Prosthetic Alignment in the The Starting Point

Transtibial Amputee

David C. Morgenroth, MD,

Department of Rehabilitation Medicine
University of Washington
VAPSHCS

Outline COM Motion in the Coronal Plane

• Normal gait review

• Coronal plane alignment
• Sagittal plane alignment

1
Coronal Plane COM Motion Normal Medial Lateral Excursion of the COM

Moment (Torque) Joint Moments (Torques)

Moment of Force

• Force that tends to cause rotation of a rigid

body in space.

• Determined by the product of the magnitude

of the force and the distance from the
center of rotation.

M=Fxd

2
 Joint Moments External versus internal joint moments

F
F d
d

Single Rigid Segment Two Segments Linked

at a Joint

Prosthetic Coronal Plane

Alignment Variations

Normal

3
 The Laterally Displaced Foot Laterally Displaced Foot

- ?Mechanism to shift COM laterally

- Increased lateral trunk shift

- ?Effect on efficiency

med lat med lat

Valgus Outset

Effect on Socket Pressure Distribution Gait Characteristics of a

Laterally Placed Foot

Increased socket pressure • Increased width of base of support.

- proximal lateral
- distal medial • Medial thrust at the proximal socket brim
during prosthetic stance phase.
Reduced socket pressure • Increased lateral trunk motion to the
- proximal medial
(medial thrust) prosthetic side during prosthetic stance.
- distal lateral

4
 The Medially Displaced Foot Medially Displaced Foot

- Path of COM is lateral to foot

- Loss of balance to the prosthetic side

med lat med lat

Varus Inset

The Medially Displaced Foot Gait Characteristics of the

Medially Placed Foot
Increased socket pressure
- proximal medial • Narrowed base of support.
- distal lateral • Lateral thrust at the proximal socket brim
during prosthetic stance phase.
Decreased socket pressure • Possible loss of balance to the prosthetic
- proximal lateral side during prosthetic stance phase.
(lateral thrust)
- distal medial

5
 Sagittal Plane Kinetics and Kinematics
Leg-length discrepancy
-Static versus dynamic
-What do you see on gait analysis?
-What problems do LLD cause?

The Gait Cycle Heel Contact

Foot Contact Opposite Foot Off Opposite Foot Contact Foot Off Foot Contact

Loading Response 0-12%

Midstance 12-30%
Terminal Stance 30-50%
Pre-Swing 50-62%
Swing 62-100%

0% 12% 50% 62% 100%

Stance Swing
Weight Single Limb Support Propulsion Limb Advancement
Acceptance
R Step L
R Stride R

6
Foot Flat/Loading Response Mid Stance Phase

Terminal stance into pre-swing Knee Kinematics during Stance

0 deg

HC Stance Phase TO

7
 Prosthetic Sagittal Plane Saggital Plane Translations
Alignment Variations of the Prosthetic Socket

Normal Posterior Pylon Anterior Pylon

Saggital Plane Angulations The Effect of Heel Height

Excessive Socket Flexion/Extension

Normal Flexion Extension Heel too high Heel too low

8
 Saggital Plane Malalignments Increased Knee Flexion Moment /
Heel Lever Toe Lever Decreased Knee Extension Moment

Normal Flexion Posterior Pylon Where do you expect to see skin breakdown?

Increased Heel Lever / Decreased Toe Lever Knee Flexion Angle in Stance Phase
Increased heel lever / Reduced Toe Lever
Heel too high, Increased socket flexion, Anterior translation of socket

• Rapid excessive knee flexion at heel Normal

Abnormal
contact through early and mid stance.
• Drop off continued excessive knee
flexion in late stance
• Rapid swing phase of contralateral limb.

HC Stance Phase TO

9
 Sagittal Plane Malalignments Knee Flexion Moment / Knee Extension Moment
Heel Lever Toe Lever

Normal Anterior Pylon Extension

Reduced Heel Lever/ Increased Toe Lever Knee Flexion Angle in Stance Phase
Heel too low, Decreased socket flexion, Posterior socket translation Reduced Heel Lever / Increased Toe Lever

• Reduced knee flexion in early stance. Normal Abnormal

• Difficulty progressing COM over stance

phase foot.
• Shortened intact limb step length.

HC Stance Phase TO

10
 Summary (1)

The effect of prosthetic

foot characteristics
on sagittal plan alignment
• Observe from the side (Sagittal plane
alignment).
• Observe from behind (Coronal plane
alignment).
• The “knee tells all”, with a few clues
from the motion of the trunk and step
kinematics.

Summary (2)
Questions?

• Prosthetic alignment when optimized can

substantially improve gait characteristics.
• A knowledge of prosthetic alignment can help
us understand and treat residual limb pain
problems.
• Evidence supports the benefits of optimum
alignment on biomechanics of gait and
metabolic energy expenditure.

11