Chapter 14 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles

Analysis of Amputee Gait

Norman Berger, M.S.
*Much of the material in this chapter is taken from the manual Lower-Limb Prosthetics, 1990 Revision,
Prosthetics and Orthotics, New York University Post-Graduate Medical School. Permission to reprint is
gratefully acknowledged.
With equipment such as force plates, electrogoniome-ters, and electromyographs, a number of research
studies have presented objective, quantified analyses of amputee gait. Clinicians, however, tend to rely on
observational gait analysis to provide information about prosthetic fit, alignment, and function for the
individual patient. This simpler, more immediately available procedure requires only the eye, the brain, and
sufficient expertise to produce clinically useful insights and understanding. Although the future may see
sophisticated measurement equipment efficient and inexpensive enough to be used routinely in daily
treatment programs, observational gait analysis remains the procedure of choice for the present and is
therefore the focus of this chapter.
Basically, observational gait analysis involves the identification of gait deviations and determination of the
causes associated with each deviation. With this accomplished, the treatment team can then plan and
recommend corrective actions to improve the situation. This process works well so long as the clinic team
understands normal gait, biomechanics, and prosthetic fit and alignment. The component parts of the gait
analysis procedure are as follows:
1.

Observation.-It is essential to observe from at least two vantage points. Sagittal-plane motions are
best seen from the side, while frontal-plane motions are best seen from the front or rear.

2.

Identification of gait deviations.-The phrase "gait deviation" is defined as any gait characteristic
that differs from the normal pattern. While all our detailed knowledge of normal locomotion will be
useful, keep in mind that the single most outstanding characteristic of the normal pattern is
symmetry. Thus, for the unilateral amputee deviations are often identified by observing asymmetry,
that is, differences in the patterns of the prosthetic and normal sides.

3.

Determination of causes.-The obvious place to look is at the prosthesis, and it is certainly true that
there are many prosthetic causes for gait deviations. However, it is equally true that there are
many non-prosthetic causes. A particular patient may have restricted range of motion at one or
more joints, muscular weakness, concomitant medical conditions, excessive fear, or old habit
patterns, any of which may cause deviant gait. Analyze the prosthesis, but do not ignore the
patient.

ANALYSIS OF TRANSTIBIAL (BELOW-KNEE) AMPUTEE GAIT

A number of important deviations that may appear in the gait of transtibial amputees are discussed below.
To assist in observing these sometimes subtle characteristics and in understanding their causes, the phase
of the walking cycle in which each deviation occurs is identified.
I.

Between heel strike and midstance

A.

Excessive knee flexion

During normal gait the knee is approximately in complete extension at heel strike.
Immediately thereafter, the knee begins to flex and continues to do so until just after the
sole of the shoe is flat on the ground. At normal walking speeds (100 to 120 steps per
minute), the average range of knee flexion after heel strike is from 15 to 20 degrees. The
transtibial amputee may exceed this range of knee flexion on the amputated side for any
of the following reasons:

B.

1.

Excessive dorsiflexion of the foot or excessive anterior tilt of the socket

Normally, foot contact with the floor after heel strike is the result of ankle plantar
flexion and knee flexion. If the prosthetic foot is set in too much dorsiflexion or the
socket displays more than the usual 5 degrees of anterior tilt, additional knee
flexion is required to allow the foot to reach the floor after heel strike.

2.

Excessively stiff heel cushion or plantar-flexion bumper

If plantar flexion of the foot is restricted by an overly stiff heel cushion or plantarflexion bumper, the amputee's knee may have to flex through more than the
normal range to allow the sole of the foot to reach the floor. Also, an overly stiff
cushion or bumper will not absorb the impact of the heel striking the floor, thus
tending to produce abrupt and excessive knee flexion.

3.

Excessive anterior displacement of the socket over the foot

As illustrated in Fig 14-1., placing the socket forward relative to the prosthetic foot
increases the distance between the lines of action of the force transmitted
through the socket (A) and the reaction force from the floor (B).
The force couple tending to cause rotation of the prosthesis in a flexion direction
thus increases as the socket is moved farther anteriorly. The effect of this force
couple will be somewhat reduced if the heel cushion or bumper is soft enough to
absorb the impact of the heel striking the floor.

4.

Flexion contracture or posterior misplacement of the suspension tabs

The knee cuff used to suspend the prosthesis is attached to the socket posterior
to the axis of motion of the knee joint. This location causes the suspension tabs
to tighten as the knee joint extends and to loosen as the knee flexes. If the
attachment points are unduly posterior, the suspension tabs will tighten to such
an extent as to prevent the knee joint from reaching full extension. The
supracondylar/suprapatellar-suspended prosthesis relies on a carefully molded
convexity above the patella to ensure adequate suspension. If this anterior
convexity is excessive, the knee joint will be restricted in extension. These
situations are comparable to a flexion contracture in which tight posterior tissues
do not permit full knee extension.

Absent or insufficient knee flexion

The transtibial amputee may walk with absent or insufficient knee flexion on the
amputated side for one or more of the following reasons:
1.

Excessive plantar flexion of the foot

In normal walking, contact of the sole of the foot with the floor coincides
approximately with the end of knee flexion and the beginning of knee extension. If
the prosthetic foot is in an attitude of plantar flexion, foot flat will occur
prematurely and prevent normal knee flexion after heel strike.

2.

Excessively soft heel cushion or plantar-flexion bumper

In the case of a solid-ankle, cushion-heel (SACH) foot with an excessively soft
heel cushion, there will be a momentary delay between heel strike and the
initiation of knee flexion. The knee will begin to flex only after the heel cushion
has been fully compressed. With a single-axis ankle, an excessively soft heel
bumper will allow the prosthetic foot to plantar-flex too rapidly and thus slap the
floor. This abrupt contact of the foot with the floor will tend to decrease the range
of knee flexion.

3.

Posterior displacement of the socket over the foot

As illustrated in Fig 14-2., posterior displacement of the socket decreases the
distance between the lines of action of the force transmitted through the
socket (A) and the reaction force from the floor (B), thus decreasing the tendency
of the force couple to rotate the prosthesis in a flexion direction.
If the socket is placed so far posteriorly that the line of force transmission through
the socket falls posterior to the floor reaction, the prosthesis will tend to rotate

backward, that is, the knee will be forced toward hyperextension rather than
flexion.

II.

Anterodistal discomfort
Supporting body weight with the knee in a flexed attitude is possible only if the
knee extensors act with sufficient force to restrain the flexion moment. When the
quadriceps muscle contracts, pressure between the anterodistal surface of the
tibia and the socket is increased considerably. Consequently, stump discomfort
may occur at heel strike.
To avoid this pain the amputee may walk so that the forces acting on the knee
tend to extend rather than to flex that joint. This can be accomplished by (1)
shortening the prosthetic step, (2) digging the heel into the ground by means of
increased hip extensor activity, (3) adopting a forward lurch of the head and the
shoulder, or (4) some combination of these.

5.

Weakness of the quadriceps muscle

If the quadriceps is not strong enough to control the knee at heel strike, the
amputee may compensate in much the same way as he would if there were
anterodistal tibial discomfort. These gait maneuvers tend to force the knee into
extension and thereby lessen or eliminate the need for quadriceps activity.

6.

Habit
Amputees who have established a pattern of walking with the knee held in
extension after heel strike may continue to walk in the same manner when they
are making the transition to a patellar tendon-bearing prosthesis. A brief period of
instruction with adequate follow-up may establish a less deviant walking pattern.

At midstance
A.

III.

4.

Excessive lateral thrust of the prosthesis

Lateral thrust derives from the tendency of the prosthesis to rotate around the amputated
limb. When this occurs, the medial socket brim presses against the femoral condyle while
the lateral part of the brim tends to gap. A slight amount of this lateral thrust is fairly
common, but if it is excessive, the amputee may complain of uncomfortable pressure on
the medioproximal aspect of his knee, and damage to the skin and to the knee ligaments
may result. Excessive lateral thrust may be caused by such factors as the following:
1.

Excessive medial placement of the prosthetic foot

At midstance, the sound limb is swinging, so all of the body weight is supported
by the prosthetic foot on the floor. If this supporting foot is too far medial to the
line of action of forces transmitted through the socket, as illustrated in Fig 14-3.,
a force couple is created that tends to rotate the socket around the stump. In
almost all instances, this lateral thrust can be minimized or eliminated by "outsetting" the prosthetic foot slightly.

2.

Abducted socket
If a socket that has been set in excessive abduction (brim tilted medially,
simulating genu valgum) is placed on the vertically positioned residual limb, the
distal end of the prosthesis shifts medially, and the patient's weight tends to be
borne on the lateral border of the foot. This, in turn, increases the lateral thrust of
the socket brim.

Between midstance and toe-off

A.

Early knee flexion (drop-off) Just prior to heel-off during normal gait, the knee is
extending. At heel-off or immediately thereafter, knee motion reverses, and flexion begins.
This knee flexion coincides with the passing of the center of gravity over the
metatarsophalangeal joints. If the body weight is carried over these joints too soon, the
resulting lack of anterior support would allow premature knee flexion or drop-off. Possible
causes for this lack of anterior support are as follows:

B.

1.

Excessive anterior displacement of the socket over the foot

The farther forward the socket is placed, the closer is the line of action of forces
transmitted through the socket to the end of the keel in a SACH foot or to the toebreak in a wood foot. The distance that the center of gravity must move forward
to pass over these prosthetic equivalents of the metatarsophalangeal joints is
thus minimized and allows knee flexion to occur too early.

2.

Posterior displacement of the toe-break or the keel

3.

Excessive dorsiflexion of the foot or excessive anterior tilt of the socket

4.

Soft dorsiflexion bumper

These conditions also minimize the distance that the body weight must move
forward before anterior support is lost. The shorter this distance, the earlier and
more abrupt will be the knee flexion.

Delayed knee flexion

The reverse of the situation described above occurs if the body weight must be carried
forward an unusually long distance before anterior support is lost. Under such
circumstances, the knee joint would remain in extension during the latter part of the
stance phase, and the amputee might complain of a "walking-uphill" sensation since his
center of gravity would be carried up and over the extended knee. This excessive anterior
support can be brought about by the following:
1.

Excessive posterior displacement of the socket over the foot

2.

Anterior displacement of the toe-break or the keel

3.

Excessive plantar flexion of the foot or excessive posterior tilt of the socket

4.

Hard dorsiflexion bumper

Some of the gait deviations discussed below in relation to the transfemoral amputee may also be noted in
the transtibial patient. However, the incidence is small, and no separate discussion is warranted.

ANALYSIS OF TRANSFEMORAL (ABOVE-KNEE) AMPUTEE GAIT

Eleven common transfemoral deviations and their usual causes are presented. The sequence of
presentation is based on the preferred vantage point for observation, with the first 6 deviations best viewed
from the rear or the front and the remaining 5 best seen from the side.

LATERAL TRUNK BENDING

Description: The amputee leans toward the amputated side when the prosthesis is in stance phase (Fig 144.).
When to observe: From just after heel strike to mid-stance.
How to observe: From behind the patient.
Causes:
1.

Weak hip abductors. By shifting the center of gravity toward the prosthesis, lateral bending
counteracts the tendency toward pelvic drop on the sound side.

2.

Abducted socket. This alignment fault reduces the effectiveness of the hip abductors in stabilizing
the pelvis. The resulting tendency of the pelvis to drop on the sound side is counteracted by lateral
trunk bending.

3.

Insufficient support by the lateral socket wall. If the lateral wall does not block lateral movement of
the femur, the pelvis will tend to drop on the sound side when the prosthesis is in stance phase. To
check this tendency, the amputee leans toward the prosthesis.

4.

Pain or discomfort, particularly on the lateral distal aspect of the femur. By bending to the
prosthetic side, the amputee relieves pressure on the lateral aspect.

5.

Lateral trunk bending. This is usually present when an amputee walks with an abducted gait. Most
of the causes of abducted gait can be responsible for lateral bending.

6.

Short prosthesis.

WIDE WALKING BASE (ABDUCTED GAIT)

Description: Throughout the gait cycle, the width of the walking base is significantly greater than the normal
range of 5 to 10 cm (2 to 4 in.). There is exaggerated displacement of the pelvis and trunk (Fig 14-5.).
When to observe: During the period of double support.
How to observe: From behind the patient.
Causes:
1.

Pain or discomfort in the crotch area. The discomfort may be due to such factors as skin infection,
adductor roll, or pressure from the medial socket brim. The amputee tries to gain relief by
abducting his prosthesis, thus moving the medial part of the brim away from the painful area.

2.

Contracted hip abductors.

3.

Prosthesis too long. Excessive length makes it difficult to place the limb directly under the hip
during stance and to clear the floor during swing. Widening the base helps to solve these
problems.

4.

Shank aligned in the valgus position with respect to the thigh section.

5.

Mechanical hip joint set so that the socket is abducted.

6.

Feeling of insecurity. The amputee compensates by widening his walking base.

CIRCUMDUCTION
Description: The prosthesis follows a laterally curved line as it swings (Fig 14-6.).
When to observe: Throughout swing phase.
How to observe: From behind the patient.
Causes: The basic cause of this deviation is a prosthesis that is too long, thus forcing the amputee to swing
it to the side to clear the ground. The following are among the factors tending to produce excessive length:
1.

Insufficient flexion of the knee because of insecurity or fear.

2.

Manual knee lock, excessive friction, or a tight extension aid preventing the knee from flexing.

3.

Inadequate suspension allowing the prosthesis to drop (piston action).

4.

Too small a socket. The ischial tuberosity is above its proper location.

5.

Foot set in excessive plantar flexion.

VAULTING
Description: The amputee raises his entire body by early and excessive plantar flexion of the sound foot
(Fig 14-7.).
When to observe: During swing phase of the prosthesis.
How to observe: From behind or from the side of patient.
Causes:
1.

Insufficient friction in the prosthetic knee. In the normal pattern, maximum elevation of the body
occurs when the supporting limb is in the middle of stance phase and the other limb swings
alongside it. When there is insufficient friction, heel rise is excessive, and the shank takes a longer
time to swing forward. Because of this time lag, the body is no longer at maximum elevation as the
prosthetic foot is at its lowest point in swinging through, and the prosthetic foot would fail to clear
the ground unless the amputee gained additional time and clearance by vaulting.

2.

Excessive length of the prosthesis. The amputee vaults to gain additional clearance so that the
prosthetic foot will clear the ground as it swings through. The following are among the factors that
may produce excessive length:
A. Insufficient flexion of the knee because of insecurity or fear.
B. Manual knee lock, excessive friction, or too tight an extension aid.
C. Inadequate suspension allowing the prosthesis to slip off the stump (piston action).
D. Too small a socket. The ischial tuberosity is above its proper location.
E. Foot set in excessive plantar flexion.

SWING-PHASE WHIPS
Description: Medial whip-At toe-off the heel moves medially (Fig 14-8.). Lateral whip-At toe-off the heel
moves laterally (Fig 14-8.).
When to observe: At and just after toe-off.
How to observe: From behind the patient.
Causes:
1.

Improper alignment of the knee bolt in the transverse plane.

2.

With a suction socket and no auxiliary suspension, whips may be seen because of the following:
A. Weak and flabby musculature that rotates freely around the femur.

B. A socket that is too tight or improperly contoured to accommodate muscles. Pressure from
contracting muscle bellies causes the prosthesis to rotate around its long axis.

FOOT ROTATION AT HEEL STRIKE

Description: As the heel contacts the ground, the foot rotates laterally, sometimes with a vibratory motion
(Fig 14-9.).
When to observe: At heel strike. How to observe: From in front of the patient.
Cause: Too hard a heel cushion or plantar-flexion bumper.

FOOT SLAP
Description: The foot plantar-flexes too rapidly and strikes the floor with a slap (Fig 14-10.).
When to observe: Just after heel strike.
How to observe: From the side. Listen for slap.
Cause: The plantar-flexion bumper is too soft and does not offer enough resistance to foot motion as
weight is transferred to the prosthesis.

UNEVEN HEEL RISE

Description: Usually the prosthetic heel rises higher than the sound heel. However, the reverse may also be
seen, that is, the prosthetic heel rises less than the sound heel (Fig 14-11.).
When to observe: During first part of swing phase.
How to observe: From the side.
Causes: Excessive heel rise results when the following are present:
1.

Insufficient friction at the prosthetic knee.

2.

Insufficient tension or absence of an extension aid.

3.

Forceful hip flexion to ensure that the prosthetic knee will be extended fully at heel strike.
Insufficient heel rise results when the following are present:
1.

Excessive friction at the prosthetic knee.

2.

Too tight an extension aid.

3.

Fear and insecurity. The amputee walks with little or no knee flexion.

4.

Manual knee lock.

TERMINAL IMPACT
Description: The prosthetic shank comes to a sudden stop with a visible and possibly audible impact as the
knee reaches full extension (Fig 14-12.).
When to observe: At the end of swing phase.

How to observe: From the side. Listen for the impact.

Causes:
1.

Insufficient friction at the prosthetic knee.

2.

Too tight an extension aid.

3.

The amputee's fear of buckling causing him to extend the hip abruptly as the knee approaches full
extension. This maneuver snaps the shank forward into full extension.

4.

Absent or worn resilient extension bumper in the knee unit.

UNEVEN STEP LENGTH

Description: The length of the step [*The term step refers to the distance between successive positions of
the sound foot and prosthetic foot. The total length of the stride taken with each foot will be the same
("stride" signifies the distance between successive positions of the same foot.) taken with the prosthesis
differs from the length of the step taken with the sound leg.
When to observe: During successive periods of double support.
How to observe: From the side.
Causes:
1.

Pain or insecurity causing the amputee to transfer his weight quickly from the prosthesis to his
sound leg. To do this he takes a short, rapid step with his sound foot.

2.

Hip flexion contracture or insufficient socket flexion. Any restriction of the hip extension range must
be reflected by a shorter step length on the sound side.

3.

Insufficient friction at the prosthetic knee or too loose an extension aid. The pendular swing of the
shank produces a prosthetic step length that is longer than the step length on the sound side.

EXAGGERATED LORDOSIS
Description: The lumbar lordosis is exaggerated when the prosthesis is in stance phase, and the trunk may
lean posteriorly (Fig 14-13.).
When to observe: Throughout stance phase.
How to observe: From the side.
Causes:
1.

Hip flexion contracture. The pelvis tends to tilt downward and forward because the center of gravity
is anterior to the support point (a theoretical point around which the supporting forces are
balanced). A flexion contracture aggravates the tendency of the pelvis to tilt anteriorly because the
shortened hip flexor muscles exert a downward and forward pull on the pelvis when the femur is at
the limit of its extension range.

2.

Insufficient socket flexion.

3.

Insufficient support from the anterior socket brim.

4.

Weak hip extensors. The extensors help to restrain the tendency of the pelvis to tilt forward. When
this restraining force is lost, the resulting forward pelvic tilt and compensatory backward trunk
bending cause increased lordosis. In addition, the amputee may roll his pelvis forward to assist the
weak extensors to control knee stability.

5.

Weak abdominal muscles. The abdominal muscles restrain the tendency of the pelvis to tilt
forward. If the abdominal muscles are weak, some of this restraint is lost, and the amputee will
show increased lordosis.

Chapter 14 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles