Common Gait Deviations Post-Amputation
Inadequate Knee Flexion - some loss of knee flexion is expected. Physical therapy and the prosthetic team use observational gait analysis to assess what can be adjusted to minimize the loss of knee flexion. Weak quadriceps, hip instability, pain and arthritis may be non-prosthetic sources of the deviation
Toe Out - physical therapy should rule out hip external rotation contracture, hip abductor weakness, and poor trunk stability as contributors to this compensatory pattern
Drop Off - a prosthetist should be consulted when drop off is observed and there is little to no evidence of a knee flexion contracture or substantial quadriceps weakness
Vaulting - this it the most energy consumptive compensatory habit: long prosthesis, excessive pflex of foot, excessive knee resistance or stability. Anatomical contributors include gait habit, fear of catching toe, weak hip flexors, or poor timing of hip flexors.
Quiz Prep: Can you think of balance and gait interventions you might select to help a patient overcome the fear of catching a toe? Or functional activities to improve hip flexor function?
Whips (medial and lateral) - these can result when the prosthesis was not donned in correct alignment and may indicate a need for further patient training in correct donning and doffing techniques
• Medial whip: tight socket, misaligned toe break (where the weight rolls over the foot/toe) ER of the knee. ANATOMICAL: Gait habit, socket not put on properly, ER of hip at toe off/hip flexion
Quiz Prep: Can you think of what your first intervention may be if you observe a medial or lateral whip?
Circumducted - this is the most common transfemoral gait deviation; presents when there is a lack of confidence in flexing knee, long prosthesis, excessive knee friction, excessive knee stability; weak hip flexors, or due to habit (using entire hip and pelvis to advance limb)
Lateral Bending - Reverse Trendelenberg - This is often observed when there is hypersensitivity and/or pain at the residual limb.
Quiz Prep: If you are working with a patient who has a transfemoral amputation and a prosthesis with a locked knee unit, what gait deviations can you expect to see during ambulation?
Quiz Prep: Can you describe why lateral bending is the observed compensatory response if the residual limb is painful?
General Prosthetic Limitations Contributing to Poor Gait
Fitting a prosthesis is individualized and takes time and feedback to optimize. Patients also change over time (size, bulk, skin, strength, etc.) so prosthesis monitoring for fit and function is ongoing.
Common sources of gait deviations driven by the prosthesis include:
- limb weight (the prosthetic limb is lighter or heaver than the intact limb)
- improper donning (alignment, stockinettes and liners)
- malfunctioning components
- proper shoe wear
- improper prosthesis height (can be observed by uneven arm swing, and patient complaints of "walking into a hole")
The rehab team should monitor for excessive and prolonged redness on the residual limb following weight bearing and gait in the prosthesis. In general, if redness persists > 10 minutes after prosthesis removal, and the patient has donned the prosthesis correctly, the patient may benefit from a referral to the CPO for component and fit assessment