Gait deviations in amputees
While assessing amputee gait it is important to be aware of normal gait and how normal gait in the amputee is affected. You can learn about this on the Gait in prosthetic rehabilitation page.
Furthermore, there may be deviations which an amputee will adopt to compensate for the prosthesis, muscle weakness or tightening, lack of balance and fear. These deviations create an altered gait pattern and it is important that these are recognised, as rehabilitation of the gait will need to encompass corrections of these deviations.
Gait deviations in lower limb amputees can be broadly broken into patient and prosthetic causes:
- Patient Causes:
- Muscle weakness
- Decreased confidence in the prosthesis or residual limb
- Habitual / learned behaviours
- Prosthetic Causes:
- Prosthetic malalignment
- Poor fitting prosthetic socket
Common deviations are listed in the tables below:
|Absent knee flexion||Knee fully extended at heel strike||
Faulty suspension of the prosthesis - too soft heel cushion or plantar flexor bumpers
Foot placement too far forward on stepping
Lack of pre-flexion of the socket
|Excessive Knee Flexion|| Increased knee flexion at heel strike (or mid stance), patient feels as though walking downhill
Faulty suspension of prosthesis
Prosthetic foot set in too much dorsiflexion
Stiff heel cushion
Flexion contracture of the knee
Foot too posterior in relation to socket
|External Rotation of Foot at Heel Strike||External rotation of the prosthesis/foot at heel strike.||
heel to hard
|Knee instability||Knee flexion ‘jerky’ in presentation during heel strike to foot flat||Weak Quadriceps|
|Valgus/Varus Moment|| Knee shifts medially or laterally during prosthetic stance phase
Foot placement (medial placement causes lateral thrust and vice versa)
Foot alignment on the prosthesis
|Drop Off||Heel off occurs too early causing early knee flexion||
Foot too posterior on the prosthesis in relation to the socket
Excessive dorsiflexion of the foot on the prosthesis
Soft heel bumper on the prosthesis.
|Knee Hyperextension||Delayed heel causing hyperextension of the knee, walking up hill sensation||
Foot set too far forward on the prosthesis in relation to socket
Too hard a heel cushion
Too much plantar flexion on the foot.
|Whip||During swing phase foot ‘whips’ laterally or medially||
Knee internally or externally rotated
|Pistoning||Amputee drops into the socket as the foot moves into flat foot, tibia moves vertically during alternately weight bearing and non-weight bearing periods of gait||
Lack of prosthetic socks
Suspension loose or inadequate
Too large or faulty socket
Transfemoral Gait Deviations:
|Prosthetic Instability|| The prosthetic knee has a tendency to buckle on weight bearing
Knee set too far anterior
Heel cushion too firm
Weak hip extensors
Heel of the shoe too high causing the pylon of the prosthesis to move anteriorly
Severe hip flexion contracture
|Foot Slap|| Foot progresses too quickly from heel strike to foot flat, creating a slapping noise
Patient forcing foot contact to gain knee stability
Heel cushion too soft
Plantar flexion cushion too soft
|Abducted Gait||Increased base of support during mobility, prosthetic foot placement is lateral to the normal foot placement during the gait cycle.||
Prosthesis too long
Socket too small
Suspension belt may be insufficient-band may be too far from the ileum
Pain in the groin or medial wall of the prosthesis
Hip abductor contractures
Lateral wall of the prosthesis not supporting the femur sufficiently
Socket of prosthesis abducted in alignment
Fear/lack of confidence transferring weight onto prosthesis
Alignment of the lower half of the pylon of the prosthesis in relation to socket.
|Lateral Trunk Bending||Trunk flexes towards prosthesis during prosthetic stance phase||
Prosthesis too short
Short stump length
Weak or contracted hip abductors
Foot outset excessively in relation to socket
Lack of prosthetic lateral wall support
Pain on the lateral distal end of the stump
Lack of balance
|Anterior Trunk Bending||Trunk flexes forwards during prosthetic stance phase|
|Increased Lumbar Lordosis|| Lumbar lordosis is exaggerated during prosthetic stance phase
Poor shaping of posterior wall of the prosthesis or pain on ischial weight bearing, resulting in anterior pelvic rotation
Flexion contracture at the hip
Weak hip extensor
Poor abdominal muscles
Lack of support from the anterior wall of the socket
Insufficient socket flexion.
|Whip (during swing phase)|| At toe off heel moves laterally (lateral whip) or medially (medial whip)
Prosthetic knee alignment
Incorrect donning of the prosthesis i.e. applied internally rotated or externally rotated weakness around femur
Prosthetic too tight.
|Pistoning||Socket dropping off when prosthesis lifted||
Socket too loose or delayed knee flexion during toe off (‘free knee only’) caused by increased resistance of the prosthesis
Alignment of prosthesis
|Excessive Heel Rise||Prosthetic heel rises more than sound side||
Lack of friction on prosthetic knee
Amputee generating more force then required to gain knee flexion
Poor/lack of extension aid
|Reduced Heel Rise|| Prosthetic heel does not rise as much as sound side
Lack of hip flexion
Too much friction on free knee
Extension aid to tight
|Circumduction||Lateral curvature of swing phase of prosthesis||
Prosthesis too long
Fixed knee and poor hip hitching
Poor suspension causing prosthesis to slip
Excessive plantar flexion of the foot
Weak hip flexors
Socket too small
Insufficient knee flexion.
|Vaulting||Amputee rises onto toe of the non prosthetic limb during prosthetic swing phase||
Prosthesis too long
Fear of catching toe on the floor
Insufficient knee flexion (free knee) due to decreased confidence
Lack of ‘hip hitching’ with a ‘locked/fixed knee’
Poor suspension prosthesis-slips off during swing phase
Socket too small
Excessive friction on knee flexion of the prosthesis.
|Terminal Impact||Forcible impact as knee goes into extension at end of terminal swing phase, just before heel strike||
Lack of friction of knee flexion
Extension aid too excessive
Absent extension bumper
Amputee deliberately snaps knee into extension by excessive force to ensure extension.
Steps are of uneven duration or length, usually a short stance phase on the prosthetic side
|Uneven Step Length||Steps are of uneven duration or length, usually a short stance phase on the prosthetic side||
Fixed flexion deformity at knee
Insufficient friction of prosthetic knee creating an increased step length on prosthetic side,
Hip flexion contracture
Pain leading to decreased weight bearing on prosthetic side
Painful poorly fitting socket
|Uneven Arm Swing (secondary deviation)||Arm on the prosthetic side is held close to the body||
Poor prosthetic fit
Always due to other gait deviations and lack of training
This is not an exhaustive list and the deviation described for each level of amputation is not exclusive to that level, but is more likely to occur for that amputation.
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