Prosthetic Alignment Part III (final)
Description
Collection
Title:
Prosthetic Alignment Part III (final)
Date:
8/15/1999
Text:
From: Stacey Asby < <Email Address Redacted> > To: Amputee Information Network
< <Email Address Redacted> >
Fm: Mark Benveniste CP
MB> Since you clearly have a thoughtful hardworking prosthetist and you
have tried numerous different component combinations, perhaps a
paradigm shift is necessary.
SA> I know I'm in trouble now, aren't I? :o)
MB> Technology can be helpful to some degree, but perhaps for your sake,
you might need to learn to walk differently than you currently do.
SA> I know you're going to hate me, because I am going to use that word
again, but. I can actually walk in just about anything they give
me, BUT, it becomes very painful because of the hip problem. We
often reach a place where I have said I could walk like Marilyn
Monroe and it would be fine, BUT, I just can't do it. :o(
MB> Maybe smaller, less forceful steps would be beneficial. It certainly
involves changing a habit pattern but that doesn't mean it can't be
done.
SA> Well another complication in this little scenario is the need to
walk with a force heavy on my heel because of the sound foot's
problems. The drop foot and tight heel cord have my foot in an
otherwise arched, heel set position, and walking without the flexion
in the foot requires me to rely on my hard and steady heel strike to
move fluidly. In actuality, I start stumbling a bit when I try to
walk slowly. I have been to therapy previously on several occasions,
and there is no way to improve the foot's capabilities to improve
this, I'm afraid. Now you're figuring why my CP is probably taking
Valiums at night.
MB> Models learn to walk differently and so do dancers.
SA> Yep, and they have the mobility in two feet to change it.
MB> Once again, I don't know if this is the answer, but if we are going
to think out of the box this is my contribution!
SA> Oh, I like this, I got one more thinking out of the textbook box.
:o) Thanks for the attempts. And please don't take my buts as a
knocking of your suggestions or denial to try a new approach. That
is not at all the case, I promise.
-----------------------------------------------------------------------
From: Anne Russell < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Subject: BK Amputee Needs Advise
I would like to put my two cents into this: nothing to lose but time.
To start off on the right foot you need to have alignment, some of what
I have to say mite sound foolish, but you got to start somewhere. If all
else fails start back at square one, with an open mind.
Standing alignment is 90% of walking alignment
a.. What I mean by that, it is very hard for someone to watch gait and
see all that is happening. Even if they could see everything, they
would have to still decide what is causing your problem.
SA> I'm glad we seem to agree on this issue. This has also been a large
part in fixing the alignment. With my being able to detect an
alignment or height problem at less than 1/10 mm, it's impossible
for anyone to see the things I am feeling in most cases.
b.. The prosthetist job is to get the foot under the person
SA> This of course is where each process has started, but it seems that
my alignment naturally is not in that box. Both legs that were
functional previously were inset very far to the point where they
questioned the ability to cover them.
c.. This allows for finding unusual gait from imbalance muscles, muscles
weakness, etc.
d.. This should be the time that radical alignment needs to be
done
SA> Here is the visual problem you mentioned. I am able to walk in most
thing even semi-close to being aligned with a nearly flawless gait,
and have to concentrate to let the foot go so some of the problems
can be seen.
B.. Flex Foot
a.. Once you have the standing alignment for the Flex Foot, there is a
need to check the spring center. How this is done is by having 50%
weight on the limb and rock back and forth, watching the heel and
toe starting to raise. This is very critical.
SA> Well now I do feel better because without anyone ever suggesting I
test the alignment of the FF, this is systematically how I test the
foot out as far as feeling correct every time it's adjusted: by
standing in place and stepping down repeatedly to feel if the foot
is right.
(a1)The ankle movements should corresponds to the sound side, of course
not as much ROM. If the toe rises too prematurely then the heel is
to hard, or the foot is not center underneath you. I have to fight
somewhat to push UP TO the ball of the foot; this foot is not
centered.
SA> This has been the biggest problem!! When making the usual adjustment
to counter these very things you mention, we find that I respond in
the opposite manner. And then when trying the wrong direction in
the way or a normal counter measure, it seems to improve the
situation until we find ourselves maxed out in that direction, and I
am either falling back on the heel or tipping forward to the right
side of the toe? They have repositioned the block which the slide
and glide pyramid system is on, and we still end up repeating the
process?
b.. Next look from the side and watch the knee center travel back and
forth over the foot, this should be normal in that the foot toe and
heel do not rise prematurely. This is not rocket science, but only
looking for this motion to look normal to the sound limb.
c.. It is my strong feeling that the FF should have 75-80% of movement
of the sound side. If you are going to have normal steps with both
feet than of course the prosthetics foot should have the similar
motion.
SA> I agree, and that has been my complaint at the moment with some of
the adjustments which seem to get the alignment close to comfortable
so far. It gets close in one direction so that it seems another turn
that way would be prefect, and they with that position we lose the
action and response of the foot completely and it becomes
non-responsive. This also was the reason for raising the category
level of the foot so much. Before the cat 4, I was just crushing the
heel and as with the other feet I tried, I was dragging the foot
rather than walking with it.
d.. Socket is aligned about 1-1/2 inches anterior (forward) more than
normal and is also about an inch inset more than normal once the
basic alignment of the foot is done. I never adjust the angle at the
socket or at the pylon. Moving the heel in the slots, what they call
adjusting the heel height, will finalize the foot alignment. I have
not used the Vari-flex, but have used lots of Mod III and the Flex
Walks, and they have slots to move the heel. There where a few
persons that I had trouble in getting good alignment with the FF,
but once I started to use the heel for the alignment instrument, no
problems.
c.. Charcot joint disease
a.. There is very strong likelihood that there are muscle weaknesses
leading to muscle imbalances in the residual limb.
SA> I respond the opposite to most normal adjustments: what this means
is the alignment will have to be abnormal and should stress the job
of controlling the strong muscles.
Or as my son would say, go into the CP office on opposite day.
SA> LOL! I like him already! :o) Must have wise parents? This is true.
To date the feet I have had successfully aligned have been set
outside the normal parameters, to say the least. The Endolite
adjustable foot was very stiff and therefore the heel was great, but
with no flexion in the toe or energy storing features, it was less
than appropriate for me.
The Seattle lite foot and endolite ankle which I currently have was
set backwards so that my toe is very soft and was a concern by my CP
that I would just fall over, and the heel is extremely stiff. It
worked great, but once again, I don't have the ability to handle
inclines and uneven terrain very well, and the energy storing is
minimal in comparison to the Vari-flex's that I can feel even
misaligned.
c.. A good muscle test would be helpful, and also looking if there is
difference between static and dynamic muscle strength.
d.. Listen to your intuitions. Just because it is not normally done does
not mean that it not right for you. As the CP it does not matter
what I would do as long it puts the foot underneath you.
SA> LOL! Yea, well I have proven a few engineering and prosthetic
theories wrong in the 4 years of being an amputee and I think I may
have also caused a few ulcers in the process as well. :o)
That's all for now. Hopefully this starts you onto a new path, and
covers some ideas that have not been discussed before.
John G. Russell Jr.
-----------------------------------------------------------------------
From: Reed < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Subject: Re: BK Amputee Needs Advise
Dear Ms. Asby,
I can only imagine your frustration with this problem. I am a
Prosthetist in Shreveport, LA. What is your geographical region?
I will be leaving town tomorrow, 8-8-99, for approx. 1 week. Please feel
free to call me to discuss this issue, as I have some ideas. I'm not
sure, but if I understand your situation correctly, I have dealt with
something similar before. I will return to my office on 8-16-99.
E. Reed Coleman, C.P., L.P.O.
-----------------------------------------------------------------------
SA> Thank you for your continued responses and suggestions. The reason
for the positioning of the foot is to indeed match the sound foot,
and while I had previously worn an orthotic on my foot, the effects
were found to be more detrimental in the end than beneficial. The
heel cord tightness in the sound foot prevents the foot from
attaining 90 degrees, and therefore must be at an angle to prevent
extreme pressure on the ball of the foot because of the inability of
the ankle to flex and absorb some of the pressure.
While I have exhausted the trials of orthotics and AFOs, I do believe
that there is some credibility to the hips deteriorating causing more of
a problem, and I will also pass the idea of a single axis foot to my
current CP, although I don't feel this is going to enable me to function
as I had and with less effort, but rather limit my current abilities to
perform.
I don't know which list or forum you saw my post on, as I posted the
plea for suggestions on several, but I will also post the resolution
when found on the same lists.
Thank you again for your suggestions,
Stacey Asby
Amputee Foundation of Greater Atlanta-North
-------------------------------------------------------
Dear Madam,
I feel that you could benefit from a SINGLE AXIS FOOT. Your statement
that the previous prostheses did not pose problems and you have more
problems now can be justified by the Arthritis that you suffer from
which could have caused progressive difficulty. Though I am not able to
clearly see your legs in the photo attached I could see the
planterflexed position of your foot.
I would also advise you to use a AFO or a molded footwear to avoid
excess pressure over the ball of the foot and prevent the complication
of a worsened charcot joint.
The single axis foot plus the AFO will be able to prevent the
instability that you have and would give you better performance. I will
also recommend you to do exercises for the hip to maintain the ROM.
I hope these suggestions will give you more comfort and increase your
efficiency.
With regards
Srivatsa
-----------------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: Vikki A. Stefans < <Email Address Redacted> >
Date: Tuesday, August 10, 1999 9:46 PM
Subject: Re: BK Amputees Needs Advise
VS> Is there any chance there is a leg-length discrepancy, either real
or occurring because of the prosthetic (e.g. residual limb not going
all the way in or just built too long vs an uncompensated proximal
difference?)
SA> The height is a continual discrepancy, because when they set the leg
to where it is level, then attempt to align the foot, it changes the
height perception. Then when they fix the height again, it changes
the alignment. It's an ongoing battle with my being bale to feel the
difference between having a knee high as a sock in my socket, for
example. Putting one in the socket when I am feeling short on the
prosthetic side will make me feel too high. These increments are
very uncomfortable to walk with, but when I get the alignment and
height close enough, I am able to get by with the difference of a
nylon, but not much more tolerance than that unfortunately. It
really would seem to be a hopeless case, but I have achieved it
twice before with legs that were made.
Vikki Stefans, pediatric physiatrist (rehab doc for kids) and working
Mom Arkansas Children's Hospital/ U of A for Medical Sciences, Little
Rock and EVERY mom is a working mom! (OK, dads too...)
----------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: Shai & Cheryl Elias < <Email Address Redacted> >
Subject: Re: BK Advice
Dear Shai;
SE> Hi, my name is Shai Elias. I'm a Prosthetist but more important is
the fact that I'm an amputee. LBK.
SA> First let me thank you for your interest and response. I will try
and answer your questions below.
SA> That helps some of the time I think. Unfortunately so far hasn't in
this case, as the CP currently tearing his hair out working to
resolve my leg dilemma is also a LBK. LOL!
SE> I would love to take a crack at this. First I have to ask you to
describe the soft tissue of your RL; soft, responsive-medium,
toned-muscled.
SA> I'm afraid I may not be able to be as specific as you would perhaps
like since I am not used to describing this in technical terms. I
recently had a friend and CP, Tony Van der Warrde, mention that it
looked to him that there was quite a bit of loose tissue and that it
could either be improved with a revision or exercise, but, I haven't
had a problem with the control of my leg in the least before and the
socket is fitting very well now after numerous attempts.
SE> Second, does your knee have full range of motion?
SA> Yes, and I am actually able to bend my knee way past 90 degrees when
the socket is cut properly. My sound knee is also in good condition.
SE>> Do you hike your hip when you walk ?
SA> No, not unless the prosthetic side is too high
SE> Has the posterior wall of the socket been lowered to allow for knee
flexion?
SA> Yes, though I am going to suggest he lower it again slightly as I
have a very pronounced hamstring and it is interfering at times when
I have worn the socket temporarily.
SE> If I can make a recommendation I would recommend to make a Short
video segment of your ambulation as an attachment to your e-mail so
it can be analyzed.
SA> I wish I had the capabilities to do that, but truthfully am quite
computer illiterate and wouldn't have the first clue as how to pull
this off.
Truly
Shai Y. Elias, CP
< <Email Address Redacted> >
Fm: Mark Benveniste CP
MB> Since you clearly have a thoughtful hardworking prosthetist and you
have tried numerous different component combinations, perhaps a
paradigm shift is necessary.
SA> I know I'm in trouble now, aren't I? :o)
MB> Technology can be helpful to some degree, but perhaps for your sake,
you might need to learn to walk differently than you currently do.
SA> I know you're going to hate me, because I am going to use that word
again, but. I can actually walk in just about anything they give
me, BUT, it becomes very painful because of the hip problem. We
often reach a place where I have said I could walk like Marilyn
Monroe and it would be fine, BUT, I just can't do it. :o(
MB> Maybe smaller, less forceful steps would be beneficial. It certainly
involves changing a habit pattern but that doesn't mean it can't be
done.
SA> Well another complication in this little scenario is the need to
walk with a force heavy on my heel because of the sound foot's
problems. The drop foot and tight heel cord have my foot in an
otherwise arched, heel set position, and walking without the flexion
in the foot requires me to rely on my hard and steady heel strike to
move fluidly. In actuality, I start stumbling a bit when I try to
walk slowly. I have been to therapy previously on several occasions,
and there is no way to improve the foot's capabilities to improve
this, I'm afraid. Now you're figuring why my CP is probably taking
Valiums at night.
MB> Models learn to walk differently and so do dancers.
SA> Yep, and they have the mobility in two feet to change it.
MB> Once again, I don't know if this is the answer, but if we are going
to think out of the box this is my contribution!
SA> Oh, I like this, I got one more thinking out of the textbook box.
:o) Thanks for the attempts. And please don't take my buts as a
knocking of your suggestions or denial to try a new approach. That
is not at all the case, I promise.
-----------------------------------------------------------------------
From: Anne Russell < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Subject: BK Amputee Needs Advise
I would like to put my two cents into this: nothing to lose but time.
To start off on the right foot you need to have alignment, some of what
I have to say mite sound foolish, but you got to start somewhere. If all
else fails start back at square one, with an open mind.
Standing alignment is 90% of walking alignment
a.. What I mean by that, it is very hard for someone to watch gait and
see all that is happening. Even if they could see everything, they
would have to still decide what is causing your problem.
SA> I'm glad we seem to agree on this issue. This has also been a large
part in fixing the alignment. With my being able to detect an
alignment or height problem at less than 1/10 mm, it's impossible
for anyone to see the things I am feeling in most cases.
b.. The prosthetist job is to get the foot under the person
SA> This of course is where each process has started, but it seems that
my alignment naturally is not in that box. Both legs that were
functional previously were inset very far to the point where they
questioned the ability to cover them.
c.. This allows for finding unusual gait from imbalance muscles, muscles
weakness, etc.
d.. This should be the time that radical alignment needs to be
done
SA> Here is the visual problem you mentioned. I am able to walk in most
thing even semi-close to being aligned with a nearly flawless gait,
and have to concentrate to let the foot go so some of the problems
can be seen.
B.. Flex Foot
a.. Once you have the standing alignment for the Flex Foot, there is a
need to check the spring center. How this is done is by having 50%
weight on the limb and rock back and forth, watching the heel and
toe starting to raise. This is very critical.
SA> Well now I do feel better because without anyone ever suggesting I
test the alignment of the FF, this is systematically how I test the
foot out as far as feeling correct every time it's adjusted: by
standing in place and stepping down repeatedly to feel if the foot
is right.
(a1)The ankle movements should corresponds to the sound side, of course
not as much ROM. If the toe rises too prematurely then the heel is
to hard, or the foot is not center underneath you. I have to fight
somewhat to push UP TO the ball of the foot; this foot is not
centered.
SA> This has been the biggest problem!! When making the usual adjustment
to counter these very things you mention, we find that I respond in
the opposite manner. And then when trying the wrong direction in
the way or a normal counter measure, it seems to improve the
situation until we find ourselves maxed out in that direction, and I
am either falling back on the heel or tipping forward to the right
side of the toe? They have repositioned the block which the slide
and glide pyramid system is on, and we still end up repeating the
process?
b.. Next look from the side and watch the knee center travel back and
forth over the foot, this should be normal in that the foot toe and
heel do not rise prematurely. This is not rocket science, but only
looking for this motion to look normal to the sound limb.
c.. It is my strong feeling that the FF should have 75-80% of movement
of the sound side. If you are going to have normal steps with both
feet than of course the prosthetics foot should have the similar
motion.
SA> I agree, and that has been my complaint at the moment with some of
the adjustments which seem to get the alignment close to comfortable
so far. It gets close in one direction so that it seems another turn
that way would be prefect, and they with that position we lose the
action and response of the foot completely and it becomes
non-responsive. This also was the reason for raising the category
level of the foot so much. Before the cat 4, I was just crushing the
heel and as with the other feet I tried, I was dragging the foot
rather than walking with it.
d.. Socket is aligned about 1-1/2 inches anterior (forward) more than
normal and is also about an inch inset more than normal once the
basic alignment of the foot is done. I never adjust the angle at the
socket or at the pylon. Moving the heel in the slots, what they call
adjusting the heel height, will finalize the foot alignment. I have
not used the Vari-flex, but have used lots of Mod III and the Flex
Walks, and they have slots to move the heel. There where a few
persons that I had trouble in getting good alignment with the FF,
but once I started to use the heel for the alignment instrument, no
problems.
c.. Charcot joint disease
a.. There is very strong likelihood that there are muscle weaknesses
leading to muscle imbalances in the residual limb.
SA> I respond the opposite to most normal adjustments: what this means
is the alignment will have to be abnormal and should stress the job
of controlling the strong muscles.
Or as my son would say, go into the CP office on opposite day.
SA> LOL! I like him already! :o) Must have wise parents? This is true.
To date the feet I have had successfully aligned have been set
outside the normal parameters, to say the least. The Endolite
adjustable foot was very stiff and therefore the heel was great, but
with no flexion in the toe or energy storing features, it was less
than appropriate for me.
The Seattle lite foot and endolite ankle which I currently have was
set backwards so that my toe is very soft and was a concern by my CP
that I would just fall over, and the heel is extremely stiff. It
worked great, but once again, I don't have the ability to handle
inclines and uneven terrain very well, and the energy storing is
minimal in comparison to the Vari-flex's that I can feel even
misaligned.
c.. A good muscle test would be helpful, and also looking if there is
difference between static and dynamic muscle strength.
d.. Listen to your intuitions. Just because it is not normally done does
not mean that it not right for you. As the CP it does not matter
what I would do as long it puts the foot underneath you.
SA> LOL! Yea, well I have proven a few engineering and prosthetic
theories wrong in the 4 years of being an amputee and I think I may
have also caused a few ulcers in the process as well. :o)
That's all for now. Hopefully this starts you onto a new path, and
covers some ideas that have not been discussed before.
John G. Russell Jr.
-----------------------------------------------------------------------
From: Reed < <Email Address Redacted> >
To: <Email Address Redacted> < <Email Address Redacted> >
Subject: Re: BK Amputee Needs Advise
Dear Ms. Asby,
I can only imagine your frustration with this problem. I am a
Prosthetist in Shreveport, LA. What is your geographical region?
I will be leaving town tomorrow, 8-8-99, for approx. 1 week. Please feel
free to call me to discuss this issue, as I have some ideas. I'm not
sure, but if I understand your situation correctly, I have dealt with
something similar before. I will return to my office on 8-16-99.
E. Reed Coleman, C.P., L.P.O.
-----------------------------------------------------------------------
SA> Thank you for your continued responses and suggestions. The reason
for the positioning of the foot is to indeed match the sound foot,
and while I had previously worn an orthotic on my foot, the effects
were found to be more detrimental in the end than beneficial. The
heel cord tightness in the sound foot prevents the foot from
attaining 90 degrees, and therefore must be at an angle to prevent
extreme pressure on the ball of the foot because of the inability of
the ankle to flex and absorb some of the pressure.
While I have exhausted the trials of orthotics and AFOs, I do believe
that there is some credibility to the hips deteriorating causing more of
a problem, and I will also pass the idea of a single axis foot to my
current CP, although I don't feel this is going to enable me to function
as I had and with less effort, but rather limit my current abilities to
perform.
I don't know which list or forum you saw my post on, as I posted the
plea for suggestions on several, but I will also post the resolution
when found on the same lists.
Thank you again for your suggestions,
Stacey Asby
Amputee Foundation of Greater Atlanta-North
-------------------------------------------------------
Dear Madam,
I feel that you could benefit from a SINGLE AXIS FOOT. Your statement
that the previous prostheses did not pose problems and you have more
problems now can be justified by the Arthritis that you suffer from
which could have caused progressive difficulty. Though I am not able to
clearly see your legs in the photo attached I could see the
planterflexed position of your foot.
I would also advise you to use a AFO or a molded footwear to avoid
excess pressure over the ball of the foot and prevent the complication
of a worsened charcot joint.
The single axis foot plus the AFO will be able to prevent the
instability that you have and would give you better performance. I will
also recommend you to do exercises for the hip to maintain the ROM.
I hope these suggestions will give you more comfort and increase your
efficiency.
With regards
Srivatsa
-----------------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: Vikki A. Stefans < <Email Address Redacted> >
Date: Tuesday, August 10, 1999 9:46 PM
Subject: Re: BK Amputees Needs Advise
VS> Is there any chance there is a leg-length discrepancy, either real
or occurring because of the prosthetic (e.g. residual limb not going
all the way in or just built too long vs an uncompensated proximal
difference?)
SA> The height is a continual discrepancy, because when they set the leg
to where it is level, then attempt to align the foot, it changes the
height perception. Then when they fix the height again, it changes
the alignment. It's an ongoing battle with my being bale to feel the
difference between having a knee high as a sock in my socket, for
example. Putting one in the socket when I am feeling short on the
prosthetic side will make me feel too high. These increments are
very uncomfortable to walk with, but when I get the alignment and
height close enough, I am able to get by with the difference of a
nylon, but not much more tolerance than that unfortunately. It
really would seem to be a hopeless case, but I have achieved it
twice before with legs that were made.
Vikki Stefans, pediatric physiatrist (rehab doc for kids) and working
Mom Arkansas Children's Hospital/ U of A for Medical Sciences, Little
Rock and EVERY mom is a working mom! (OK, dads too...)
----------------------------------------------------------------
From: Stacey Asby < <Email Address Redacted> >
To: Shai & Cheryl Elias < <Email Address Redacted> >
Subject: Re: BK Advice
Dear Shai;
SE> Hi, my name is Shai Elias. I'm a Prosthetist but more important is
the fact that I'm an amputee. LBK.
SA> First let me thank you for your interest and response. I will try
and answer your questions below.
SA> That helps some of the time I think. Unfortunately so far hasn't in
this case, as the CP currently tearing his hair out working to
resolve my leg dilemma is also a LBK. LOL!
SE> I would love to take a crack at this. First I have to ask you to
describe the soft tissue of your RL; soft, responsive-medium,
toned-muscled.
SA> I'm afraid I may not be able to be as specific as you would perhaps
like since I am not used to describing this in technical terms. I
recently had a friend and CP, Tony Van der Warrde, mention that it
looked to him that there was quite a bit of loose tissue and that it
could either be improved with a revision or exercise, but, I haven't
had a problem with the control of my leg in the least before and the
socket is fitting very well now after numerous attempts.
SE> Second, does your knee have full range of motion?
SA> Yes, and I am actually able to bend my knee way past 90 degrees when
the socket is cut properly. My sound knee is also in good condition.
SE>> Do you hike your hip when you walk ?
SA> No, not unless the prosthetic side is too high
SE> Has the posterior wall of the socket been lowered to allow for knee
flexion?
SA> Yes, though I am going to suggest he lower it again slightly as I
have a very pronounced hamstring and it is interfering at times when
I have worn the socket temporarily.
SE> If I can make a recommendation I would recommend to make a Short
video segment of your ambulation as an attachment to your e-mail so
it can be analyzed.
SA> I wish I had the capabilities to do that, but truthfully am quite
computer illiterate and wouldn't have the first clue as how to pull
this off.
Truly
Shai Y. Elias, CP
Citation
“Prosthetic Alignment Part III (final),” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 26, 2024, https://library.drfop.org/items/show/212600.
