Gait deviations in amputees

Introduction

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[1][2][3][4][5].

Gait deviations in lower limb amputees can be broadly broken into the patient and the prosthetic causes:[6]

  • Patient Causes:
    • Muscle weakness
    • Contracture
    • Pain
    • Decreased confidence in the prosthesis or residual limb
    • Habitual/learned behaviours
  • Prosthetic Causes:
    • Prosthetic malalignment
    • Poor-fitting prosthetic socket

Important things to note about the gait of people with lower-limb amputations:[7]

  • Gait patterns are different than age-matched people without an amputation
  • "Transtibial and transfemoral amputees show a common and specific gait pattern"[7]
  • Transfemoral amputees have a more asymmetric gait than transtibial amputees
  • The level of the amputation and the type of prosthesis affect gait, for e.g. in transfemoral amputees, the type of prosthesis will influence the gait pattern of the same person, in both performance and adaptation. [7]

The trunk and lower limb gait:[8]

  • Someone with a lower limb amputation can have altered trunk motion during functional tasks
  • Increased trunk flexion and trunk velocity can be some of the risks associated with falling for this population.
  • Assessment and rehab should include not only trunk-pelvis, core, and hip abductor strength but also focus on training of the placement of the prosthetic knee and foot to help modify trunk movement during gait. [8]

Common deviations are listed in the tables below:

Transtibial :[2][9][4]

Name Description Causes Illustration
Absent/inadequate 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

Discomfort/pain

Quads weakness.

Excessive Knee Flexion Increased knee flexion at heel strike (or mid stance), the patient feels as though walking downhill

Faulty suspension of the prosthesis

Prosthetic foot set in too much dorsiflexion

Stiff heel cushion

Flexion contracture of the knee

Foot too posterior in relation to the socket

External Rotation of Foot at Heel Strike External rotation of the prosthesis/foot at heel strike. 

heel to hard

loose socket.[10]

Knee instability Knee flexion ‘jerky’ in the 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

Socket loose.[10]

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.[10]

Knee Hyperextension Delayed heel causing hyperextension of the knee, walking uphill sensation

Foot set too far forward on the prosthesis in relation to the socket

Too hard a heel cushion

Too much plantar flexion on the foot.

Whip During swing phase foot ‘whips’ laterally or medially

Poor suspension

Knee internally or externally rotated[10]

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:[4]

Name Description Causes Illustration
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

The heel of the shoe too high causing the pylon of the prosthesis to move anteriorly

Severe hip flexion contracture[10]

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

Excessive dorsiflexion.[10]

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

The 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[10].

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

Habit[10].

Anterior Trunk Bending  Trunk flexes forwards during prosthetic stance phase
Increased Lumbar Lordosis Lumbar lordosis is exaggerated during prosthetic stance phase

Poor shaping of the posterior wall of the prosthesis or pain on ischial weight bearing, resulting in anterior pelvic rotation

Flexion contracture at the hip

Weak hip extensor

Habit

Poor abdominal muscles

Lack of support from the anterior wall of the socket

Insufficient socket flexion[10].

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 the femur

Prosthetic too tight.

Pistoning Socket dropping off when prosthesis lifted

Insufficient suspension

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 than required to gain knee flexion

Poor/lack of extension aid[10]

Reduced Heel Rise Prosthetic heel does not rise as much as sound side

Locked knee

Lack of hip flexion

Too much friction on free knee

Extension aid to tight[10]

Circumduction Lateral curvature of the 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

Abduction contractures

Habit

Weak hip flexors

Socket too small

Insufficient knee flexion[10].

Vaulting Amputee rises onto the toe of the non-prosthetic limb during the prosthetic swing phase

Prosthesis too long

Habit

Fear of catching the toe of the prosthesis 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[10].

Terminal Impact Forcible impact as the 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.


Both Transfemoral and Transtibial: [11][5]

Steps are of uneven duration or length, usually a short stance phase on the prosthetic side

Name Description Causes Illustration
Uneven Step Length Steps are of uneven duration or length, usually a short stance phase on the prosthetic side  

Fixed flexion deformity at the knee

Insufficient friction of prosthetic knee creating an increased step length on prosthetic side,

Hip flexion contracture

Pain leading to decreased weight bearing on the prosthetic side 

Fear

Poor balance

Painful poorly fitting socket

Uneven Arm Swing (secondary deviation) The arm on the prosthetic side is held close to the body

Poor prosthetic fit

Poor balance

Fear

Habit

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.

Recourses

[12]

YouTube Playlist with Amputee Gait Deviations

References

  1. Esquenazi A. Gait analysis in lower-limb amputation and prosthetic rehabilitation. Physical Medicine and Rehabilitation Clinics. 2014 Feb 1;25(1):153-67.
  2. 2.0 2.1 Silverman AK, Fey NP, Portillo A, Walden JG, Bosker G, Neptune RR. Compensatory mechanisms in below-knee amputee gait in response to increasing steady-state walking speeds. Gait & posture. 2008 Nov 1;28(4):602-9.
  3. Murphy DP, editor. Fundamentals of amputation care and prosthetics. Demos Medical Publishing; 2013 Aug 28.
  4. 4.0 4.1 4.2 Pasquina PF, Cooper RA. l-ower Extremity Amputation.
  5. 5.0 5.1 REhABiLitAtion A. Evidence Based Clinical Guidelines for the Physiotherapy Management of Adults with Lower Limb Prostheses.
  6. LE VAN TU. Evaluation of Trans-femoral Prosthesis Function Using Finite Element Analysis (Doctoral dissertation, SHIBAURA INSTITUTE OF TECHNOLOGY).
  7. 7.0 7.1 7.2 Varrecchia T, Serrao M, Rinaldi M, Ranavolo A, Conforto S, De Marchis C, Simonetti A, Poni I, Castellano S, Silvetti A, Tatarelli A. Common and specific gait patterns in people with varying anatomical levels of lower limb amputation and different prosthetic components. Human movement science. 2019 Aug 1;66:9-21.
  8. 8.0 8.1 Yoder AJ, Silder AB, Farrokhi S, Dearth CL, Hendershot BD. Lower extremity joint contributions to trunk control during walking in persons with transtibial amputation. Scientific reports. 2019 Aug 22;9(1):1-8.
  9. Winter DA, Sienko SE. Biomechanics of below-knee amputee gait. Journal of biomechanics. 1988 Jan 1;21(5):361-7.
  10. 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 10.12 Hunter New England. NSW Health Duff K. Prosthetic gait deviations. Page link on Australian Physiotherapist in Amputee Rehabilitation. http://www.austpar.com/portals/gait/docs-and-presentations/ProstheticGaitDeviations.pps (accessed 6 February 2015)
  11. Gailey R. Rehabilitation of a traumatic lower limb amputee. Physiotherapy Research International. 1998 Nov;3(4):239-43.
  12. PT Final Exam. PT Final Exam. June 2019. Available from: https://youtu.be/VtPQrHmnmhw