Pediatric Transtibial Amputee Gait Deviations adapted from Berger and Gailey (with our additions)
Heel strike to mid stance
Gait deviation
Excessive knee flexion
Insufficient knee flexion
Prosthetic cause
1) Excessive dorsiflexion of foot
2) Excessive stiff heel cushion or
plantarflexion bumper
3) Excessive anterior placement of
socket over the foot
4) Misplacement of suspension and
support structures of socket
1) Excessive plantarflexion of foot
2) Overly soft heel cushion or
plantarflexion bumper
3) Posterior placement of socket over
foot
Anatomical cause
1) Flexion contracture of knee or hip
2) Weak quadriceps
1)
2)
3)
4)
Pain, anterior and distal residual limb
Weak quadriceps
Overall joint laxity
Habit
Mid stance
Valgus moment at knee
1) Outset prosthetic foot
2) Abducted socket
1) Change in residual limb volume
Valgus moment at knee
1) Inset prosthetic foot
2) Adducted socket
1) Change in residual limb volume
1) Excessive plantarflexion of foot
2) Overly soft heel cushion or
plantarflexion bumper
3) Posterior placement of socket over
foot
1) Prosthesis too long
2) Plantarflexed foot
1)
2)
3)
4)
Knee hyperextension
Posterior pelvic rotation
1
Pain, anterior and distal residual limb
Weak quadriceps
Overall joint laxity
Habit
3) Pelvic weakness
4) contractures
Mid stance to toe off
Early knee flexion
(drop off)
Delayed knee flexion
(walking up a hill)
1) Excessive anterior placement of
socket over foot
2) Posterior placement of foot
3) Excessive prosthetic foot dorsiflexion
or anterior bumper too soft
1) Excessive posterior placement of
prosthetic foot
2) Plantarflexed prosthetic foot or
anterior bumper too hard
1) Pelvic/core weakness
1) Weak hip extensors
Swing phase
Pelvic rise
1) Prosthesis too long
1) Inadequate suspension
2) Prosthesis too short
Decreased stride length on prosthetic side
Increased stride length on prosthetic side
Decreased toe clearance
1) Prosthesis too long
1) Prosthesis too long
2) Pistoning in socket-suspension
Increased toe clearance
Lateral whip
Medial whip
1)
2)
1)
2)
Internally rotated socket
Inadequate suspension
Externally rotated socket
Inadequate suspension
2
1)
1)
2)
3)
Pelvic/core weakness
Volume change in residual limb
Pain in uninvolved limb
Hip flexion contracture on uninvolved
limb
4) Knee flexion contracture involved side
5) Anxiety
1) Pain in residual limb
1)
2)
3)
1)
2)
Improper donning
Change in volume
Weak hip and knee flexors
Vaulting
Excessive hip and knee flexion
(anxiety and exposure)
1) Improper donning
1) Improper donning
Pediatric Transfemoral Amputee Gait Deviations adapted from Berger and Gailey (with our additions)
Heel strike to mid stance
Lateral trunk bend
Trendelenberg
External rotation of prosthesis
Knee flexion
Instability
1) Abducted socket
2) Socket fit/trim lines
1) Trim lines anterior
2) Heel cushion or posterior bumper too
stiff
1) Knee axis to anterior
2) Dorsiflexed foot or heel cushion
posterior bumper too stiff
3) Insufficient extension assist
1)
2)
3)
4)
1)
2)
Weak hip abductors
Pain
Abduction contracture
Short residual limb
Improper donning
Poor residual limb control
1) Weak hip extensors
2) Hip flexion contracture
3) Change in shoe heel height
Mid stance to toe off
Abducted gait
Wide BOS
Lateral trunk bend/Trendelenberg
Trunk lordosis
Trunk flexion
Decreased stance time
1) Prosthesis too long
2) Medial wall of socket too high
3) Foot offset incorrect
Same as above
1) Insufficient socket flexion
2) Posterior wall trim lines
1) Socket flexed too much
1) Socket fit
3
1) Pain
2) Anxiety
1)
2)
3)
1)
1)
2)
Same as above
Hip flexor contracture
Weak core
Weak hip extensors
Hip flexion contracture
Pain
Anxiety
Swing phase
Terminal impact
Medial whip
Lateral Whip
Circumduction
Vaulting
Decreased prosthetic knee flexion
Decreased stride length on prosthetic side
Increased stride length on prosthetic side
1) Insufficient knee friction
2) Excessive extension assist
1) Prosthetic knee aligned in internal
rotation
2) Socket fit
1) Prosthetic knee aligned in external
rotation
2) Socket fit
1) Prosthesis too long
2) Medial trim lines to high
1) Prosthesis too long- multiple reasons
1) Prosthesis too short
1) Prosthesis too short
2) Inadequate suspension
1) Prosthesis too long
1)
2)
1)
2)
1) Improper donning
2) Change in residual limb volume
1)
2)
1)
1)
1)
2)
3)
4)
1)
2)
Decreased toe clearance
1) Prosthesis too long
2) Pistoning in socket-suspension
Increased toe clearance
4
Anxiety
Habit
Improper donning
Change in residual limb volume
1)
2)
3)
1)
2)
Anxiety
Abduction contracture
Anxiety
Patient growth in height
Pain in uninvolved limb
Hip flexion contracture in uninvolved
limb
Anxiety
Change in residual limb volume
Hip flexion contracture on uninvolved
limb
Knee flexion contracture on
uninvolved limb
Improper donning
Change in volume
Weak hip and knee flexors
Vaulting
Excessive hip and knee flexion
(anxiety and exposure)
Additional notes: Before you start gait analysis, observe static standing posture. Do this just as you would with any other patient. Start from
the ground up or the head down, find the asymmetries present, take notes, and then watch the patient walk. You will have a good idea what
you will see when you are seeing it. Static posture is easier to find alignment issues, but in gait you will see dynamic strength. You have to
remember eccentric versus concentric control in both the involved and uninvolved sides. After you watch gait, then take the prosthesis off and
test range and strength of the uninvolved limb, the residual limb, and the core. Figure this out first, and then you can call the prosthetist. If you
can’t figure it out, call the prosthetist and ask questions. By the time the patient sees you, it will probably be a strength/range issue. But
pediatric patients are allows growing, so fit is an issue more than in adults.
Also remember this list is not inclusive and often you will see more than one deviation present at the same time. Please use this reference as a
starting point of the most common causes.
Berger, Analysis of Amputee Gait, Chap 14, Atlas of Limb Prosthetics
Gailey, One Step Ahead, 1996
Apple and Decker, clinical observations, 2011
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