AAPMR Limb Deficiency Draft
Paul E. Prusakowski
Description
Collection
Title:
AAPMR Limb Deficiency Draft
Creator:
Paul E. Prusakowski
Date:
4/11/2000
Text:
Dear subscribers,
I am posting the next draft of a segment for the Limb Deficiency Study Guide
for Chuck Levy, MD. Please direct all comments and suggestions directly to
him at <Email Address Redacted>
Thank you.
Paul E. Prusakowski, CPO
Moderator OANDP-L
> Dear List Serve Members,
>
> I am posting another draft of a question and answer for the American
> Academy of Physical Medicine and Rehabilitation's Limb Deficiency Study
> Guide. Please bear in mind that this is only a rough first draft. I have
> tried to avoid using brand names. Word counts prevent me from explaining
> in much greater depth. I would appreciate your comments. References are
> always helpful.
>
> I appreciate the help I have received in the past and will post final
> drafts in the future.
>
> Thanks,
>
Chuck Levy, MD
4.4 Objective – Evaluate the potential causes of recurrent knee buckling in
a college coach with a transfemoral amputation.
The identification of the causes of gait deviation should include assessment
for neurologic or musculoskeletal impairments that may contribute to gait
instability. A patient with a lower limb amputation specifically requires
evaluation of the residual limb for any evidence of focal or diffuse
tenderness, rash, abrasions, or ulcerations. It should also include
assessment of the prosthesis for proper fit and alignment and both static
and dynamic analysis of their gait pattern. It should include visual
evaluation of the gait pattern laterally, anteriorly, and posteriorly and
identification of the specific phase in which the gait deviation occurs.
The gait pattern should initially be assessed on a level surface. If
possible, it should also be evaluated while the patient ascends and descends
stairs and on uneven terrain, particularly if the amputee is quite active or
involved in sports activities. A patient with a poorly fitting prosthesis
may actually ambulate with relative comfort if he or she compensates to
avoid discomfort. However, careful analysis of the gait pattern may reveal
even subtle compensatory gait deviations.
One of the most common gait deviations in a patient with transfemoral
amputations is abrupt or excessive knee flexion during ambulation. This may
result in dynamic instability with recurrent knee buckling, loss of balance
and falls. (Esquenazi A. Analysis of prosthetic gait. In: Esquenazi A,
editor. Physical Medicine and Rehabilitation State of the Art Reviews.
Hanley & Belfus, Inc. Philadelphia, February 1994;8(1), 213) The prosthetic
knee joint should normally be stable in extension in stance phase from
heel-contact to foot-flat during ambulation. One of the potential causes of
prosthetic knee joint instability in stance phase includes the inadequate
compression of the heel of the prosthetic foot. This may be due to an
overly firm prosthetic heel or a prosthetic heel inserted in a tight shoe,
which limits compressibility of the heel. Other causes include a stiff
plantarflexion bumper, excessive foot dorsiflexion, overly long heel lever
arm, excessively anterior knee axis relative to the hip and ankle joints,
excessive socket flexion, severe hip flexion contracture, weak hip
extensors, change in shoe heel height from low to high, and a socket with
too small an anterior-posterior diameter.
The SACH heel may not compress adequately from heel-contact to foot-flat due
to an excessively firm heel or the SACH may fit too tightly in the shoe with
associated reduction in compressibility. Weak hip extensors are more likely
to be factor in causing knee joint instability when the amputee ambulates
with a mechanical friction knee unit, especially if the knee axis is
anterior to a straight line drawn between the greater trochanter and the
ankle. Knee flexion contracture will prevent adequate extension of the knee
at heel strike. The prosthetic socket with too small an anterior-posterior
diameter may cause undue and repetitive pressure on the hamstring tendons at
the level of the ischial tuberosity resulting in reduced hamstring function
with increased tendency for knee instability during stance phase,
particularly at heel strike. (Sanders GT. Lower Limb Amputations: a guide
to rehabilitation. Philadelphia; FA Davis, 1986:455-6).
Careful static and dynamic analysis of the gait pattern of an individual
with a lower limb deficiency, as well as close inspection of the condition
and alignment of the residual limb and prosthetic device should be helpful
in identifying and correcting the great majority of gait deviations.
Word Count for Objective 4.4: 568.
Total word count for Objectives 1.1-1.4 and 4.4: 3,168 including all bolded
& sometimes repeated references. Without the extra words due to repeated
references, total word count should be close to 3,000. Word limit is 3,000
for the aforementioned learning objectives.
Esquenazi A. Analysis of prosthetic gait. In: Esquenazi A, editor.
Physical Medicine and Rehabilitation State of the Art Reviews. Hanley &
Belfus, Inc. Philadelphia, February 1994;8(1), 213
Sanders GT. Lower Limb Amputations: a guide to rehabilitation.
Philadelphia; FA Davis, 1986:455-6
New Additional References (*indicates key reference)
Meyers PA: Malignant bone tumors in children: Osteosarcoma. Hematol Oncol
Clin North Am 1987:1;655-65.
*Dormans JP. Limb-salvage surgery versus amputation for children with
extremity sarcomas. with limb deficiency. In: Herring JA, Birch JG,
editors. The Child with Limb Deficiency. Rosemont, Illinois, published by
the American Academy of Orthopaedic Surgeons, 1998, 289-303.
*Esquenazi A. Analysis of prosthetic gait. In: Esquenazi A, editor.
Physical Medicine and Rehabilitation State of of the Art Reviews. Hanley &
Belfus, Inc. Philadelphia, February 1994;8(1), 213.
Link MP,Goorin AM, Miser AW, et al: The effect of adjuvant chemotherapy on
relapse free survival in patients with osteosarcoma of the extremity. N
Engl J Med 1986;314:1600-6.
Rougraff BT, Simon MA, Kneis JS, Greenberg DB, Mankin HJ: Limb salvage
compared with amputation for osteosarcoma of the distal end of the femur: A
long-term oncological, functional, and quality-of-life study. J Bone Joint
Surg 1994;76A:649-656
Davis AM, Devlin M, Griffin AM, Wunder JS, and Bell RS. Arch Phys Med
Rehabil 1999;80:615-8.
Dillingham TR. Rehabilitation of the Lower Limb Amputee. In: Dillingham
TR, Belandres PV, editors. Rehabilitation of the Injured Combatant, Volume
1. Washington, DC: Office of The Surgeon General at TMM Publications, Borden
Institute, Walter Reed Army Medical Center, 1998:79-159).
*Zaffer SM, Braddom RL, Conti A, Goff, and Bokma D: Total hip
disarticulation prosthesis with suction socket: report of two cases. Am J
Phys Med Rehabil 1999;78:160-2.
Nowroozi F, Salvanelli ML64: Energy expenditure in hip disarticulation &
hemipelvectomy amputees. Arch Phys Med Rehabil 1983;64:300-303.
Bowker JH, Michael JW, editors. Atlas of Limb Prosthetic and Rehabilitation
Principles. 2nd edition. St. Louis: Mosby, 1992.
I am posting the next draft of a segment for the Limb Deficiency Study Guide
for Chuck Levy, MD. Please direct all comments and suggestions directly to
him at <Email Address Redacted>
Thank you.
Paul E. Prusakowski, CPO
Moderator OANDP-L
> Dear List Serve Members,
>
> I am posting another draft of a question and answer for the American
> Academy of Physical Medicine and Rehabilitation's Limb Deficiency Study
> Guide. Please bear in mind that this is only a rough first draft. I have
> tried to avoid using brand names. Word counts prevent me from explaining
> in much greater depth. I would appreciate your comments. References are
> always helpful.
>
> I appreciate the help I have received in the past and will post final
> drafts in the future.
>
> Thanks,
>
Chuck Levy, MD
4.4 Objective – Evaluate the potential causes of recurrent knee buckling in
a college coach with a transfemoral amputation.
The identification of the causes of gait deviation should include assessment
for neurologic or musculoskeletal impairments that may contribute to gait
instability. A patient with a lower limb amputation specifically requires
evaluation of the residual limb for any evidence of focal or diffuse
tenderness, rash, abrasions, or ulcerations. It should also include
assessment of the prosthesis for proper fit and alignment and both static
and dynamic analysis of their gait pattern. It should include visual
evaluation of the gait pattern laterally, anteriorly, and posteriorly and
identification of the specific phase in which the gait deviation occurs.
The gait pattern should initially be assessed on a level surface. If
possible, it should also be evaluated while the patient ascends and descends
stairs and on uneven terrain, particularly if the amputee is quite active or
involved in sports activities. A patient with a poorly fitting prosthesis
may actually ambulate with relative comfort if he or she compensates to
avoid discomfort. However, careful analysis of the gait pattern may reveal
even subtle compensatory gait deviations.
One of the most common gait deviations in a patient with transfemoral
amputations is abrupt or excessive knee flexion during ambulation. This may
result in dynamic instability with recurrent knee buckling, loss of balance
and falls. (Esquenazi A. Analysis of prosthetic gait. In: Esquenazi A,
editor. Physical Medicine and Rehabilitation State of the Art Reviews.
Hanley & Belfus, Inc. Philadelphia, February 1994;8(1), 213) The prosthetic
knee joint should normally be stable in extension in stance phase from
heel-contact to foot-flat during ambulation. One of the potential causes of
prosthetic knee joint instability in stance phase includes the inadequate
compression of the heel of the prosthetic foot. This may be due to an
overly firm prosthetic heel or a prosthetic heel inserted in a tight shoe,
which limits compressibility of the heel. Other causes include a stiff
plantarflexion bumper, excessive foot dorsiflexion, overly long heel lever
arm, excessively anterior knee axis relative to the hip and ankle joints,
excessive socket flexion, severe hip flexion contracture, weak hip
extensors, change in shoe heel height from low to high, and a socket with
too small an anterior-posterior diameter.
The SACH heel may not compress adequately from heel-contact to foot-flat due
to an excessively firm heel or the SACH may fit too tightly in the shoe with
associated reduction in compressibility. Weak hip extensors are more likely
to be factor in causing knee joint instability when the amputee ambulates
with a mechanical friction knee unit, especially if the knee axis is
anterior to a straight line drawn between the greater trochanter and the
ankle. Knee flexion contracture will prevent adequate extension of the knee
at heel strike. The prosthetic socket with too small an anterior-posterior
diameter may cause undue and repetitive pressure on the hamstring tendons at
the level of the ischial tuberosity resulting in reduced hamstring function
with increased tendency for knee instability during stance phase,
particularly at heel strike. (Sanders GT. Lower Limb Amputations: a guide
to rehabilitation. Philadelphia; FA Davis, 1986:455-6).
Careful static and dynamic analysis of the gait pattern of an individual
with a lower limb deficiency, as well as close inspection of the condition
and alignment of the residual limb and prosthetic device should be helpful
in identifying and correcting the great majority of gait deviations.
Word Count for Objective 4.4: 568.
Total word count for Objectives 1.1-1.4 and 4.4: 3,168 including all bolded
& sometimes repeated references. Without the extra words due to repeated
references, total word count should be close to 3,000. Word limit is 3,000
for the aforementioned learning objectives.
Esquenazi A. Analysis of prosthetic gait. In: Esquenazi A, editor.
Physical Medicine and Rehabilitation State of the Art Reviews. Hanley &
Belfus, Inc. Philadelphia, February 1994;8(1), 213
Sanders GT. Lower Limb Amputations: a guide to rehabilitation.
Philadelphia; FA Davis, 1986:455-6
New Additional References (*indicates key reference)
Meyers PA: Malignant bone tumors in children: Osteosarcoma. Hematol Oncol
Clin North Am 1987:1;655-65.
*Dormans JP. Limb-salvage surgery versus amputation for children with
extremity sarcomas. with limb deficiency. In: Herring JA, Birch JG,
editors. The Child with Limb Deficiency. Rosemont, Illinois, published by
the American Academy of Orthopaedic Surgeons, 1998, 289-303.
*Esquenazi A. Analysis of prosthetic gait. In: Esquenazi A, editor.
Physical Medicine and Rehabilitation State of of the Art Reviews. Hanley &
Belfus, Inc. Philadelphia, February 1994;8(1), 213.
Link MP,Goorin AM, Miser AW, et al: The effect of adjuvant chemotherapy on
relapse free survival in patients with osteosarcoma of the extremity. N
Engl J Med 1986;314:1600-6.
Rougraff BT, Simon MA, Kneis JS, Greenberg DB, Mankin HJ: Limb salvage
compared with amputation for osteosarcoma of the distal end of the femur: A
long-term oncological, functional, and quality-of-life study. J Bone Joint
Surg 1994;76A:649-656
Davis AM, Devlin M, Griffin AM, Wunder JS, and Bell RS. Arch Phys Med
Rehabil 1999;80:615-8.
Dillingham TR. Rehabilitation of the Lower Limb Amputee. In: Dillingham
TR, Belandres PV, editors. Rehabilitation of the Injured Combatant, Volume
1. Washington, DC: Office of The Surgeon General at TMM Publications, Borden
Institute, Walter Reed Army Medical Center, 1998:79-159).
*Zaffer SM, Braddom RL, Conti A, Goff, and Bokma D: Total hip
disarticulation prosthesis with suction socket: report of two cases. Am J
Phys Med Rehabil 1999;78:160-2.
Nowroozi F, Salvanelli ML64: Energy expenditure in hip disarticulation &
hemipelvectomy amputees. Arch Phys Med Rehabil 1983;64:300-303.
Bowker JH, Michael JW, editors. Atlas of Limb Prosthetic and Rehabilitation
Principles. 2nd edition. St. Louis: Mosby, 1992.
Citation
Paul E. Prusakowski, “AAPMR Limb Deficiency Draft,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/214172.
