Use of Quantitative Gait Analysis for the Evaluation of

Prosthetic Walking Performance

Steven A. Gard, PhD

ABSTRACT
Prosthetists must be skilled in observational gait analysis to perform a rapid assessment of their client’s gait in the clinic
and make appropriate adjustments to the prosthesis to eliminate or reduce gait abnormalities. Quantitative gait
evaluations are able to provide additional, objective information to supplement the clinical observation. Although
quantitative gait analysis has become a clinically accepted means for evaluating and documenting certain pathologies that
affect pediatric gait such as cerebral palsy and myelomeningocele, routine clinical quantitative gait analyses are not
performed on lower-limb prosthesis users. Unfortunately, limitations in our understanding about the pathomechanics of
amputee gait and the functions that need to be provided by prostheses inhibit our ability to effectively use quantitative
gait data as a means to diagnose and treat observed gait deviations. Furthermore, data pertaining to amputee gait can be
difficult to assess and interpret because the data can be highly influenced by the particular choice of prosthetic
components, socket type, and suspension, as well as by the residual anatomy, abilities, and psychological well-being of the
patient. Studies of prosthetic users reported in the literature tend to indicate a lack of consistency in quantitative gait
measures, even in similar populations of amputee subjects who are walking with comparable prosthetic configurations.
Therefore, the value of using these data individually for outcome measures is questionable. At present, quantitative gait
analysis appears to be beneficial for documenting the rehabilitation progress of patients over time and may be useful for
evaluating some prosthetic gaits, but the information may not necessarily enable the experienced clinician to make better
decisions regarding prosthetic prescription or modifications. Nonetheless, it is important that we continue to strive to
effectively integrate these quantitative measurements with the experience and skill of the prosthetist and the subjective
feedback of the prosthetic user.

INTRODUCTION teristics to an able-bodied pattern for a relatively quick de-

A
quantitative gait analysis is generally considered to be
any objective means that can be used to measure
walking performance. The procedure can be as simple
as measuring step length with a ruler or determining cadence
with a stopwatch, or it can be as sophisticated as full-body
motion capture with state-of-the-art instrumentation. Re-
gardless of the methods, the measurements that are collected
are used to assess the quality of the gait and to characterize
the motion. Observational gait analysis involves a subjective
assessment of an individual’s gait, but experienced individu-
als are often able to visually identify many of the same gait
abnormalities that can be discerned with quantitative gait
analysis. However, key advantages of quantitative gait analy-
sis for persons with lower-limb pathologies are that the
results allow for easy comparison of a patient’s gait charac-
STEVEN A. GARD, PhD, is Director of Northwestern University
Prosthetics Research Laboratory and Rehabilitation Engineering
Research Program, Chicago, Illinois; is Research Associate Profes-
sor, Department of Physical Medicine and Rehabilitation, Feinberg
School of Medicine, Northwestern University, Chicago, Illinois; is
Research Assistant Professor, Department of Biomedical Engineer-
ing, McCormick School of Engineering, Northwestern University,
Evanston, Illinois; and is Research Health Scientist, Jesse Brown VA
Medical Center, Department of Veterans Affairs, Chicago, Illinois.
Copyright © 2006 American Academy of Orthotists and Prosthetists.
Correspondence: Steven A. Gard, PhD, NUPRL & RERP, 345 E. Supe-
rior, RIC 1441, Chicago, IL 60611; e-mail: sgard@northwestern.edu
termination of abnormal movements, and it documents a
patient’s gait at a particular point in time so rehabilitation
progress can be tracked.
Using quantitative gait analyses to fully describe a person’s
gait generally entails the combination of a multitude of
measurements, including temporal-spatial parameters, kine-
matics, kinetics, and energy expenditure. When presented
with large quantities of descriptive measurements, wading
through all of the data and picking out relevant information
can take a tremendous amount of time and effort. However,
the process can generally be facilitated by involving someone
who is knowledgeable about the measures and skilled in
analyzing and interpreting the data. Visual gait analysis,
performed first-hand or by viewing a videotape recording of
the subject’s gait, can greatly aid with the interpretation of
the quantitative gait data.
Once regarded as a research endeavor, quantitative gait
analysis has now become a clinically accepted means for
documenting and evaluating the characteristics of a person’s
gait, particularly in the presence of pathologies that affect
walking. Presently, there are numerous clinical gait analysis
laboratories dedicated to the evaluation of children with
cerebral palsy, myelomeningocele, or other disabling condi-
tions that affect walking. The results from these analyses are
used by physicians and therapists to determine appropriate
surgical interventions or courses of treatment for the child
with the intent of improving walking efficiency and appear-
ance. Gait analyses are typically performed before and after

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the intervention to determine efficacy of treatment. Treat-
ment is considered beneficial if improvement in the gait
pattern is observed, evident by a reduction in abnormal
movements with an evolution toward patterns that are more
like those of able-bodied individuals.
Gait analysis may be useful for evaluating an amputee’s
prosthesis by providing objective measurements that charac-
terize the walking pattern.1 Fundamentally, the prosthetist’s
goal in fitting a lower-limb amputee is to restore the ability
to perform everyday activities in an easy, natural, and com-
fortable manner. The prosthesis user’s basic requirements of
the prosthetic limb are comfort, function, and appearance,
the latter embracing both cosmetic appearance and appear-
ance in use.2 The goals of the practitioner and the patient are
similar, but prosthesis users may not be able to fully or
accurately articulate what they perceive when they stand and
walk, making it difficult for the prosthetist to make all of the
necessary adjustments. Augmenting the human body with a
prosthesis markedly affects the individual’s mode of travel,
and the task of the clinician should be to recognize optimal
gait with a given device so that departures from the standard
can be identified, their causes determined, and, wherever
possible, corrected.3 Of all the elements affecting locomotion,
those most amenable to change relate to the device; thus, in
the description of walking patterns, emphasis should be
placed on prosthetic design, alignment, and fit.
Subjective methods of gait assessment may be inadequate
for optimizing the gaits of lower-limb amputees.4 However,
the benefit of performing routine clinical quantitative gait
analyses has yet to be realized for several different reasons.
Cost is a primary deterrent to performing clinical gait anal-
yses, because much time and effort are required by trained
personnel for the acquisition, processing and interpretation
of data. Clinicians want gait analysis techniques that can be
routinely used in the diagnostic and decision-making pro-
cess, and if these techniques were able to improve the quality
of patient care or reduce treatment cost, they would probably
find widespread clinical acceptance.5 Too, limitations in our
understanding about the pathomechanics of amputee gait
and the functions that need to be provided by prostheses
inhibit our ability to effectively use quantitative gait data as a
means to diagnose and treat observed gait deviations. Fur-
thermore, data pertaining to amputee gait can be difficult to
assess and interpret because it can be highly influenced by
the particular choice of prosthetic components, socket type,
and suspension, as well as by the residual anatomy, abilities
and psychological well-being of the patient.
Prosthetists must be skilled in observational gait analysis
to perform a rapid assessment of their client’s gait in the
clinic and make appropriate adjustments to the prosthesis to
eliminate or reduce gait abnormalities. Quantitative gait eval-
uations are able to provide additional, objective information
to supplement the clinical observation, and it may prove to be
useful for documenting the rehabilitation progress of patients
over time. The gaits of amputees vary according to a number
of factors, including the level of their amputation, their state
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of health, and whether they have unilateral or bilateral am-
putations. Typically, the more distal the amputation, the
better control the amputee has of his prosthesis, the more
efficient the gait, and the more closely their pattern of walk-
ing resembles that of able-bodied persons. As the level of
amputation occurs more proximal, the amputee must com-
pensate for his loss to a greater extent and more abnormal
gait patterns usually result. Despite the objective data, the
information gained from a quantitative gait analysis will
probably not enable the experienced clinician to make better
decisions regarding prosthetic prescription or indicate how
the prosthesis should be modified. Even though deviations
from a normal gait pattern can be readily discerned in the
quantitative data, diagnosing the origin of the problem can be
difficult.
Despite limited clinical utility, quantitative gait analyses
are useful to researchers in gait and lower-limb prosthetics.
Published studies report on the analyses of different walking
parameters for the purpose of characterizing amputee gait
relative to able-bodied persons, and for comparing the effects
of different types of prosthetic components on walking abil-
ity. These data may benefit therapists by enabling them to
better recognize and identify abnormalities in gait and to
develop more appropriate training regimens that would allow
prosthesis users to walk more efficiently. Additionally, the
information could potentially be used for establishing guide-
lines for prosthetic prescription. Researchers may also use
the data from quantitative gait analyses to identify and ad-
dress deficiencies in current prosthetic componentry that
prevent amputees from walking with more normal patterns of
gait and with greater efficiency. However, gait analyses are
not typically performed on prosthetic users for clinical deci-
sion-making, because on individual patients the data have not
been shown to be particularly enlightening or indicative of a
particular prosthetic or therapeutic solution. There are prob-
ably very few cases, if any, when a prosthetist would change
his mind about component selection or prosthesis adjust-
ment based upon the results of a quantitative gait analysis. It
is widely known that prosthesis users typically demonstrate
gait patterns that are different from those of able-bodied
individuals, with specific patterns generally being adopted
according to their level of involvement and type of prosthetic
components used to construct the prosthesis. However,
quantitative gait analyses are not diagnostic; that is, it is
generally not possible to analyze a set of gait data and be able
to diagnose a condition that prosthetic prescription or mod-
ification would alleviate. At the moment, the preferred and
likely better means of optimizing a person’s gait requires
open dialogue between the prosthetic user and his or her
prosthetist, combined with the careful attention, observation
and experience of the prosthetist.
A number of gait parameters are used to characterize
human ambulation, and these may potentially be used to
document prosthetic outcomes. Temporal-spatial parame-
ters, such as walking speed, cadence, and step length, are
useful because they provide gross indications of overall walk-
Number 6 • Proceedings • 2006
SSC Proceedings Use of Quantitative Gait Analysis for the Evaluation of Prosthetic Walking Performance
ing ability, and many of them can be made with simple
clinical methods or tools. Other measures, such as joint
kinematics and kinetics, ground reaction forces, and energy
expenditure, require more sophisticated, expensive equip-
ment that may not be practical for clinical purposes. The
purpose of this article is to review many of the typical mea-
sures of quantitative gait analyses reported in the literature
for evaluating prosthetic walking performance, particularly
those that may be used as outcome measures. Although many
quantitative gait studies have been performed on users of
prosthetic limbs, this document is not intended to be a
comprehensive review. Rather, this paper presents an over-
view of some of the more widely accepted gait measures that
have been employed for prosthetic gait analyses and provides
typical results from those types of studies.
TEMPORAL-SPATIAL GAIT PARAMETERS
Temporal-spatial parameters are particularly useful measure-
ments for prosthetic evaluation because they provide funda-
mental timing and position information about a person’s gait,
and they can be made relatively easily in a clinical setting
with simple measurement tools. The most common tempo-
ral-spatial parameters used are walking speed, stride length,
step length and cadence. Able-bodied adults tend to demon-
strate similar temporal-spatial measures at freely-selected
walking speeds. Persons with lower-limb amputation gener-
ally exhibit characteristics inferior to those of able-bodied
persons but are generally comparable across individuals,
based on their level and cause of amputation.
Walking speed probably provides a better indication of a
person’s walking ability than any other quantitative gait mea-
sure. The speed of walking is directly associated with the
biomechanics of gait, which relies on achieving and main-
taining forward momentum of the body mass, accelerating
the masses of the body segments from one step to the next,
transferring load from one leg to the other, and taking
advantage of energy conserving mechanisms, thereby achiev-
ing an efficient, dynamic walking pattern. Most adult, able-
bodied ambulators typically adopt freely-selected speeds of
approximately 1.2 to 1.5 m/sec.6,7 The freely-selected walking
speed is the comfortable speed that an individual naturally
chooses and is believed by many to represent the speed at
which the energy expended per unit distance traveled is
minimized. Related evidence suggests that the body’s conser-
vation of mechanical energy is greater at freely-selected
speeds than at speeds significantly faster or slower.8
Persons who walk with lower-limb prostheses generally
walk slower than able-bodied persons, with those persons
having more proximal levels of amputation typically adopting
slower speeds. Unilateral transtibial amputees have been re-
ported to walk at freely-selected speeds from about 1.0 to 1.3
m/sec.9,10 Transfemoral amputees typically walk at freely-
selected speeds from about 0.9 to 1.2 m/sec.11–13 Because
their walking speeds are generally slower, prosthetic users
may not have sufficient body dynamics to enable them to take
Number 6 • Proceedings • 2006
full advantage of the energy-conserving mechanisms utilized
during able-bodied gait. Walking speed can be used as a
means to assess prosthetic performance by determining if
prosthetic modification produces a higher freely-selected
speed. Presumably, an increase in a prosthetic user’s freely-
selected speed indicates that the prosthetic configuration is
able to produce a more efficient pattern of walking. However,
most of the walking parameters analyzed using quantitative
gait analysis are known to vary with walking speed. Therefore,
when comparing pathological gait data with that of able-
bodied individuals, it is important to distinguish between
variations due to walking speed and those due to the pathol-
ogy.14
The stride length is the linear distance along the line of
progression that a person travels during one gait cycle. Stride
length, by definition, must be the same when measured on
either side of the body for both normal and pathological gaits.
For a unilateral amputee, the distance traversed during a
stride will be the same whether it is measured on the pros-
thetic side or the sound side. By definition, the stride length
is equal to the sum of the right and left step lengths. Able-
bodied persons walking at freely-selected speeds generally
adopt a stride length of about 1.4 to 1.5 m, with step lengths
of approximately 0.7 to 0.75 m.7,15 In normal walking, the
right and left step lengths are generally equal, but this is
typically not the case for pathological gaits. For persons with
unilateral amputation, the prosthetic step length is usually
slightly longer than the sound limb step length. A satisfactory
explanation for this difference has not been offered, but it
may relate to stability during stance phase or to foot/ankle
function of the prosthesis. Walking speed is equal to the
product of one-half the stride length and the cadence, where
cadence is simply the number of steps taken per unit time.
Able-bodied ambulators typically walk with a cadence of
about 110 steps/min at freely-selected speeds.7,15 Higher
walking speeds are accompanied by simultaneous, predictable
increases in cadence and stride length in able-bodied individ-
uals,6,16 but amputees may demonstrate a greater reliance on
one mechanism or the other to increase their speed due to
constraints imposed by amputation or by their prostheses.
Temporal-spatial measures are useful for characterizing
walking performance of amputees, with values that typically
cluster for prosthetic users having similar amputation levels
and cause of amputation. Dysvascular transtibial amputees
have been shown to walk with significantly slower freely-
selected walking speeds than traumatic transtibial amputees
(0.85 vs. 0.99 m/sec).17 Unilateral transfemoral amputees
walking with constant-friction knee components have been
found to adopt a significantly slower freely-selected speed (1.0
m/sec), a lower cadence (87 steps/min), and a shorter stride
length (1.36 m) compared with able-bodied subjects.12 Addi-
tionally, the amputee subjects demonstrated a significantly
shorter step length with their sound leg than with their
prosthesis (0.64 m vs. 0.72 m), a result that is typical of
persons with unilateral amputations. The relatively shortened
sound step length may have resulted from the inability of the
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subjects to actively plantarflex the prosthetic ankle to raise
the heel, and from the inability to flex the prosthetic knee
until weight was transferred to the forward limb. One study of
unilateral transfemoral amputees measured a mean freely-
selected speed of 1.13 m/sec, with a cadence of 90.5 steps/
min.18 The stride length of the transfemoral amputee sub-
jects was comparable to that of able-bodied individuals, indi-
cating that cadence appeared to be the primary factor that
limited walking speed. Similar results were reported in a
study that found transfemoral amputees walking at faster
self-selected speeds utilized longer step lengths and lower
cadences relative to able-bodied individuals.11 These findings
may not be particularly surprising, as transfemoral amputees
often believe that it is the swing of their prosthesis that limits
their ability to walk at different speeds. Quantitative gait
measures have also been used to track the rehabilitation of
transfemoral amputee patients; walking speed was observed
to increase by 48% after prosthetic training,19 a period of
approximately 6 to 7 weeks. The temporal-spatial measures of
gait reported here are consistent with results from other
studies of unilateral transfemoral amputees.11,20
Symmetry between temporal-spatial measures for the
sound and prosthetic legs of unilateral amputees is often used
as a means to evaluate prosthetic gait, but the value of using
gait symmetry as a performance measure is questionable. It
has been suggested that symmetry between the sound and
prosthetic limbs is the best method to analyze and evaluate
different prosthetic feet.21 However, the mass of prosthetic
limbs is generally lower than that of an anatomical leg, the
segmental positions of the centers of mass are different, and
the moments of inertia are typically reduced, which would
affect the swing of the prosthesis. Additionally, the prosthesis
does not function as well as the sound leg, so the amputee
typically compensates for the inadequacies of the prosthesis
through the actions of his sound leg. Therefore, it is not only
the prosthetic leg that affects the pattern of walking, but the
adaptation of the anatomical leg as well. Symmetry between
the sound and prosthetic legs is typically concerned with an
assessment of appearance during walking (i.e., step length or
timing issues), when in fact it is gait function that should be
addressed. Therefore, asymmetries between the sound and
prosthetic limbs should not necessarily be the basis for de-
termining the quality of a person’s gait. When an amputee is
learning to walk with a prosthesis, he or she may seek out a
new nonsymmetrical pattern of walking that is optimal
within the constraints of his or her residual anatomy and the
mechanics of the prosthesis.9 Furthermore, when a prosthe-
tist fits a client with a prosthesis and incorporates different
components or changes alignment, there will likely be trade-
offs in gait performance that will affect symmetry. For exam-
ple, it may be possible to improve gait symmetry through
changes in prosthetic alignment,22 but doing so could ad-
versely affect other key parameters of walking, such as speed.
Conversely, some prosthetic components may improve loco-
motor function during gait, such as with increased shock
absorption or improved forward progression, but they may
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reduce gait symmetry.10 Therefore, prosthetists must care-
fully evaluate their clients’ gait to determine the effects of
various interventions and prosthetic modifications, and
weigh the advantages and disadvantages appropriately when
trying to arrive at an optimal prosthetic solution.
Temporal-spatial measures have also been used in re-
search studies to determine the effects of different types of
prosthetic components on amputee gait. However, the results
from many studies that perform similar comparisons of com-
ponents are often at odds. For example, faster freely-selected
walking speeds have been reported for unilateral transtibial
amputee subjects walking with a Flex Foot (Ossur, Reykjavik,
Iceland) compared with when they walked with a SACH
foot.23 However, no differences in walking speed were re-
ported for transfemoral amputees walking with a Flex Foot
and a SACH foot.24 A study of unilateral transtibial amputee
subjects walking with a Seattle Lite Foot (Seattle Systems,
Poulsbo, WA) and a SACH foot reported no statistically or
clinically significant differences.25 In another study, gait
analysis was used to compare six prosthetic feet—the SACH,
SAFE II (Campbell Childs, White City, OR), Seattle Lite Foot
(Seattle Systems), Quantum (Hosmer Dorrance, Campbell,
CA), Carbon Copy II (Ohio Willow Wood, Mt. Sterling, OH),
and Flex-Walk (Ossur)—in male unilateral transtibial ampu-
tees on the basis of various temporal and spatial measures of
walking.21 The investigators observed statistically significant
differences between vascular and traumatic amputee groups
in walking speed (0.75 vs. 1.01 m/sec), cadence (82.4 vs. 94.7
steps/min), and stride length (1.1 vs. 1.4 m). Additionally,
some differences in sound limb step length were observed in
only the traumatic group between the different prosthetic
feet. Another investigation compared the gait of transtibial
amputees wearing a single-axis foot, a Seattle Lightfoot, and
a Flex Foot.26 Regardless of foot type, the subjects were
observed to walk slower than able-bodied control subjects
(63.3 to 65.8 m/min vs. 78.5 m/min, respectively), and their
stride length was shorter (1.21 to 1.26 m vs. 1.41 m, respec-
tively). In a study that compared the SACH foot with four
different dynamic elastic response feet, there were no clini-
cally significant differences between the feet during freely-
selected or fast walking on level ground, nor was symmetry
affected.27 An investigation of dysvascular transtibial amputee
subjects reported that a Flex Foot significantly increased
walking speed compared with a SACH foot, and significantly
increased stride length compared with a Seattle, Carbon Copy
II (Ohio Willow Wood), and SACH foot.28 In a study that
compared six different prosthetic knee joints in transfemoral
amputees, no differences were observed in the freely-selected
walking speed, step length, or cadence.29 However, the inves-
tigators did find that cadence-responsive knees—those incor-
porating hydraulic or pneumatic damping mechanisms for
swing phase control—permitted higher walking speeds with
less perceived effort. The investigators concluded that the
more complicated prosthetic knee designs offered little ben-
efit when walking on flat level surfaces. Other studies, how-
ever, report higher walking speeds and improved symmetry
Number 6 • Proceedings • 2006
SSC Proceedings Use of Quantitative Gait Analysis for the Evaluation of Prosthetic Walking Performance
when subjects walked with knees providing swing-phase con-
trol compared with when they walked with a constant friction
knee.30,31 In a study that investigated age and causative
effects on transfemoral amputees walking with a locked ver-
sus unlocked prosthetic knee, older amputees who had an
amputation secondary due to vascular problems were found
to adopt faster freely-selected walking speeds with a locked
knee than with an unlocked knee, whereas younger traumatic
amputees walked faster with the unlocked knee.32
Unfortunately, the disparate results presented here for
different quantitative studies that use temporal-spatial pa-
rameters to characterize walking performance of amputee
subjects are typical, and as a result they are difficult to draw
conclusions from for the purposes of influencing prosthetic
prescription. Studies that compare different types of pros-
thetic components often do not agree, which may relate to
slightly different methodologies being adopted by investiga-
tors, to the small numbers of research subjects that are
included in the study, or to different amounts of accommo-
dation time that subjects are permitted on each component
before data collection. Different sets of inclusion/exclusion
criteria used by investigators may also influence the outcome
of the studies. Differences among individual amputee sub-
jects may also relate to physical capabilities, training, confi-
dence, and experience. Temporal-spatial measures are appeal-
ing because they are simple to acquire and easy to
comprehend, but they appear to lack consistency and repeat-
ability as a dependable outcome measure when evaluating
prosthetic gait.
KINEMATIC GAIT MEASURES
Kinematic measures describe the position, velocity, and ac-
celeration of an object without regard for the forces that
create the observed motion. Temporal-spatial parameters are
one form of kinematic data that have been set apart from
what are now considered the typical kinematic gait measures.
In quantitative gait analysis, kinematics provide detailed in-
formation about the linear and angular motions of the trunk
and body segments. Of particular interest are the rotations of
the pelvis and the joints of the leg. Data are typically pre-
sented as graphical curves that show how the body moves
over the course of a gait cycle. When matched according to
walking speed, the characteristics of the kinematic curves for
able-bodied ambulators are remarkably similar. Kinematic
data acquired from pathological gaits are typically analyzed
by utilizing a type of differential analysis, plotting able-bodied
curves onto the same graphs as patient or subject data so that
deviations from normal can be readily discerned. Addition-
ally, kinematic curves from different gait analyses performed
on the same subject can be plotted onto the same graph to
facilitate the identification of changes that occur in a person’s
gait due to different interventions or testing conditions.
Kinematic data acquired from prosthetic users must be
interpreted in light of the assumptions that are used to create
the link segment model from which kinematic measures are
Number 6 • Proceedings • 2006
derived. In the model, physical joints are assumed to exist at
the junction between the various limb segments; that is, an
ankle joint is assumed to connect the foot segment to the
tibia segment. Many amputees do not have physical ankle
joints in their prostheses, so in a set of kinematic curves what
appears to be prosthetic ankle joint motion is simply the
result of bending in the keel of the prosthetic foot. Addition-
ally, joints are generally assumed to rotate about a single axis
or center of rotation, which can present problems when
scrutinizing data of knee kinematics acquired from a trans-
femoral amputee walking with a polycentric knee joint.
Therefore, caution is urged when analyzing kinematic walk-
ing data acquired from a prosthesis user.
Quantitative gait studies have repeatedly shown that am-
putees typically demonstrate different gait kinematics than
able-bodied individuals. Of course, visual analysis of an am-
putee’s gait often indicates that the pattern of walking is
different from normal, but kinematic analysis can help iden-
tify the joints in the body that are affected, and may help
determine the causative source from which those abnormal
movements originate. The kinematic patterns of prosthetic
joints are usually very different from the anatomical joint
they replace, owing to deficiencies of the technology and
incomplete knowledge about the function being provided.
Furthermore, more proximal levels of amputation demand
greater compensatory actions to walk, so deviations from
normal movement patterns are often observed in the ana-
tomical joints of the residual limb and of the sound limb.
Transtibial amputees tend to walk with similar kinematics
as able-bodied individuals, but subtle differences can some-
times be distinguished in kinematic data. Primarily, the ankle
kinematics of their prosthetic limb will differ from the nor-
mal pattern due to the inability to plantarflex in late stance
phase. Knee kinematics for the sound and residual limbs may
also be affected. Some unilateral transtibial amputees have
reduced prosthetic-side knee flexion in early stance phase of
walking at their freely-selected speeds.33 On the sound side,
excessive stance-phase knee flexion angles of transtibial am-
putees during early stance phase have been speculated to be
a compensatory action to reduce impact forces due to im-
paired ability to transfer body weight from the prosthetic
limb onto the sound side.28 Differences between the kine-
matic walking data of transtibial amputees and that of able-
bodied individuals may be due to both the loss of the normal
foot-ankle mechanism and the compensatory actions that are
required by the prosthesis user to overcome this deficiency.34
Transfemoral amputees tend to demonstrate greater devi-
ations from able-bodied gait kinematic patterns than trans-
tibial amputees. The patterns of motion on the prosthetic side
of transfemoral amputees generally resemble those of able-
bodied individuals, but the magnitudes of rotation tend to be
reduced.35 Transfemoral amputees have been reported to
walk with slightly reduced prosthetic swing phase knee flex-
ion (45° ⫾ 13°) compared with their sound leg (51° ⫾ 6°) or
with that typically achieved by able-bodied persons.36 Trans-
femoral amputees usually demonstrate a complete absence of
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stance-phase knee flexion during the loading response phase
of gait on the prosthetic limb, particularly when walking with
single-axis knees.12 Some prosthetic knees are designed to
restore stance-phase knee flexion, but a few degrees of added
flexion during stance can be difficult to detect using obser-
vational gait analysis due to minute changes in the appear-
ance of the knee and the short duration of the event. How-
ever, kinematic data can be particularly useful for verifying
their proper operation and use with accurate measurement of
the magnitude of the stance-flexion wave.37–39
Kinematic data can be useful for identifying compensatory
movements used by amputees during walking. Some trans-
tibial amputees may exhibit hip-hiking—a compensatory ac-
tion to lift the pelvis on the side of the swing leg to increase
foot clearance— during prosthetic swing phase. Transfemoral
amputees typically exhibit hip-hiking during prosthetic swing
phase, and they sometimes demonstrate it during sound limb
swing phase as well. As a result of hip-hiking, the pelvic
obliquity patterns in persons with unilateral transtibial or
transfemoral amputations are often different from normal,
showing asymmetry with less excursion during prosthetic
stance phase and with significantly different timing during
the gait cycle.40 A persistent offset in the pelvic obliquity
waveform toward the prosthetic side in transtibial and trans-
femoral amputee subjects may indicate that some lower-
extremity amputees suffer from a dynamic leg-length discrep-
ancy that can be detected only with instrumented gait
analysis.40 This characteristic has also been observed in some
children walking with known leg length discrepancies, with
the pelvis continually listing toward the side of the shorter
limb during gait.41 Vaulting, another compensatory move-
ment in which the sound limb ankle plantarflexes during
midstance to raise the body and increase prosthetic swing
phase foot clearance, can also be readily identified in kine-
matic data.12,35,42 Hip-hiking and vaulting both require mus-
cular effort to lift the body against gravity, increasing the
energy required for walking and altering the normal kine-
matic patterns of motion. However, merely identifying devi-
ations in the kinematic patterns of prosthesis users does not
necessarily diagnose the root cause of the problem. Presum-
ably, identifying and addressing functional deficiencies in the
prosthesis would reduce these observed differences and en-
able more normal walking patterns.
Studies have been conducted to determine how different
prosthetic components affect walking kinematics. The major-
ity of these investigations have attempted to discriminate
between the effects of different prosthetic foot designs. Gen-
erally, more compliant prosthetic feet are typically observed
to produce greater apparent ankle dorsiflexion during late
stance phase than stiffer feet. In one study, transtibial ampu-
tee subjects walking with six different prosthetic feet dem-
onstrated some significant differences in the late-stance ankle
dorsiflexion occurring at opposite heel contact, and in the
ankle initial plantarflexion to dorsiflexion transition occur-
ring during early to late stance phase.21 The investigators in
this study pointed out that the quantitative differences be-
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tween the prosthetic feet demonstrated each one was activity-
and gait-specific for the individual amputee. Another study
showed that a Flex Foot and Quantum foot provided signifi-
cantly increased dorsiflexion in late stance phase compared
with a Seattle, Carbon Copy II, or SACH foot.28 A similar
study compared walking performance on a SACH foot to a
Flex Foot, a Carbon Copy II, a Seattle Foot, and a STEN
(Kingsley Manufacturing Co., Kelso, WA) foot, and reported
that the Flex Foot increased dorsiflexion throughout the
prosthetic stance phase.27 No other kinematic parameters
were affected, and the investigators concluded that there
were no clinically significant differences among the different
prosthetic feet.
Plots of kinematic data curves that show how the leg joints
and pelvis move during the gait cycle are useful for charac-
terizing pathological gaits. Using differential analysis to com-
pare data from prosthetic gait with that of able-bodied indi-
viduals facilitates the identification of abnormal movements
because, at a glance, deviations from normal can be easily
recognized. However, the literature is replete with inconsis-
tencies in kinematic data that have been reported for similar
samples of amputee subjects who were walking under com-
parable testing conditions. Therefore, kinematic data do not
appear to be particularly useful as outcome measures for
prosthetic ambulation.
KINETIC GAIT MEASURES
Kinetic measures of walking are useful for assessing aspects
of gait that are not readily evident through visual gait analysis
or by analyzing kinematic data alone. Kinetic parameters
include the forces, moments, and powers associated with
limb movement. These measures may relate to the user’s
perception of the interaction between their residual limb and
the prosthesis during walking.
The ability of a person to move through space requires
some structure external to the body against which bodily
forces can be exerted. In normal human ambulation, this
structure is generally and primarily the ground. According to
Newton’s Third Law, a force acting on an object creates an
action for which there is an equal and opposite reaction.
Therefore, the forces exerted by the body through the legs
resist the pull of gravity and serve to move the body forward,
and they produce equal and opposite reaction forces by the
ground. The ground reaction force is a 3-dimensional vector
quantity, typically displayed in three orthogonal components
defined by the walkway coordinate system. The profiles of the
ground reaction force components reflect the dynamics of
gait and are indicative of the accelerations imposed on the
body’s center of mass.
The orientation and magnitude of the ground reaction
force vector is one of the primary determinants of the joint
moments that are produced during the stance phase of walk-
ing. Joint moments are created about the ankle, knee and hip
joint axes of rotation to either produce or oppose rotational
motion during gait. Accurate moment calculations require
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SSC Proceedings Use of Quantitative Gait Analysis for the Evaluation of Prosthetic Walking Performance
knowledge about the masses of the limb segments, the loca-
tion of the segmental centers of mass, and the distribution of
mass within the segments. This information is generally not
known for prosthetic limbs, so caution is advised when ana-
lyzing and interpreting joint moment data calculated for
amputee gait.
Joint powers are probably one of the more popular param-
eters of interest in clinical gait analysis. The joint power
during walking is equal to the product of the instantaneous
joint moment and angular velocity. Joint powers can be
particularly revealing when considering the contribution of
the ankle and hip joints to forward progression, but limita-
tions and assumptions of the model used to perform the
power calculations can make interpretation difficult, partic-
ularly at the prosthetic ankle joint. Because passive pros-
thetic components cannot actively produce power, what ap-
pears to be power absorption and generation associated with
ankle push-off in late prosthetic stance phase probably rep-
resents energy storage and return, respectively, from a pros-
thetic foot and/or ankle mechanism.
The vertical component of the ground reaction force is the
largest, and most studied, of the three components, and has
a characteristic double hump for able-bodied individuals
walking at comfortable self-selected speeds. The first peak of
the vertical ground reaction force is believed to be particu-
larly important for analyzing shock absorption that occurs
during the loading response phase of gait. Persons with
unilateral transtibial amputations have been reported to walk
with decreased vertical ground reaction forces under their
prosthetic limb compared with able-bodied individuals,
whereas the forces under their sound limb are slightly great-
er.43– 45 Similarly, unilateral transfemoral amputees have
been found to produce greater vertical ground reaction forces
with their sound leg than with their prosthetic limb.35,45
Differences in the fore-aft ground reaction forces have also
been observed between the prosthetic and sound sides of
unilateral transtibial and transfemoral amputees, with forces
under the sound limb typically having a larger magnitude.45
These differences become even more pronounced as speeds of
walking increase, suggesting that amputees may walk more
cautiously on their prostheses to reduce the magnitude of the
transmitted force to their residual limbs. Alternatively, the
bulk of residual limb soft tissue that interfaces with the
socket may serve to decrease stiffness on the prosthetic side
and thus automatically reduce the magnitude of ground
reaction forces without conscious intervention by the pros-
thesis user. Some bilateral amputees with transtibial ampu-
tation of one leg and a knee disarticulation on the other were
observed to walk with higher peak magnitudes of the vertical
ground reaction force on their knee disarticulation side.46
Ground reaction forces may be higher for persons with a knee
disarticulation due to the reduced bulk of soft tissue that
provides load bearing through the residual limb, making the
residual limb/prosthesis system stiffer than either a trans-
tibial or transfemoral amputation would provide.
Measurements of the ground reaction forces have been
Number 6 • Proceedings • 2006
used to analyze the effects of different shock absorbing com-
ponents on gait and may provide some indirect indication of
the force and pressure sensation that prosthetic users per-
ceive on their residual limbs. Studies have demonstrated
reduced peak forces under the prosthesis during running and
other high impact activities when shock-absorbing compo-
nents are placed in the prosthesis. In one study, differences in
ground reaction forces and moments of force during the gait
of a transtibial amputee were measured using the Re-Flex
Vertical Shock Pylon (VSP; Ossur) as designed and with the
shock absorber immobilized.47 Investigators found that when
subjects walked with the VSP, the vertical and the fore-aft
components of the ground reaction force on the prosthetic
side were slightly decreased during the loading response
phase, a period when shock absorption is critical. In another
study, quantitative gait measures were used to analyze the
effect of the Re-Flex VSP on two transtibial amputees who
were walking and jogging in place.48 Few biomechanical
differences were found for walking when comparing trials
with and without the VSP, but increases in vertical ground
reaction forces were noted during fast walking and jogging
with the VSP. Though these results are counterintuitive, they
probably relate to the ability of prosthesis users to readily
adapt to prosthetic modifications. Subjects may have applied
greater impact forces to their prostheses when using the VSP
because of its increased shock absorption capabilities. In a
study of unilateral transtibial amputee subjects walking at
freely-selected slow and fast speeds with and without an
Endolite TT (Telescopic-Torsion) Pylon (Endolite North
America, Centerville, OH), few quantitative changes were
found in kinematic and kinetic gait parameters.10 However,
the investigators did observe a reduction in a force transient
associated with impact loading during the prosthetic loading
response phase, an effect that was more evident at walking
speeds above about 1.3 m/sec when shock forces are greater.
In a study involving transtibial amputee subjects walking
with a SACH foot and four different types of dynamic elastic
response feet, similar ground reaction force patterns were
observed among all of the feet.27 However, there was an
increased dorsiflexion moment that occurred about the ankle
joint during stance with a Flex Foot. In a similar study,
measurements of the vertical ground reaction force were
used to compare the gaits of unilateral transtibial amputees
walking with a SACH foot, a Seattle foot and a Jaipur (Vhag-
wan Mahaveer Viklang Sahayata Samiti, Jaipur, India) foot.49
The SACH foot was found to provide better shock absorption
(i.e., a smaller impact force peak) than the other two feet.
Conversely, another study reported better shock absorption
in the Seattle foot compared to the SACH.50 Prosthetic foot
type does not generally appear to affect loading characteris-
tics in the prosthetic limb, but it does appear to influence the
ground reaction forces under the sound limb.25,28,51–53
Amputee subjects consistently demonstrate reduced ankle
power in late prosthetic stance phase compared with able-
bodied ambulators. In one study, ankle joint powers were
analyzed in unilateral transtibial amputees to determine en-
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ergy return from a SACH foot and two other energy-storing
feet.9 The data showed that the energy-storing feet were able
to return 20% to 30% more energy than the SACH foot.
Another study showed greater energy absorption and return
at the ankle by transtibial amputees walking with a Flex Foot
compared with a SACH foot. Energy return by the Flex Foot
was greater than with the other feet, but it had no effect on
the pattern or magnitude of the knee and hip joint powers
compared with the SACH foot.33 In a study that compared the
gaits of unilateral amputees walking with a SAFE II foot and
a Flex Foot, the Flex Foot provided greater power absorption
(i.e., energy storage) during early to midstance, and a trend
toward a greater plantarflexion moment and power genera-
tion (i.e., energy return) in late stance.54 Other studies have
reported similar results, indicating that dynamic elastic re-
sponse feet store and return more energy than SACH feet or
other types of less dynamic feet.53,55–57 How this increased
energy returned by dynamic elastic response feet is utilized
by the prosthetic user for walking has not been sufficiently
explained. In response to the reduced ankle powers associated
with the prosthetic side, it appears that transtibial amputees
increase power generation by the anatomical knee and hip
joints of their residual limbs.58
Individuals with amputations may modify the way they
walk based on the perception of the forces, moments, and
pressures transmitted between their residual limbs and pros-
theses. A change in gait that is visually apparent can be
confirmed with kinematic gait measures. However, kinemat-
ics provide no direct indication of the forces and moments
imposed on the residual limb by the prosthesis. Kinetic
measures of walking are useful because they convey informa-
tion that cannot be discerned visually by an observer, and
they may directly relate to what the prosthetic user perceives
while they walk. Nonetheless, research studies have failed to
demonstrate consistent results in kinetic measures— ground
reaction forces, joint moments, and powers—from various
investigations of amputee gait and prosthetic components.
Some of the variability undoubtedly relates directly to the
inconsistency of the kinematic data, which has already been
mentioned. Therefore, kinetic measures do not appear to be
reliable clinical outcome measures for assessing prosthetic
gait performance.
ENERGY EXPENDITURE
When considering the different measurements employed in
conducting a quantitative gait analysis, it is difficult to point
to any single measure as being more important than the
others. Temporal-spatial parameters provide fundamental
gait characterization; kinematic data are useful for determin-
ing patterns of individual joint motion during gait; and ki-
netic data indicate how force is being transmitted to the leg,
the influence of that force on joint rotation, and how the
joints ultimately affect motion (i.e., joint moments and pow-
ers). These measures are typically taken together and used to
characterize an individual’s gait, but they do not directly
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indicate a person’s efficiency or perceived effort during the
activity. However, energy expenditure measurements may
provide some of the most informative data for assessing
walking efficiency because they represent an aggregate mea-
sure of overall walking performance that corresponds with
the perceived effort required by an individual to ambulate.
Because amputees are anatomically deficient they may re-
quire some form of compensatory action, or combination
thereof, to achieve adequate, functional ambulation. The loss
of one of the major joints of the lower extremity may be
almost fully compensated for by exaggerated motions at other
levels, but the loss of two or more major joints of the lower
extremity makes effective compensation nearly impossible,
and the cost of locomotion in terms of energy is increased
with an inevitable drain upon ambulation economy.59
Energy expenditure may be expressed as a rate (i.e., energy
expended per unit time) or as an energy cost (i.e., energy
expended per unit distance). The energy expenditure rate is
equal to the product of the energy cost and the steady-state
walking speed. Energy expenditure measurements are typi-
cally made by indirect means using a face mask to capture
respirations to monitor O2 consumption and CO2 production
as subjects ambulate at a steady-state speed.
Some researchers have claimed that individuals possess a
single speed of walking that corresponds to a minimum level
of energy cost and at or near this most comfortable speed
there is minimal use of muscles with maximal reliance on
gravity and pendulum action. However, human beings are
unlikely to have a natural or habitual mode of walking,
although we may have a preferred mode in a given environ-
mental situation.60 Most able-bodied adults are able to com-
fortably walk at speeds in the range of about 1.0 to 1.7
m/sec.61 Over this range, the energy cost curves are relatively
flat, indicating that virtually uniform efficiency exists for
normal gait throughout the comfortable range of walking
speeds.
The energy cost has been shown to increase with more
proximal levels of leg amputation, but the rate of energy
expenditure appears to be relatively uniform across able-
bodied and amputee individuals at freely-selected walking
speeds.61– 64 How is this possible? Because amputees naturally
adopt slower speeds when they walk. By lowering their walk-
ing speeds, prosthesis users are able to keep their rate of
energy expenditure within normal limits, but the reduced
speed consequently increases their energy cost. Significantly
higher heart rates have been observed in transtibial amputees
compared with normal subjects when they walked at their
freely-selected speeds, but the oxygen consumption rates are
comparable between the two groups.65 At freely-selected
speeds, unilateral transtibial amputees have been reported to
expend approximately 9% more energy than able-bodied in-
dividuals, unilateral transfemoral amputees approximately
49% more, and bilateral transfemoral amputees nearly 280%
more.66 The residual limb length has been determined to
have a significant effect on metabolic cost when transtibial
amputees are stratified by long and short stump length, but
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SSC Proceedings Use of Quantitative Gait Analysis for the Evaluation of Prosthetic Walking Performance
prosthesis mass does not appear to significantly alter ambu-
lation energy consumption when other variables are con-
trolled.65 Transtibial amputees with longer residual limbs
have been shown to expend less energy during walking than
those with shorter residual limbs.65,67
Energy expenditure studies have been used to evaluate and
compare different types of prosthetic components, particu-
larly prosthetic feet. The inherent assumption underlying
these studies is that dynamic elastic response feet should
return more energy at the end of stance phase than other
types of feet, and presumably the increased energy returned
may somehow be effectively utilized to reduce the metabolic
energy required by the prosthesis user to ambulate. Some
studies report that dynamic elastic response feet reduce the
energy required to walk compared with a SACH foot.24,68
However, other studies have found that there are no differ-
ences in the energy rate or cost for transtibial amputees
walking with the SACH foot and different types of dynamic
elastic response feet.25,27,69 Transfemoral amputees have been
reported to reduce their energy expenditure when they walk
with a Flex Foot compared with a SACH foot.24 In a compar-
ison of vascular versus traumatic unilateral amputees walk-
ing with six different prosthetic feet, significantly greater
energy cost was measured in vascular amputees compared
with traumatic amputees.21 However, there were no signifi-
cant differences in energy cost between the different pros-
thetic feet for either group. The inconsistency in energy
expenditure measures between studies such as these that
have similar experimental protocols is of concern, and is
currently without a satisfactory explanation.
Other types of prosthetic components have also been
shown to influence the energy expenditure of walking in
prosthesis users. The Re-Flex VSP has been observed to
significantly reduce energy cost, increase gait efficiency, and
decrease exercise intensity in subjects with unilateral trans-
tibial amputations.70 However, the benefits were found to be
speed dependent, with the advantages becoming more appar-
ent at speeds above about 1.1 m/sec. Similarly, the Endolite
TT Pylon has been reported to reduce energy expenditure in
transtibial amputees at fast walking speeds.71 These observed
effects of shock absorbing components on energy expenditure
may be unanticipated, but one possible explanation is that the
increased shock absorption may make faster walking speeds
more comfortable, so the amputee compensates less in order
to reduce shock and thereby decreases muscular effort and
reduces metabolic demand. Studies that have compared the
Contoured Adducted Trochanteric-Controlled Alignment
Method (CAT-CAM) socket to a quadrilateral socket in trans-
femoral amputees have reported that subjects expend consid-
erably less energy when walking with the CAT-CAM sock-
et.72,73 Surprisingly, no significant differences were found in
the energy expenditure of a group of unilateral transfemoral
amputees walking with their prosthetic knee locked and
unlocked.74
Explanations for the observed differences in energy expen-
diture between different types of prosthetic components will
Number 6 • Proceedings • 2006
require further investigation and a better understanding
about prosthetic walking mechanics. Compared with tempo-
ral-spatial, kinematic, and kinetic data, the energy expendi-
ture measures are appealing as an outcome measure for
prosthetic gait because they directly relate to walking effi-
ciency and to subject perception.
DISCUSSION
Quantitative gait analyses are useful for characterizing the
motions of walking and for documenting progress as a person
undergoes rehabilitation. They can be beneficial for verifying
visual observation, providing objective measurements that
substantiate a subjective assessment. Assuming that the able-
bodied pattern of walking represents the most efficient bipe-
dal form of ambulation given the constraints of human anat-
omy, then quantitative gait analyses may be of tremendous
benefit for identifying and addressing differences in a pros-
thetic user’s gait from normal. However, at present, quanti-
tative gait analysis does not appear to be particularly useful
for assisting the prosthetist with an individual’s prosthetic
prescription or for diagnosing problems with the prosthesis,
because at the moment we possess insufficient knowledge
about how to adequately address functional deficiencies in
prosthetic ambulation. Further research is required to iden-
tify the functional requirements of able-bodied walking,
which can be used to establish appropriate criteria for eval-
uating prosthetic gait.
Many studies that have compared different types of pros-
thetic components generally report little or no difference in
the data obtained from quantitative gait analyses, and when
improvements are observed, they tend to be incremental in
nature and are often not statistically significant. It is unlikely
that one component will demonstrate a dramatically im-
proved pattern of walking in amputee subjects, even when the
most sophisticated technologies are compared with the sim-
plest component designs. These results suggest that the types
of components being compared may actually be quite similar
in function, even though their modes of operation may be
significantly different. If different prosthetic component de-
signs produce gait characteristics in subjects that are similar,
but are consistently inferior to that of able-bodied persons,
then perhaps the primary causative factors behind the poor
walking performance are being overlooked. Significant im-
provements in prosthetic gait performance may not be real-
ized until a new generation of components is developed that
more accurately reproduces the functions used in able-bodied
walking.
There should be greater consideration for the testing en-
vironment when evaluating prosthetic walking performance.
Well-lighted motion analysis laboratories with level walkways
are probably not the best conditions for evaluating the effects
of prosthetic components that may be designed for improving
ambulation on other types of walking surfaces or in more
demanding circumstances. More meaningful results, with
increased validity, would probably be obtained by developing
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and utilizing gait measurement systems that enable different
components to be compared in “real world” situations outside
of the gait laboratory.
Many of the published quantitative gait studies seem to
indicate that amputees are able to readily adapt to changes in
their prostheses. Most prosthetists have probably noticed this
effect in the clinic—they fit their client with a new prosthetic
component, and visual gait analysis indicates no discernible
difference from a previous prosthetic configuration. Experi-
enced prosthetic users are able to readily adapt to minor, and
major, prosthetic modifications. In those cases, their gait
does not usually improve and they will often display the same
gait pattern as before. Therefore, greater attention must be
paid to gait training for new amputees, and retraining for
more experienced users to break their bad habits and to instill
proper form. For prosthetic users to achieve maximum ben-
efit from new technology, they must be taught how to walk
with their prostheses in such a manner that they take full
advantage of the design features. Good gait requires that the
user develop trust, security and confidence in his or her
prosthesis, learning one’s capabilities and identifying limita-
tions, all of which take time and experience.
Even though statistically significant differences among
components are usually not detected using quantitative gait
measures, subjects often express clear preference for one
component over another, suggesting that very subtle changes
in gait may be detected by the user and be perceived as
significant.27 Further exploration and analysis are required to
unravel the complex relationship that exists among quanti-
tative gait data, clinical observation and patient perception of
the prosthesis.75 The inability to detect changes between
prosthetic configurations using quantitative gait analysis is
not a limitation of current motion measurement systems;
they are able to measure body motion and forces with suffi-
cient accuracy. The problems we are currently struggling
with concern our lack of understanding about how to best
restore ambulation ability in someone with a leg amputation,
how to provide sufficient function through prosthetic design
and with appropriate selection of componentry, and how to
best use and incorporate quantitative gait data with visual
observation and subjective feedback to effect substantive im-
provement in the function, aesthetics, and efficiency of pros-
thetic gait.
Quantitative gait analysis is recognized as being useful for
providing an objective assessment about the way a person
walks. Studies of prosthetic users reported in the literature
tend to indicate a lack of consistency in quantitative gait
measures, even in similar populations of amputee subjects
who are walking with comparable prosthetic configurations.
Therefore, the value of using these data individually for
outcome measures is questionable. Energy expenditure mea-
sures, as a gross indicator of walking performance, tend to
show some promise as reliable outcome measures for the
evaluation of prosthetic gait, though it is not possible to
readily identify specific gait abnormalities that may be evi-
dent in temporal-spatial, kinematic or kinetic data. For the
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time being, quantitative gait analysis may be best used in the
research laboratory as opposed to the clinic, but it is impor-
tant that we continue to strive to effectively integrate these
measurements with the experience and skill of the prosthetist
and the subjective feedback of the prosthetic user.
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Number 6 • Proceedings • 2006