Gait deviations in amputees

Original Editor - Abby Cain as part of the World Physiotherapy Network for Amputee Rehabilitation Project

Top Contributors - Admin, Shaimaa Eldib, Kalyani Yajnanarayan, Naomi O'Reilly, Kim Jackson, Tarina van der Stockt and Tony Lowe

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.

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

• 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:

• Gait patterns are different than age-matched people without an amputation
• "Transtibial and transfemoral amputees show a common and specific gait pattern"
• 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.

The trunk and lower limb gait:

• 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.

Common deviations are listed in the tables below:

Transtibial :

Table 1. Transtibial Gait deviations

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.
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.
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 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
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:

Table 2. Transfemoral Gait Deviations

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
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.
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.
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.
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.
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
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
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.
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.
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:

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

Table 3. Both Transfemoral and Transtibial Gait Deviations

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.

Resources

YouTube Playlist with Amputee Gait Deviations