Downloaded from https://academic.oup.
com/ptj/article-abstract/45/10/940/4615622 by guest on 10 January 2019
GAIT ANALYSIS
for Lower-Extremity Child Amputees
H. LORRAINE OGG, M.A.
o NE OF THE most important fact­
ors in evaluating the function of children wearing
lower extremity prosthetic devices is an objective
and critical analysis of the patterns and deviations
of their gaits. The information derived from such
an evaluation may serve as the basis of recom­
mendations for more training, repair or revision of
the prosthesis, or the need for a new device.
METHOD
There are three aspects to be considered in this
evaluation procedure. The first two provide back­
ground information for the third.
The Patient
First, the patient must be considered without his
prosthesis. The strength of the musculature in­
volving the stump should be determined. Informa­
tion concerning the bony structure of the joints
related to prosthesis control is also very important.
The presence of contractures will affect not only
the gait pattern but also design criteria for the
prothesis. An assessment of the child's general
physical condition will provide an index to his
endurance during periods of training, and his
ability to build his tolerance to wear. His level
of motor development will also indicate the profi­
ciency and developmental level of his gait pattern.
Such data are commonly found on muscle-testing
records, range-of-motion charts, the historical re-
Child Amputee Prosthetics Center, University of Cali­
fornia, Los Angeles.
940
port on the child, and on his roentgenograms and
their summaries.
The Prosthesis
In the second evaluation procedure, the pros­
thesis must be considered without the patient. It
is imperative that the mechanical parts of the
prosthesis function adequately, and that the com­
ponents are in proper alignment. The set angles
of the socket in the prosthesis will be determined
by the presence of any contractures involving
joints proximal to the stump. Standards of vertical
alignment of prosthetic parts to the body must be
met for each type of prosthesis. The socket fit is
critical.
It is good practice to maintain a history or
record of the prosthesis, beginning at the time of
check-out following fabrication, and augmented
at each check for fit and function during the serv­
ice life of the prosthesis.
Listed below are the essential criteria of pros­
thesis fit which should be considered: 1
I. Alignment of the prosthesis to the amputee:
A. Standing position:
1. Lateral vertical alignment—(greater
trochanter, knee center, and ankle center)
—or stability of the knee joint.
2. Posterior vertical alignment—ischial
tuberosity to heel center.
3. Alignment of the foot in horizontal
plane—"toe-out."
4. Level of the pelvis—leg length.
5. Alignment of the spinal column—
scoliosis; lordosis.
GAIT ANALYSIS

6. Angle of the alignment of the foot to
the shin—15-degree limit.
7. Comfort of the stump in the socket—
pressure; motion.
8. Proper position of bony prominences
in the socket—ischial tuberosity, tibial pla­
teau, condyles, patella.
9. Level of knee axis relative to the op­
posite side.
10. Proper placement of prosthetic sus­
pension.
B. Sitting position:
1. Length of the prosthetic shin relative
to the opposite side.
2. Allowance of 120-degree knee flexion
for the kneeling position.
3. Length of the prosthetic thigh relative
to the opposite side.
4. Comfort of the patient in upright sit­
ting and forward lean.
5. Stump security in the socket.
II. Static alignment of the prosthesis:
A. There should be a proper relationship be­
tween the angle of flexion of the prosthetic socket
and the angle of extension of the patient's stump.
B. The angle of adduction of the prosthetic
socket and the patient's stump should also have
a proper relationship.
C. When socket fit is questionable, a tension
analysis should be made from corresponding cir­
cumferential measurements of the patient's stump
and the socket of the prosthesis.
JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION
D. The following should be considered:
1. Level of the top of the ischial wall.
2. Contour of the socket brim.
3. Vertical alignment of the shin to the foot.
4. Position of rotation of the knee bolt.
5. Durometer of the heel cushion for the SACH
foot.
6. Appropriate sizing of the prosthetic foot in
the shoe.
All items on this list may not be applicable to
all prostheses.
Downloaded from https://academic.oup.com/ptj/article-abstract/45/10/940/4615622 by guest on 10 January 2019
Compatibility of Patient and Prosthesis
The observation of the compatibility of the
prosthesis and the patient is the final and most
important aspect of an analysis of gait patterns.
The information gathered as a result of observation
of the child without his prosthesis, plus a critical
analysis of the status of the prosthesis itself, form
the basis for judgment concerning the function of
the two together. Gait defects are numerous and
occur in complex combinations: they include the
swing of the arms, movement of the trunk, and
actions of both the sound limb and the prosthesis
during the swing and stance phases. These can
best be preserved on movie film, augmented by a
written record.
COMMON GAIT DEVIATIONS
Most of the terms used in describing gait devia­
tions are self-explanatory. Table 1 illustrates a
convenient way of recording these deviations.
However, some are less clear and are defined in
Table 2.
It is necessary to be able to identify major gait
defects visually and rather quickly. This in­
volves observing the patient with an amputation
from three points of view: laterally, anteriorly,
and posteriorly. Observation also involves know­
ing at what point during swing or stance phase
deviations will be most apparent.
Stance Phase
Those that commonly occur during stance phase
are piston action, hyperextension of the knee, and
uneven timing—all of which can be seen from
the lateral aspect. Those to be observed from an
anterior or posterior point of view are lateral
trunk bending, lateral pelvic tilt, broad walking
base, medial-lateral motion of the stump in the
socket, and bearing weight on the medial or lateral
border of the prosthetic foot.
Swing Phase
During the swing phase, and from the lateral
view, one may see terminal impact, excessive heel
rise, unequal step length, or unequal timing of
steps. An anterior-posterior view of the patient
may reveal an abducted gait during swing phase.
941
 TABLE 1

GAIT DEVIATIONS

NAME: _ CAPP NO. PROSTHESIS NO.

Stance Phasa Swing Phase

Date: Date:
1

Lateral View Age: Lateral View Age:

Lordosis Slow shin swing

Drop-off Terminal impact

Piston action Unequal step length

Excessive heel rise

Downloaded from https://academic.oup.com/ptj/article-abstract/45/10/940/4615622 by guest on 10 January 2019

Double knee action 1
Hyperextended knee Insufficient toe clearance 1
Excessive knee flexon Uneven timing !
Vaulting A-P socket motion I
Foot siap 1
Uneven timing I
l

Anterior-Posterior View Anterior-Posterior View

Lateral trunk Dending Abducted gait | j )

Lateral pelvic t i l t Circumduction

Medial-lateral socket Internal rotation of

motion prosthesis

Unstaole knee Whip-lateral

Broad base Whip-medial

Rotation of foot at
heel strike
Weight on medial
border of foot

Ham
Noise
"Hill-rise" sensation

Comment

The patient may complain of pain; or one may
hear noise, which indicates improper function of
the mechanical parts.
Causes of Gait Defects
The major causes of deviations in walking pat­
terns are changes resulting from growth, or the
wear of parts from use. Any of the gait devia­
tions can occur as a result of faulty alignment
of the limb during fabrication; however, some de­
viations of gait must be accepted as maximum
performance because of a physical problem of the
patient. These are most commonly related to
the presence of contractures or the malformation
of joint structures which cause hypermob ; lity or
instability.
Hip D isar+iculafion Prostheses
The Canadian hip disarticulation prosthesis is
perhaps the most difficult to fabricate and align
of all the lower-extremity devices. The infant
or toddler does not yet have well-defined bony
structures for anchor points for the socket, and the
residual '"baby fat" of small children compounds
the problem. Adjustable hip joints for children un­
der the age of eight or nine years are not commer­
cially available, and knee joints are not available
for those under two to three years of age. An adjust­
able mechanism for aligning the hip joint is also
not available. These problems make proper align­
ment much more difficult, and are a common
source of gait defects. It is very important for
the physical therapist to recognize alignment prob-

942 GAIT ANALYSIS

 lems, in order to avoid imposing unrealistic train­
ing goals upon the child or to ask him to expend
excessive energy in the attempt to correct a gait
defect caused by malalignment. For example, in
Figure 1, the horizontal placement of the hip joint
and the knee joints are at an angle to the floor
line, although they should be parallel to the floor
line. In addition, the foot is outset too far from
the hip and knee centers in relation to the vertical
line in the illustration.
When this youngster walks (Fig. I), he vaults
excessively, circumducts his prosthesis, bends his

Downloaded from https://academic.oup.com/ptj/article-abstract/45/10/940/4615622 by guest on 10 January 2019

trunk laterally over the prosthesis during stance
phase, and exaggerates his uneven arm swing. He
is not able to utilize the basic control motion of
pelvic tilt to initiate the swing phase of the pros­
thesis. These defects are all directly related to

TABLE 2

COMMON GAIT DEVIATIONS

Deviation Description

1. Lordosis Accentuation of the lordosis during

mid-stance on the amputated side.

2. Drop-off Excessive dipping of the pelvis on the

prosthetic side, occurring during the
last half of stance phase.

3. Piston action Vertical movement of the stump

within the socket during stance and
swing phase.
FIG. 1. This shows improper alignment of hip and knee
4. Double knee action Rapid flexion, extension flexion se­
joints.
quence of knee action on the pros­
thetic side at mid-stance phase.

5. Vaulting Rising rapidly on the ball of the foot

during stance phase on the sound
side.
6. Terminal impact A jarring impact of the prosthetic
shin as i t terminates the swing phase.
7. Excessive heel rise Rise of the prosthetic heel during
swing phase in excess of the sound
side or to the extent that i t retards
the swing phase.
8. A-P socket motion Movement of the socket in an
terior-posterior direction.
9. Abducted gait Maintenance of the prosthesis in an
abducted position during swing and
stance phase.
10. Circumduction Circumduction of the prosthesis dur­
ing swing phase with return to a nar­
row base during stance phase.
11. Lateral whip Heel swing in a lateral direction,
noted at toe-off at the beginning of
swing phase.
12. Medial whip Heel swing in a medial direction,
noted at toe-off at the beginning of
swing phase.
13. "Hill-rise" sensation The amputee has the sensation of as­
cending an incline during stance
phase on the prosthesis.
the improper alignment of the hip and knee joints,
and would disappear with optimum adjustment of
the prosthesis. It is not feasible to correct these
defects through training.
A new prosthesis of any type may pass check­
out with excellent alignment and function on the
patient. One to three months later the patient
may return with the same prosthesis and exhibit
an­ a number of gait deviations which are primarily
the result of normal physical changes in the child.
Above-Knee Prostheses
Prosthetic parts for children wearing above-knee
prostheses are becoming more readily available,
and adjustable legs for the alignment of these limbs
also exist. If the prosthetist is expert, and familiar
with the unique problems involved in fitting chil­
dren, initial malalignment should not occur.
Changes in gait pattern are more apt to be a re­
sult of rapid spurts of growth, wear of parts from
vigorous activity during play, and the constant
threat of increasing contractures if these have been
present prior to fitting.
The boy in Figure 2 shows evidence of shortness
of his prosthesis. This was observed one month

JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION 943


FIG. 2. Evidence of shortness of prosthesis is illustrated.
following the satisfactory check-out of the pros­
thesis. Two months later, movies of his gait were
taken. At that time, he was noted to have increased
lateral trunk bending and lateral pelvic tilt be­
cause of the shortness of his limb. Hyperextension
of the knee was present during the mid-stance
phase because he had begun to wear tennis shoes
without a hard heel wedge to compensate for the
change in heel height. He had terminal impact
of the shin sufficient in intensity to jar the extrem­
ity at the end of the swing phase. This was because
of the loss of the friction which was originally
set in the constant-friction knee unit. Because of
these deviations, this boy had an exaggeration of
his normally present uneven arm swing.
Below-Knee Prostheses
Optimum performance of a below-knee am­
putee, when wearing a patellar tendon-bearing
prosthesis which is adequately aligned, is very
close to the normal gait pattern of an individual
with two normal extremities.
If there is localized weakness from prolonged
disuse, pain or tenderness of the stump, and gen­
eral lack of good general physical condition, one
944
Downloaded from https://academic.oup.com/ptj/article-abstract/45/10/940/4615622 by guest on 10 January 2019
FIG. 3. Gait defects appeared concurrently with early
walking.
can expect certain gait defects to appear concur­
rent with early independent walking.
The boy in Figure 3 was plagued with all of
these problems. When he began to walk inde­
pendently, he exhibited uneven timing of steps and
uneven step length, because of tenderness and pain
in the stump during full weight bearing. The
weakness of his entire right lower extremity, par­
ticularly in the quadriceps muscles, contributed to
the instability of the knee joint and to lordosis
during the mid-stance phase. There was an ob­
vious exaggeration and unevenness of arm swing
which was caused by all of the above deviations.
Pylons
The use of pylon extension prostheses is com­
mon practice for replacement of leg-length dis­
crepancy in lower-extremity phocomelia.
The amount of instability of the hip joint is
primarily dependent upon the degree of loss in
the structure of the femur. Also, the strength of
the hip flexor muscles varies with the malformation
of the femur.
A child with a special phocomelia prosthesis
will have a pylon gait. He can be expected to
GAIT ANALYSIS
 of gait taken from lateral, anterior, and posterior
points of view, together with specific records of
observation, yield valuable information as the basis
for recommendations for treatment, prescription
for a new limb, or major repairs.

REFERENCES

1. Setoguchi, Yoshio, Assistant to the Medical Director,

Child Amputee Research Project, UCLA. Personal
C ommunication.

SELECTED BIBLIOGRAPHY

Downloaded from https://academic.oup.com/ptj/article-abstract/45/10/940/4615622 by guest on 10 January 2019

1. Anderson, Miles H., Clinical Prosthetics for Physicians
and Therapists. Springfield, Illinois, Charles C Thomas,
1959.
2. Anderson, Miles H„ John J. Bray, and Charles A. Hen-
nessy, Prosthetic Principles: Above Knee Amputations.
Springfield, Illinois, Charles C Thomas, 1960.
3. Blakeslee, Berton, ed., The Limb-Deficient Child. Berke­
ley and Los Angeles, University of California Press, 1963.
4. Brunnstrom, Signe, and Donald Kerr, Training of the
Lower Extremity Amputee. Springfield, Illinois, Charles
C Thomas, 1956.
5. Hampton, Fred, A hemipelvectomy prosthesis. Artif.
Limbs, 8:3-27, Spring 1964.
6. McGraw, Myrtle B., The Neuromuscular Maturation of
the Human Infant. New York and London, Hafner
Publishing Co., 1963.
7. Radcliffe, C. W., and J. Foort, The Patellar Tendon-Bear­
ing Below-Knee Prosthesis. Berkeley, Department of
Engineering, University of California, Biomechanics Lab­
oratory, 1961.
8. Radcliffe, Charles W., The biomechanics of the Canadian
hip disarticulation prosthesis. Artif. Limbs, 4:29-38,
Autumn 1957.
9. Saunders, M. B., Verne T. Inman, and Howard D. Eber-
hardt, The major determinants of normal and patho­
logical gait. J. Bone Joint Surg. (Amer.), 35:543-558,
1953.
FIG. 4. Although standing on a broad base, the child walks
on a narrow base.

have some lateral trunk bending and piston action

of the hip joint, and he may vault somewhat in
| STYLE MANUAL
order to shorten the prosthetic side for swing-
through of the limb in a straight line.
Although the boy in Figure 4 is standing on a
broad base, he walks with the narrow base com­
mensurate with his age of five years. He has none
of the common gait deviations seen in these chil­
dren—such as excessive lateral trunk bending, in­
ternal rotation of the socket during swing phase,
or gapping of the lateral socket wall during the
stance phase.
SUMMARY
of the |
American Physical Therapy Association
Compiled by the Editorial Board and staff,
the Manual presents the preferred word
usage and style for preparing manuscripts
and articles for the JOURNAL.
Among the topics covered in the section on
style are capitalization, abbreviation,
punctuation, use of numerals.

In summary, there are several important factors
which must be considered in an adequate gait eval­
uation: range of motion, muscular strength, bony
structure, and the developmental level of the pa­
tient's gait pattern must be known. The general
condition of the prosthesis, its static alignment,
and the alignment of the limb relative to the pa­
tient are pertinent to gait patterns. The pros­
thesis and its function on the patient are the final
aspects in consideration of the problem. Movies
Specific helps in preparing original manu­
scripts, case reports, suggestions from the
field, clinic notes, and Annual Reports,
and other contributions are included.
Reserve your copy now!
American Physical Therapy Association
1790 Broadway, New York, New York 10019 |

JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION 945