadequate balance
– Fear of catching the toe
– Weak hip flexors of residual limb
– Improper initiation of hip flexors on residual limb

Wide Gait
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Wide Gait
• Prosthetic Cause
– Prosthetic foot Too far Outset
– Excessive components
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb Inadequate balance
– Insecurity, wants to widen base in attempt to increase stability
– Weak ML knee control

TT Gait Deviations Conclusions

TransFemoral Demographics
• When toe amputation is not considered:
• Trans-femoral amputation is 2 nd most represented level of limb loss:
– 45% trans-tibial followed closely by
• 40% trans-femoral then steep drop to
– <10% below elbow (UE) at 3 rd most represented level

KD/TFA
• Components significantly effect gait
• Prognoses highly variable
• View from all planes
• Anatomic/pathologic contributions?
• Component contributions?
• Socket contributions?

Trans-Femoral
• Ideas about grouping deviations:
• Some deviations result from length problems
– (or perceived length problems)
– E.g. vaulting, hip hiking, toe drag
• Some are transverse plane problems
– E.g. IR/ER socket, toe in/out, whips
• Some are strictly patient related
– E.g. Uneven timing, Trendelenburg, Vaulting
• Some are strictly component/alignment related
– E.g. knee instability, excess toe in/out, whips
• Some are much more dangerous than others
• Quite a few overlap categories

Things to Consider…
• Which knee is most stable?
• What foot characteristics are most/least desirable with TF prostheses?

Gait Deviation Definition
• Toe Lever Arm
• Heel Lever Arm
• Socket Flexion

Gait Deviation Definitions
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Gait Deviation Definitions
TKA
Trochanter/ knee/ ankle
Stationary alignment line to identify the relative alignment between the center of interface weight line, center of axis of the knee and the axis of the foot
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Normal Gait
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Deviations
• Toe Drag
• Vaulting
• Hip Hiking
• Circumduction
• Internal Rotation of the Prosthesis
• Internal Rotation of the Toe
• External Rotation of the Prosthesis
• External Rotation of the Toe
• Lateral Whip
• Medial Whip
• Knee Flexion Moment

Toe Drag
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Toe Drag
• Prosthetic Cause
– Too Long
– Too much Plantarflexion
– Poor suspension
– Excessive knee flexion
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Weak hip extensors
– Weak hip ABDuctors on sound side
– Poor posture

Vaulting
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Vaulting
• Prosthetic Cause
– Too Long
– Knee friction incorrectly set
– Poor suspension
– Excessive Plantarflexion of the foot
– Excessive knee resistance of stability
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Weak hip flexors on residual limb
– Improper initiation of hip flexors on residual limb

Hip Hiking
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Hip Hiking
• Prosthetic Cause
– Too Long
– Poor suspension
– Excessive knee stability
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb

Circumduction
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Circumduction
• Prosthetic Cause
– Too Long
– Excessive knee stability
– Excessive knee friction
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Lack of confidence in flexing the knee
– ABDuction contracture
– Weak hip flexors

Internal Rotation of the
Prosthesis
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Internal Rotation of the
Prosthesis
• Prosthetic Cause
– Poor fitting interface
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Prosthesis Donned incorrectly
– Weak muscles

Internal Rotation of Toe
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Internal Rotation of the Toe
• Prosthetic Cause
– Toe in Too far
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb

Lateral Whip
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Lateral Whip
• Prosthetic Cause
– Internal rotation of the knee
– Loose socket
– Mis-aligned toe break
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Socket not donn properly
– Internal rotation of the hip at toe off/hip flexion

External Rotation of the
Prosthesis
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External Rotation of the prosthesis
• Prosthetic Cause
– Prosthesis donned incorrectly
– Poor fitting interface
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Weak muscles

External Rotation of the Toe
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External Rotation of the Toe
• Prosthetic Cause
– Toe Out Too far
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Improper donning of the prosthesis

Medial Whip
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Medial Whip
• Prosthetic Cause
– External rotation of the knee
– Socket Too tight
– Mis-aligned toe break
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Socket donn improperly
– External rotation of the hip at toe off/hip flexion

Knee Flexion Moment
(Knee Buckles)
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Knee Flexion Moment
(Knee Buckles)
• Prosthetic Cause
– Knee Too anterior/socket Too Posterior
– Excessive Dorsiflexion
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Weak hip extensors
– Hip flexion contracture
– Change in Heel height

Trendeleburg Gait
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Trendelenburg Gait
• Prosthetic Cause
– Poor fitting interface
– Short prosthesis
– Foot Too far outset
– Ineffective lateral socket containment
– High medial wall
– Aligned in ABDuction
• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Congenital Defects
– Weak muscles

ABDuction Gait
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ABDuction Gait
• Prosthetic Cause
– Prosthesis Too Long
– Medial wall Too High
– Insufficient femoral stability
– Induces medial whip
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– ABDuction contracture

Heel Rise
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Heel Rise
• Prosthetic Cause
– Inadequate extension aid
– Insufficient knee friction
– Improper knee selection
• Amputee Cause
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– Bad Gait Habits, Strength, Short Residual Limb
– Excessive use of hip flexors to initiate swing phase, overpowering knee unit

Lateral Shift
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Lateral Shift
• Prosthetic Cause
– Prosthetic foot Too far Inset
– Excessive socket ADDuction
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Weak hip ABDuction
– Narrow gait base

Long Prosthetic Step
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Long Prosthetic Step
• Prosthetic Cause
– Excessive Plantarflexion of foot
– Excessive component extension
– Long toe lever arm
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb Flexion contracture
– Patient Insecurity
– Pain on sound side

Short Prosthetic Step
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Short Prosthetic Step
• Prosthetic Cause
– Socket pain
– Weak extension aid
– Unstable knee
– Excessive Dorsiflexion
– Poor suspension
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• Amputee Cause
– Bad Gait Habits, Strength, Short Residual Limb
– Patient insecurity
– Weak hip muscles
– Poor balance

TF Gait Deviations Conclusions