Alignment Problem: Replies
Description
Collection
Title:
Alignment Problem: Replies
Date:
8/15/1999
Text:
To: OANDP-L subscribers and professionals;
Last week I reposted a question from Ms. Stacey Asby about the
difficulty she is facing with her prosthesis. The question was also
posted to AMP-L and so far we have received a total of 27 replies. The
following ten are reposted in according with OANDP-L protocol. Others
will follow in a separate post once they have been edited for brevity,
clarity, spelling, and to remove numerous HTML attachments.
Wayne Renardson
AMP-L < <Email Address Redacted> >
-----------------------------------------------------------------------
Original :
From: Stacey Asby < <Email Address Redacted> >
Subject: BK Amputee Needs Advise
Sender: <Email Address Redacted>
< <Email Address Redacted> > Wayne Renardson
To: Amputee Information Network < <Email Address Redacted> >
As many of you know, I have been battling to get my new leg aligned for
almost a year. Unfortunately, the difference between the last two legs,
both of which took a similar amount of time to nail, by different
prosthetists, is that we are making no headway and we (me and the two
prosthetists who have worked on it) are equally frustrated and confused
about where to go from here.
I understand the difficulty trying to make suggestions without the
person in front of you, but in this case any SUGGESTIONS would be
welcome, whether on the list or privately, so I can answer questions
that may help you understand the situation. Here is the best description
I can offer.
I am R-BK. RL is 6 inches in length. At 5'4 + and about 110 lbs., I use
a total contact socket with a semi-supracondular support to minimize
movement.
The socket is snug to within 1-ply of sock and I am using an Alpha liner
(6mm) with pin, and finally, a silipos sleeve to minimize movement. The
movement I feel in the socket and in all planes of alignment is
immeasurable, with the closest increment less than 1/10 mm.
These increments off aren't tolerable because of a gap in the hips
(arthritis) plus some back problems in the L4-L5 region. (We are talking
Percosets after an hour or two of misaligned walking because the back
goes out!): Been there--done that, and AM NOT doing it again if at all
possible! :o)
The foot we are trying to get working is the Vari-flex for flexibility,
low maintenance, and cosmesis. According to my CP, the socket is aligned
about 1-1/2 inches anterior (forward) more than normal, and is also
about an inch inset more than normal.
This situation, apparently and seemingly contrary to the laws of physics
and prosthetics, has me feeling I am sitting sloped back on my heel and
that I have to fight somewhat to push UP TO the ball of the foot, at
which point I receive the response of the foot that I should, and then
fall over the toe. The foot is comprised of a cat. 4 with the thinnest
wedge in the heel and cat. 2 in the toe. We started at cat. 1 all the
way around, according to FF specs, and progressed to this because of my
very hard heel strike.
We also tried increasing the wedges in the heel, but lost all
responsiveness in the foot.
Now, trying to visualize this, so far, according to almost every CP who
has worked on this little problem to date (all very competent and
respected in their field), I respond the opposite to most normal
adjustments, for some reason. I can feel the slightest changes.
We have tried other feet during this process including: the College Park
(no response, heel too soft), Genesis 2 (same inflexibility to inclines
that my current set up has, which is a Seattle Lite foot with Endolite
ankle), the Chiles Campbell, and the Safe foot (very similar to the
college park).
All these feet resulted in me falling forward to the outside, or tilted
back, as I do on the Vari-flex, when attempting to align them. Oh yes,
and not that I think it has much relevancy to this issue, but the lack
of a good, working prosthesis for a year is putting additional stress on
my sound foot, which is in the beginning stages of the Charcot joint
disease (diabetes complication) which took the right foot, and the now
too-large socket of my current leg has caused an open area on the RL,
but I do have a lifetime of diabetes to contend with, which also causes
a bit of fluid retention in the limb.
So how many of you brave souls would like to have a crack at this
problem? In the words of Popeye, I've about had alls I can take!!
Oh yes: I am poor and have two small children, so the possible
suggestions can not include a requirement of large sums of money or
travel. :o)
So this means ask your amputee friends, colleagues, technicians,
prosthetists, and pets if you think of a possible solution or if you've
resolved a similar problem yourself, please!! :o)
Sincerely,
Stacey Asby
-----------------------------------------------------------------------
Having read your letter posted to the O&P listserv I found the following
sentence raised the greatest question in my mind as to proper
alignment:
SA> According to my CP, the socket is aligned about 1-1/2 inches
anterior (forward) more than normal, and is also about an inch inset
more than normal.
While flexion-extension and adduction-abduction angles can vary
significantly to achieve proper alignment, it has been my experience
that placement of the foot with respect to the weight line (especially
with a flex-foot) should remain near zero (to only very slightly inset)
in the frontal plane and near Flex Foots' recommendation (to only
slightly forward) in the sagittal plane. Sometimes this can be a
technical challenge when using the pin system. This is especially true
if the pyramid connector is an integral part of the shuttle lock or
connected directly distal to the pin.
It is also particularly true if there is an unusual amount of flexion,
adduction or abduction in the socket. We sometimes incorporate a pyramid
connector independent of the shuttle lock in order to achieve a more
conventional placement of the foot relative to the weight line.
Also, many times cosmesis must be sacrificed significantly, and some
weight may be added in doing this.
As you acknowledge, it is difficult to analyze problems with a
prosthesis from a verbal explanation. Every amputee has their own
physiological considerations which often vary from the norm. But the
degree of deviation expressed in this sentence seems radical, and I
wonder why this should be. It is certainly possible that there is a good
reason for it.
I hope you are successful in your attempts to get a satisfactory
alignment with your prosthesis. I will be glad to discuss this with your
prosthetist if he desires.
Eddie V. White, CP
-----------------------------------------------------------------------
From: IN% <Email Address Redacted> Stacey Asby
To: IN% <Email Address Redacted> Wayne Renardson
CC:
Subj: Fw: Alignment of Prosthesis
From: Stacey Asby < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Date: Sunday, August 08, 1999 12:21 AM
Subject: Re: Alignment of Prosthesis
Dear Eddie;
First, let me thank you for the response, and now I will attempt to fill
in the blanks with your comments and questions.
> Having read your letter posted to the O&P listserv I found the
following sentence to raise the greatest question in my mind as to
proper alignment:
> According to my CP, the socket is aligned about 1-1/2 inches anterior
(forward) more than normal, and is also about an inch inset more than
normal.
> While flexion-extension and adduction-abduction angles can vary
significantly to achieve proper alignment, it has been my experience
that placement of the foot with respect to the weight line (especially
with a flex-foot) should remain near zero (to only very slightly
inset) in the frontal plane and near Flex Foots' recommendation (to
only slightly forward) in the sagittal plane.
SA> We all agree this is what SHOULD be the case, but placing the
alignment as you mention, I am falling so far back on my heel that
it isn't even possible to stand erect or I am falling to the outside
(left) of the right front side of the foot when walking.
> Sometimes this can be a technical challenge when using the pin system.
SA> We have had the exact same problems using a pelite liner and
supracondular set up, as well as a transtibial (clip in)
supracondular by themselves, and in using the Alpha liner without
pin in conjunction with the supracodular and a sleeve. All of these
other suspensions did not eliminate the movement within the socket,
or restricted the movement of my knee too much to be functional.
> This is especially true if the pyramid connector is an integral part
of the shuttle lock or connected directly distal to the pin.
We have changed pyramid systems numerous times as well as remounting
them because we have maxed out the adjustment possible in one direction
or another. We currently have a slide and glide on the pylon at the
moment.
> It is also particularly true if there is an unusual amount of flexion,
adduction or abduction in the socket. We sometimes incorporate a
pyramid connector independent of the shuttle lock in order to achieve
a more conventional placement of the foot relative to the weight line.
SA> I believe this is separate, but am not positive, to be honest. I
will have to verify this with my C.P. when I show him the
suggestions here.
> Also, many times cosmesis must be sacrificed significantly, and some
weight may be added in doing this.
SA> Cosmesis was attained with previous legs, though it was close to
looking abnormal because of the inset of the foot. I have attached a
photo recently taken at the ACA convention for your benefit.
> As you acknowledged, it is difficult to analyze problems with a
prosthesis from a verbal explanation. Every amputee has their own
physiological considerations and we often vary from the norm, but the
degree of deviation expressed in this sentence seems radical, and I
wonder why this should be.
SA> Yes, well you'll have to form a line I'm afraid. My own CPs have
stated that they would fail prosthetic school as it is at the moment
and has been even close to tolerable to walk in. The last leg was
also set contrary to manufacturer and prosthetic guidelines, with
the endolite ankle being set backwards so the foot was very, very
soft and the heel very stiff.
>It is certainly possible that there is a good reason for it.
SA> I'd personally like to figure it out myself. :o)
> I hope you are successful in your attempts to get a satisfactory
alignment with your prosthesis. I will be glad to discuss this with
your prosthetist if he desires.
SA> Thank you. I will pass this note when I see him next Friday and he
will be free to contact you as he sees fit. I will post the
resolution of this dilemma on the list when it occurs.
-----------------------------------------------------------------------
Subject: Alignment problem
In response to your post to OANDP-L by Wayne Renardson, please answer
these questions so I may think further about your problem:
1) What shoe are you wearing? What is the heel height? Have your tried
different shoes? When you place the prosthesis in the shoe and look
at it from the side is the pylon of the FF perpendicular to the
ground?
2) Are your knees OK? Muscles?
3) What if any Physical Therapy have you had? How long is your average
stride? Can you run?
4) Are you sure that the length of the prosthesis is correct?
John Rheinstein, C.P.
----------------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: John Rheinstien < <Email Address Redacted> >
Please call me Stacey and thank you for the response. I will try and
supply the information as best I can.
1) What shoe are you wearing?
I have switched to several pair of shoes, all of which I am able to wear
with my current leg and all are 3/4
2) What is the heel height? Have your tried different shoes?
I have tried various types of shoes ranging from a sneaker to a pump,
and sandal. But all the same height as I would prefer not to have to
throw all of them out AGAIN.
3) When you place the prosthesis in the shoe and look at it from the
side is the pylon of the FF perpendicular to the ground?
Yes
4) Are your knees OK? Muscles?
Yes, no problems at all in the knee area on either leg.
5) What if any Physical Therapy have you had?
I lost my leg almost 4 years ago, and at that time I was scripted to PT,
but after the first visit I was told that there wasn't anything they
needed to improve. Once again, being the unusual case, I received my
first temporary and walked out of the office on it using no crutches or
assistive devices, and once the fit was right and the leg was finished.
I truthfully rely more on my prosthetic side to weight bear and step up
on and I'm sure this is due to the drop foot and heel cord tightness in
the sound side where Charcot is also beginning.
Though it seems incorrect, the reason for my hard heel strike and need
for such a stiff heel is because of this. I rely on hitting hard and
keeping stable to roll over through swing phase and therefore any give
in the heel throws my stability because the sound foot doesn't flex, and
has to remain in a heel setting without placing strain on the foot.
My gait is highly regarded by all orthopedists and prosthetists that
have seen it. I am used to model perfect gait to other clients and
patients by many.
6) How long is your average stride?
It is about 10-11 from rear toe to front heel.
7) Can you run?
Not with the fit of my current leg as it is now. I would only be able
to run at a slow jog for a short distance because of the sound foot I am
sure though because of the drop foot, and the toes catching the ground
if I try to run.
8) Are you sure that the length of the prosthesis is correct?
At this very last setting I feel it is high on the prosthetic side and
they feel it's slightly short, but I plan on having an x-ray done to
show them the misalignment of my hips, and though they have always been
willing to accommodate my requests despite the appearance I want to be
bale to document the difference for them as well as myself. Again, this
has been a problem because of my being able to feel the difference of a
piece of typing paper in height, and the height difference throws my
foot alignment: hence it goes back and forth.
Thanks for your time John, and hopefully you will have some
suggestions for me
-----------------------------------------------------------------------
From: IN% <Email Address Redacted> Stacey Asby
To: IN% <Email Address Redacted> Wayne Renardson
Subj: Fw: Alignment problem
> Thanks for your very descriptive answers. I will continue to give
thought to your situation. Have you ever worn any type of brace for
your sound side?
The only time I ever wore any type of brace was in 1990, for about a
year. I wore AFOs when the foot drop first started and I was doing a
tremendous amount of walking because I had no car, I kept tripping. I
found they did not help to counter the falling of the foot without the
braces, as they were intended to eventually do, and were more of a
bother than anything else. Not to mention that quite frankly, they
looked awful and I tend to have a thing about being fashionable. I
apparently learned to compensate and have ambulated quite well without
them since.
> As prosthetists we tend to concentrate more on the prosthesis when
sometimes imbalances are coming from the other side or the rest of the
body.
Well, there are some effects from the sounds side, hence the need for
the stiff heel to stabilize me in the walking, and I have reminded them
of this on several occasions, but they also keep telling me it's
immaterial what the other foot does as long as the prosthetic side
allows me to walk comfortably and with a good gait.
> Where are you located? Who is the prosthetist or company that you
are working with?
The CP who managed to complete my leg last year and who was working on
this one is Dan Zenas, and he handed it over in part to try some new
approaches and /or techniques to Marc Ridgely. They currently work for
Novacare/Sabolich which is now transforming into Hanger, in Tucker, GA,
just outside of Atlanta.
Once again, thanks for the continued interest, they few respondents have
already seemed to start dropping like flies. LOL! Course, I can't really
blame them. I can clear a prosthetic office in minutes. :o)
Stacey Asby
-----------------------------------------------------------------------
From: IN% <Email Address Redacted> Stacey Asby
To: IN% <Email Address Redacted> Wayne Renardson
CC:
Subj: Fw: Alignment problem
> Still pondering your situation.
That's what I like to see, determination! LOL!
1) Is the prosthesis stable in the side to side direction?
Yes, it is quite secure now, even pinching me a bit around the knee
which he will have to let out again
> Do you feel as if you are walking on the inside or outside edge of
your shoe at the point in your walking where your good leg is in the
air and all your weight is on the prosthesis?
At the moment it's falling to the outside of my foot at this point. In
other words it's my right foot and the weight is leaning to the right as
well.
2) Do you take an equal step with both legs? What happens if you shorten
your stride a bit?
Yes, they are fairly equal, and if I shorten the stride, it seems to
cause my prosthetic side to turn inwards more, and is immediately
pulling on the right hip in front and back.
3) When standing on both legs close your eyes and rock forward and back
shifting your body weight - find the point where you feel the center
of the foot is - then open your eyes and see if this is the same as
the real center of the foot.
Well, it is the same as near as I can tell, but on the prosthetic foot I
am not able to balance on the center of the foot because the ball area
of the foot, just in front of foot center, is too hard and it's as if I
am trying to balance on a ball or are falling backwards on the heel as I
had mentioned in the first note.
4) You said you wear different shoes. Do any of them have a hard sole?
Yes, I always have the foot set to the same shoes. It has a rubber sole
pair of boots or hiking shoes that the last leg was set to and we
started with those again on this leg. I could also wear a pair of pumps
that have a hard heel at that same setting exactly and I even started
just using those to set this foot in case the rubber of the other shoe
was wearing or giving when walking or standing to jeopardize the
accuracy of the height.
Stacey ---> John Rheinstein, C.P.
-----------------------------------------------------------------------
>From: IN% <Email Address Redacted> 7-AUG-1999 16:57:14.93
>To: IN% <Email Address Redacted>
Subj: RE: BK Amputees Needs Advise
You need to try a College Park foot with the proper planterflexion
bumper! There are at least six different durometers of bumpers for
heelstrike on the College Park TrueStep foot. At your weight, there's no
such thing as too soft a heel on the College Park foot!
Believe me, after 22 years experience, I know. If you can't get it right
with a Flex-foot, you've got to try a C.P, foot with the right
bumpers...If your prosthetist can't figure it out, have him call the
Technical services Manager, Mike Link, at College Park in Fraser,
Michigan. He'll give him the answers he needs. I promise!
Barry Steineman, CPO
-------------------------------------------------
Dear Barry;
Thank you very much for your response, I will try and respond to your
comments and fill in the blanks.
> You need to try a College Park foot with the proper planterflexion
bumper! There are at least six different durometers of bumpers for
heelstrike on the College Park Trustep foot. At your weight, there's
no such thing as too soft a heel on the College Park foot!
SA> Want to bet? :o) Let's put it this way: according to my CP, I
should weigh 300 lbs with the apparent force I crush heels with. We
had the foot adjusted with the stiffest bumpers and I was still
leaving the heel stuck to the floor and having to drag it with me.
That and the fact that going up an incline, which is unavoidable in
this area of Atlanta, with the CP foot was not much of an
improvement over my current set up of the Seattle lite foot and
Endolite ankle. I also think I forgot to mention that this was even
set contrary to the manufacturer's guidelines with the ankle being
set backwards of normal, so that my toe is VERY soft and my heel
VERY stiff.
-----------------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: Amputee Information Network < <Email Address Redacted> >
Subject: Answers for Mark B./Can Anyone Help?
> Dear Mark; First thank you for the response. I will try and respond to
each of your questions here.
MB> It seems that your prosthetists have worked very hard on your
prosthesis. I personally prefer a sleeve suspension with a valve
SA> I agree with you, as this is what is suspending the current leg I
have, but unfortunately after trying all sleeves on the market, the
silipos was the only one that didn't cause me some sort of problem
be cause of weight, restriction, shape, gapping, etc,..and it gets
the slightest nick too easily to be reliable.
MB> ...for the best suspension, but it seems your prosthetists have
succeeded with an excellent fit. While I think you have described
minimal movement in the socket, are you saying the the 1/10 of
millimeter of movement is still significant...or is it the alignment
that causes the significant difference?
SA> At the moment the movement within the socket was finally eliminated
with a very snug socket, the pin, the support with the supracondular
modification incorporated in the socket, and the silipos sleeve. The
intolerance of 1/10 mm is a problem in the alignment and height of
the foot.
MB> Your size and the fact that you have the beginning of a Charcot foot
on the sound side, makes me think that the College Park is the
better choice because you may not be able to really load the Flex
foot to get a benefit from it.
SA> Well, once again I seem to fall in to the opposite category here as
my CP insists I should weigh about 300 lbs with the force that I
exert to the foot while walking? LOL! In fact one of the biggest
problems with all the feet has been crushing the heel, despite the
highest rated bumpers, and feeling like I am dragging the foot.
MB> So...I wonder if your problematic sound side foot and back problems
may be causing variations in gait that cause it to be difficult to
align the prosthesis. Are you wearing an orthosis on your sound
side?
SA> Not intending to argue your points, but merely explain the situation
best I can with each suggestion, I do not wear an orthosis as it
isn't necessary. It actually had been tried to disperse pressure in
the sound foot, but was causing more problems that not. However,
let me assure you my gait is probably one of the best there is when
the foot is working and the socket is fitting, and I'm not trying to
be conceded, but this is what all the orthopedist, prosthetists,
etc, have told me.
MB> Do you have support for your back?
SA> No, my back problem is a nodule, or disc, which protrudes out into
the spinal column, and a support would not be beneficial. Also, just
to mention, using the previous legs I had were not affected by
either my hip or back problem at all.
MB> Perhaps your painful joints are adding to the problem more than you
think.
SA> Joints don't bother me unless the prosthesis is improperly aligned
or the height is off. This is where the alignment and height within
that very small increment is crucial. Perhaps it will seem a bit
odd as well, but I can feel my entire leg and foot as though it is
still there, and I don't mean just the foot, but each muscle in the
leg and foot. This gives me a remarkable advantage in walking I
believe, but I can also tell when the alignment is off in one
direction or another immediately because I can feel the muscles
being pulled and strained in the foot that isn't there. I know,
strange, and yes all the CP's test me on this...and all quickly rely
on my sensations shortly there after also. :o)
MB> Does your prosthetic side need more knee support?
SA> We tried using a socket that was a total supracondular and even
tried a transtibial clip in supracondular socket, but didn't resolve
the pistoning issue, inhibited my leg movement entirely too much.
MB> Do you need torque absorption on the prosthetic side?
SA> I went into making this new leg with the idea of using the TT pylon,
but the feeling is that the Shock absorption feature will be too
difficult to tolerate because of my height sensitivity, and we
discussed using an Otto bock rotation component of some sort with
out the shock feature. This was going to be put into play after we
achieved an alignment as is, and this hasn't happened, and when it
does, I don't think anyone will want to touch anything again!!??
MB> Obviously I don't know but just looking for things that may have
been overlooked.
SA> Yep, that's the whole point of throwing this out! I understand the
difficulty of looking at it from your side--I really do. I am going
to relay all information to my CPs if it hasn't been tried and that
is about all I can do at this point.
MB> I think your situation is indeed a challenge. It is certainly
difficult to think about a situation without being there to see it.
SA> The CP that I am working with right now was in Oklahoma City working
with John Sabolich for years and handling the most difficult
clients. It's not very consoling to hear him tell me I'M the most
difficult case he's ever seen!? :o(
MB> What kind of a foot did you have before where you didn't have
alignment problems?
SA> We did have all the same alignment problems, but somehow stumbled on
the right mix after a years time also. Previously successful was an
Endolite adjustable foot with an Iceross and Juzo sleeve suspension
(I don't have to tell you why I got rid of that foot I'm sure. :o)
), the other was the current leg which is the Seattle lite foot,
Endolite ankle (which was set in the reverse of normal to allow my
toe to be VERY soft and the heel very stiff) This was the suction
valve suspension (one way valve) and silipos
sleeve was used for the suspension.
Good luck,
Mark Benveniste CP
----------------------------------------------------------------
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Any questions should be directed to Paul E. Prusakowski, CPO at
<Email Address Redacted>
Last week I reposted a question from Ms. Stacey Asby about the
difficulty she is facing with her prosthesis. The question was also
posted to AMP-L and so far we have received a total of 27 replies. The
following ten are reposted in according with OANDP-L protocol. Others
will follow in a separate post once they have been edited for brevity,
clarity, spelling, and to remove numerous HTML attachments.
Wayne Renardson
AMP-L < <Email Address Redacted> >
-----------------------------------------------------------------------
Original :
From: Stacey Asby < <Email Address Redacted> >
Subject: BK Amputee Needs Advise
Sender: <Email Address Redacted>
< <Email Address Redacted> > Wayne Renardson
To: Amputee Information Network < <Email Address Redacted> >
As many of you know, I have been battling to get my new leg aligned for
almost a year. Unfortunately, the difference between the last two legs,
both of which took a similar amount of time to nail, by different
prosthetists, is that we are making no headway and we (me and the two
prosthetists who have worked on it) are equally frustrated and confused
about where to go from here.
I understand the difficulty trying to make suggestions without the
person in front of you, but in this case any SUGGESTIONS would be
welcome, whether on the list or privately, so I can answer questions
that may help you understand the situation. Here is the best description
I can offer.
I am R-BK. RL is 6 inches in length. At 5'4 + and about 110 lbs., I use
a total contact socket with a semi-supracondular support to minimize
movement.
The socket is snug to within 1-ply of sock and I am using an Alpha liner
(6mm) with pin, and finally, a silipos sleeve to minimize movement. The
movement I feel in the socket and in all planes of alignment is
immeasurable, with the closest increment less than 1/10 mm.
These increments off aren't tolerable because of a gap in the hips
(arthritis) plus some back problems in the L4-L5 region. (We are talking
Percosets after an hour or two of misaligned walking because the back
goes out!): Been there--done that, and AM NOT doing it again if at all
possible! :o)
The foot we are trying to get working is the Vari-flex for flexibility,
low maintenance, and cosmesis. According to my CP, the socket is aligned
about 1-1/2 inches anterior (forward) more than normal, and is also
about an inch inset more than normal.
This situation, apparently and seemingly contrary to the laws of physics
and prosthetics, has me feeling I am sitting sloped back on my heel and
that I have to fight somewhat to push UP TO the ball of the foot, at
which point I receive the response of the foot that I should, and then
fall over the toe. The foot is comprised of a cat. 4 with the thinnest
wedge in the heel and cat. 2 in the toe. We started at cat. 1 all the
way around, according to FF specs, and progressed to this because of my
very hard heel strike.
We also tried increasing the wedges in the heel, but lost all
responsiveness in the foot.
Now, trying to visualize this, so far, according to almost every CP who
has worked on this little problem to date (all very competent and
respected in their field), I respond the opposite to most normal
adjustments, for some reason. I can feel the slightest changes.
We have tried other feet during this process including: the College Park
(no response, heel too soft), Genesis 2 (same inflexibility to inclines
that my current set up has, which is a Seattle Lite foot with Endolite
ankle), the Chiles Campbell, and the Safe foot (very similar to the
college park).
All these feet resulted in me falling forward to the outside, or tilted
back, as I do on the Vari-flex, when attempting to align them. Oh yes,
and not that I think it has much relevancy to this issue, but the lack
of a good, working prosthesis for a year is putting additional stress on
my sound foot, which is in the beginning stages of the Charcot joint
disease (diabetes complication) which took the right foot, and the now
too-large socket of my current leg has caused an open area on the RL,
but I do have a lifetime of diabetes to contend with, which also causes
a bit of fluid retention in the limb.
So how many of you brave souls would like to have a crack at this
problem? In the words of Popeye, I've about had alls I can take!!
Oh yes: I am poor and have two small children, so the possible
suggestions can not include a requirement of large sums of money or
travel. :o)
So this means ask your amputee friends, colleagues, technicians,
prosthetists, and pets if you think of a possible solution or if you've
resolved a similar problem yourself, please!! :o)
Sincerely,
Stacey Asby
-----------------------------------------------------------------------
Having read your letter posted to the O&P listserv I found the following
sentence raised the greatest question in my mind as to proper
alignment:
SA> According to my CP, the socket is aligned about 1-1/2 inches
anterior (forward) more than normal, and is also about an inch inset
more than normal.
While flexion-extension and adduction-abduction angles can vary
significantly to achieve proper alignment, it has been my experience
that placement of the foot with respect to the weight line (especially
with a flex-foot) should remain near zero (to only very slightly inset)
in the frontal plane and near Flex Foots' recommendation (to only
slightly forward) in the sagittal plane. Sometimes this can be a
technical challenge when using the pin system. This is especially true
if the pyramid connector is an integral part of the shuttle lock or
connected directly distal to the pin.
It is also particularly true if there is an unusual amount of flexion,
adduction or abduction in the socket. We sometimes incorporate a pyramid
connector independent of the shuttle lock in order to achieve a more
conventional placement of the foot relative to the weight line.
Also, many times cosmesis must be sacrificed significantly, and some
weight may be added in doing this.
As you acknowledge, it is difficult to analyze problems with a
prosthesis from a verbal explanation. Every amputee has their own
physiological considerations which often vary from the norm. But the
degree of deviation expressed in this sentence seems radical, and I
wonder why this should be. It is certainly possible that there is a good
reason for it.
I hope you are successful in your attempts to get a satisfactory
alignment with your prosthesis. I will be glad to discuss this with your
prosthetist if he desires.
Eddie V. White, CP
-----------------------------------------------------------------------
From: IN% <Email Address Redacted> Stacey Asby
To: IN% <Email Address Redacted> Wayne Renardson
CC:
Subj: Fw: Alignment of Prosthesis
From: Stacey Asby < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Date: Sunday, August 08, 1999 12:21 AM
Subject: Re: Alignment of Prosthesis
Dear Eddie;
First, let me thank you for the response, and now I will attempt to fill
in the blanks with your comments and questions.
> Having read your letter posted to the O&P listserv I found the
following sentence to raise the greatest question in my mind as to
proper alignment:
> According to my CP, the socket is aligned about 1-1/2 inches anterior
(forward) more than normal, and is also about an inch inset more than
normal.
> While flexion-extension and adduction-abduction angles can vary
significantly to achieve proper alignment, it has been my experience
that placement of the foot with respect to the weight line (especially
with a flex-foot) should remain near zero (to only very slightly
inset) in the frontal plane and near Flex Foots' recommendation (to
only slightly forward) in the sagittal plane.
SA> We all agree this is what SHOULD be the case, but placing the
alignment as you mention, I am falling so far back on my heel that
it isn't even possible to stand erect or I am falling to the outside
(left) of the right front side of the foot when walking.
> Sometimes this can be a technical challenge when using the pin system.
SA> We have had the exact same problems using a pelite liner and
supracondular set up, as well as a transtibial (clip in)
supracondular by themselves, and in using the Alpha liner without
pin in conjunction with the supracodular and a sleeve. All of these
other suspensions did not eliminate the movement within the socket,
or restricted the movement of my knee too much to be functional.
> This is especially true if the pyramid connector is an integral part
of the shuttle lock or connected directly distal to the pin.
We have changed pyramid systems numerous times as well as remounting
them because we have maxed out the adjustment possible in one direction
or another. We currently have a slide and glide on the pylon at the
moment.
> It is also particularly true if there is an unusual amount of flexion,
adduction or abduction in the socket. We sometimes incorporate a
pyramid connector independent of the shuttle lock in order to achieve
a more conventional placement of the foot relative to the weight line.
SA> I believe this is separate, but am not positive, to be honest. I
will have to verify this with my C.P. when I show him the
suggestions here.
> Also, many times cosmesis must be sacrificed significantly, and some
weight may be added in doing this.
SA> Cosmesis was attained with previous legs, though it was close to
looking abnormal because of the inset of the foot. I have attached a
photo recently taken at the ACA convention for your benefit.
> As you acknowledged, it is difficult to analyze problems with a
prosthesis from a verbal explanation. Every amputee has their own
physiological considerations and we often vary from the norm, but the
degree of deviation expressed in this sentence seems radical, and I
wonder why this should be.
SA> Yes, well you'll have to form a line I'm afraid. My own CPs have
stated that they would fail prosthetic school as it is at the moment
and has been even close to tolerable to walk in. The last leg was
also set contrary to manufacturer and prosthetic guidelines, with
the endolite ankle being set backwards so the foot was very, very
soft and the heel very stiff.
>It is certainly possible that there is a good reason for it.
SA> I'd personally like to figure it out myself. :o)
> I hope you are successful in your attempts to get a satisfactory
alignment with your prosthesis. I will be glad to discuss this with
your prosthetist if he desires.
SA> Thank you. I will pass this note when I see him next Friday and he
will be free to contact you as he sees fit. I will post the
resolution of this dilemma on the list when it occurs.
-----------------------------------------------------------------------
Subject: Alignment problem
In response to your post to OANDP-L by Wayne Renardson, please answer
these questions so I may think further about your problem:
1) What shoe are you wearing? What is the heel height? Have your tried
different shoes? When you place the prosthesis in the shoe and look
at it from the side is the pylon of the FF perpendicular to the
ground?
2) Are your knees OK? Muscles?
3) What if any Physical Therapy have you had? How long is your average
stride? Can you run?
4) Are you sure that the length of the prosthesis is correct?
John Rheinstein, C.P.
----------------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: John Rheinstien < <Email Address Redacted> >
Please call me Stacey and thank you for the response. I will try and
supply the information as best I can.
1) What shoe are you wearing?
I have switched to several pair of shoes, all of which I am able to wear
with my current leg and all are 3/4
2) What is the heel height? Have your tried different shoes?
I have tried various types of shoes ranging from a sneaker to a pump,
and sandal. But all the same height as I would prefer not to have to
throw all of them out AGAIN.
3) When you place the prosthesis in the shoe and look at it from the
side is the pylon of the FF perpendicular to the ground?
Yes
4) Are your knees OK? Muscles?
Yes, no problems at all in the knee area on either leg.
5) What if any Physical Therapy have you had?
I lost my leg almost 4 years ago, and at that time I was scripted to PT,
but after the first visit I was told that there wasn't anything they
needed to improve. Once again, being the unusual case, I received my
first temporary and walked out of the office on it using no crutches or
assistive devices, and once the fit was right and the leg was finished.
I truthfully rely more on my prosthetic side to weight bear and step up
on and I'm sure this is due to the drop foot and heel cord tightness in
the sound side where Charcot is also beginning.
Though it seems incorrect, the reason for my hard heel strike and need
for such a stiff heel is because of this. I rely on hitting hard and
keeping stable to roll over through swing phase and therefore any give
in the heel throws my stability because the sound foot doesn't flex, and
has to remain in a heel setting without placing strain on the foot.
My gait is highly regarded by all orthopedists and prosthetists that
have seen it. I am used to model perfect gait to other clients and
patients by many.
6) How long is your average stride?
It is about 10-11 from rear toe to front heel.
7) Can you run?
Not with the fit of my current leg as it is now. I would only be able
to run at a slow jog for a short distance because of the sound foot I am
sure though because of the drop foot, and the toes catching the ground
if I try to run.
8) Are you sure that the length of the prosthesis is correct?
At this very last setting I feel it is high on the prosthetic side and
they feel it's slightly short, but I plan on having an x-ray done to
show them the misalignment of my hips, and though they have always been
willing to accommodate my requests despite the appearance I want to be
bale to document the difference for them as well as myself. Again, this
has been a problem because of my being able to feel the difference of a
piece of typing paper in height, and the height difference throws my
foot alignment: hence it goes back and forth.
Thanks for your time John, and hopefully you will have some
suggestions for me
-----------------------------------------------------------------------
From: IN% <Email Address Redacted> Stacey Asby
To: IN% <Email Address Redacted> Wayne Renardson
Subj: Fw: Alignment problem
> Thanks for your very descriptive answers. I will continue to give
thought to your situation. Have you ever worn any type of brace for
your sound side?
The only time I ever wore any type of brace was in 1990, for about a
year. I wore AFOs when the foot drop first started and I was doing a
tremendous amount of walking because I had no car, I kept tripping. I
found they did not help to counter the falling of the foot without the
braces, as they were intended to eventually do, and were more of a
bother than anything else. Not to mention that quite frankly, they
looked awful and I tend to have a thing about being fashionable. I
apparently learned to compensate and have ambulated quite well without
them since.
> As prosthetists we tend to concentrate more on the prosthesis when
sometimes imbalances are coming from the other side or the rest of the
body.
Well, there are some effects from the sounds side, hence the need for
the stiff heel to stabilize me in the walking, and I have reminded them
of this on several occasions, but they also keep telling me it's
immaterial what the other foot does as long as the prosthetic side
allows me to walk comfortably and with a good gait.
> Where are you located? Who is the prosthetist or company that you
are working with?
The CP who managed to complete my leg last year and who was working on
this one is Dan Zenas, and he handed it over in part to try some new
approaches and /or techniques to Marc Ridgely. They currently work for
Novacare/Sabolich which is now transforming into Hanger, in Tucker, GA,
just outside of Atlanta.
Once again, thanks for the continued interest, they few respondents have
already seemed to start dropping like flies. LOL! Course, I can't really
blame them. I can clear a prosthetic office in minutes. :o)
Stacey Asby
-----------------------------------------------------------------------
From: IN% <Email Address Redacted> Stacey Asby
To: IN% <Email Address Redacted> Wayne Renardson
CC:
Subj: Fw: Alignment problem
> Still pondering your situation.
That's what I like to see, determination! LOL!
1) Is the prosthesis stable in the side to side direction?
Yes, it is quite secure now, even pinching me a bit around the knee
which he will have to let out again
> Do you feel as if you are walking on the inside or outside edge of
your shoe at the point in your walking where your good leg is in the
air and all your weight is on the prosthesis?
At the moment it's falling to the outside of my foot at this point. In
other words it's my right foot and the weight is leaning to the right as
well.
2) Do you take an equal step with both legs? What happens if you shorten
your stride a bit?
Yes, they are fairly equal, and if I shorten the stride, it seems to
cause my prosthetic side to turn inwards more, and is immediately
pulling on the right hip in front and back.
3) When standing on both legs close your eyes and rock forward and back
shifting your body weight - find the point where you feel the center
of the foot is - then open your eyes and see if this is the same as
the real center of the foot.
Well, it is the same as near as I can tell, but on the prosthetic foot I
am not able to balance on the center of the foot because the ball area
of the foot, just in front of foot center, is too hard and it's as if I
am trying to balance on a ball or are falling backwards on the heel as I
had mentioned in the first note.
4) You said you wear different shoes. Do any of them have a hard sole?
Yes, I always have the foot set to the same shoes. It has a rubber sole
pair of boots or hiking shoes that the last leg was set to and we
started with those again on this leg. I could also wear a pair of pumps
that have a hard heel at that same setting exactly and I even started
just using those to set this foot in case the rubber of the other shoe
was wearing or giving when walking or standing to jeopardize the
accuracy of the height.
Stacey ---> John Rheinstein, C.P.
-----------------------------------------------------------------------
>From: IN% <Email Address Redacted> 7-AUG-1999 16:57:14.93
>To: IN% <Email Address Redacted>
Subj: RE: BK Amputees Needs Advise
You need to try a College Park foot with the proper planterflexion
bumper! There are at least six different durometers of bumpers for
heelstrike on the College Park TrueStep foot. At your weight, there's no
such thing as too soft a heel on the College Park foot!
Believe me, after 22 years experience, I know. If you can't get it right
with a Flex-foot, you've got to try a C.P, foot with the right
bumpers...If your prosthetist can't figure it out, have him call the
Technical services Manager, Mike Link, at College Park in Fraser,
Michigan. He'll give him the answers he needs. I promise!
Barry Steineman, CPO
-------------------------------------------------
Dear Barry;
Thank you very much for your response, I will try and respond to your
comments and fill in the blanks.
> You need to try a College Park foot with the proper planterflexion
bumper! There are at least six different durometers of bumpers for
heelstrike on the College Park Trustep foot. At your weight, there's
no such thing as too soft a heel on the College Park foot!
SA> Want to bet? :o) Let's put it this way: according to my CP, I
should weigh 300 lbs with the apparent force I crush heels with. We
had the foot adjusted with the stiffest bumpers and I was still
leaving the heel stuck to the floor and having to drag it with me.
That and the fact that going up an incline, which is unavoidable in
this area of Atlanta, with the CP foot was not much of an
improvement over my current set up of the Seattle lite foot and
Endolite ankle. I also think I forgot to mention that this was even
set contrary to the manufacturer's guidelines with the ankle being
set backwards of normal, so that my toe is VERY soft and my heel
VERY stiff.
-----------------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: Amputee Information Network < <Email Address Redacted> >
Subject: Answers for Mark B./Can Anyone Help?
> Dear Mark; First thank you for the response. I will try and respond to
each of your questions here.
MB> It seems that your prosthetists have worked very hard on your
prosthesis. I personally prefer a sleeve suspension with a valve
SA> I agree with you, as this is what is suspending the current leg I
have, but unfortunately after trying all sleeves on the market, the
silipos was the only one that didn't cause me some sort of problem
be cause of weight, restriction, shape, gapping, etc,..and it gets
the slightest nick too easily to be reliable.
MB> ...for the best suspension, but it seems your prosthetists have
succeeded with an excellent fit. While I think you have described
minimal movement in the socket, are you saying the the 1/10 of
millimeter of movement is still significant...or is it the alignment
that causes the significant difference?
SA> At the moment the movement within the socket was finally eliminated
with a very snug socket, the pin, the support with the supracondular
modification incorporated in the socket, and the silipos sleeve. The
intolerance of 1/10 mm is a problem in the alignment and height of
the foot.
MB> Your size and the fact that you have the beginning of a Charcot foot
on the sound side, makes me think that the College Park is the
better choice because you may not be able to really load the Flex
foot to get a benefit from it.
SA> Well, once again I seem to fall in to the opposite category here as
my CP insists I should weigh about 300 lbs with the force that I
exert to the foot while walking? LOL! In fact one of the biggest
problems with all the feet has been crushing the heel, despite the
highest rated bumpers, and feeling like I am dragging the foot.
MB> So...I wonder if your problematic sound side foot and back problems
may be causing variations in gait that cause it to be difficult to
align the prosthesis. Are you wearing an orthosis on your sound
side?
SA> Not intending to argue your points, but merely explain the situation
best I can with each suggestion, I do not wear an orthosis as it
isn't necessary. It actually had been tried to disperse pressure in
the sound foot, but was causing more problems that not. However,
let me assure you my gait is probably one of the best there is when
the foot is working and the socket is fitting, and I'm not trying to
be conceded, but this is what all the orthopedist, prosthetists,
etc, have told me.
MB> Do you have support for your back?
SA> No, my back problem is a nodule, or disc, which protrudes out into
the spinal column, and a support would not be beneficial. Also, just
to mention, using the previous legs I had were not affected by
either my hip or back problem at all.
MB> Perhaps your painful joints are adding to the problem more than you
think.
SA> Joints don't bother me unless the prosthesis is improperly aligned
or the height is off. This is where the alignment and height within
that very small increment is crucial. Perhaps it will seem a bit
odd as well, but I can feel my entire leg and foot as though it is
still there, and I don't mean just the foot, but each muscle in the
leg and foot. This gives me a remarkable advantage in walking I
believe, but I can also tell when the alignment is off in one
direction or another immediately because I can feel the muscles
being pulled and strained in the foot that isn't there. I know,
strange, and yes all the CP's test me on this...and all quickly rely
on my sensations shortly there after also. :o)
MB> Does your prosthetic side need more knee support?
SA> We tried using a socket that was a total supracondular and even
tried a transtibial clip in supracondular socket, but didn't resolve
the pistoning issue, inhibited my leg movement entirely too much.
MB> Do you need torque absorption on the prosthetic side?
SA> I went into making this new leg with the idea of using the TT pylon,
but the feeling is that the Shock absorption feature will be too
difficult to tolerate because of my height sensitivity, and we
discussed using an Otto bock rotation component of some sort with
out the shock feature. This was going to be put into play after we
achieved an alignment as is, and this hasn't happened, and when it
does, I don't think anyone will want to touch anything again!!??
MB> Obviously I don't know but just looking for things that may have
been overlooked.
SA> Yep, that's the whole point of throwing this out! I understand the
difficulty of looking at it from your side--I really do. I am going
to relay all information to my CPs if it hasn't been tried and that
is about all I can do at this point.
MB> I think your situation is indeed a challenge. It is certainly
difficult to think about a situation without being there to see it.
SA> The CP that I am working with right now was in Oklahoma City working
with John Sabolich for years and handling the most difficult
clients. It's not very consoling to hear him tell me I'M the most
difficult case he's ever seen!? :o(
MB> What kind of a foot did you have before where you didn't have
alignment problems?
SA> We did have all the same alignment problems, but somehow stumbled on
the right mix after a years time also. Previously successful was an
Endolite adjustable foot with an Iceross and Juzo sleeve suspension
(I don't have to tell you why I got rid of that foot I'm sure. :o)
), the other was the current leg which is the Seattle lite foot,
Endolite ankle (which was set in the reverse of normal to allow my
toe to be VERY soft and the heel very stiff) This was the suction
valve suspension (one way valve) and silipos
sleeve was used for the suspension.
Good luck,
Mark Benveniste CP
----------------------------------------------------------------
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Citation
“Alignment Problem: Replies,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 4, 2024, https://library.drfop.org/items/show/212386.
