In the second part of the series, Heinrich Grimsehl investigates the ideal socket fitment protocol
Please be informed that this article is a follow up from my article in the previous edition of ROLLING INSPIRATION. The same disclaimer applies. This is simply my opinion. Also, this article should only be interpreted if you have read part one.
We continue the possible treatment protocol presuming that your stump has healed, has been coned and you have had time to wear the silicone liner. Wearing the liner prior to the prosthesis will give you a good idea of how your skin will react to its new environment.
If it seems that your stump volume has settled (measurements should have been taken from day one), it is time to cast your stump with the liner on so that a test socket can be manufactured. These usually are made from a clear polymer (plastic) material. It looks like a glass socket. Test sockets can easily be adjusted with a heat gun. They are rock hard, but if you warm them up, the heated area becomes soft and pliable like bubble gum.
This is very handy if you have to make adjustments. For instance, if there is a pressure point on a prominent bony structure, the test socket can be adjusted to relieve pain.
Test sockets can be strengthened so that you can wear them for several weeks. This gives the patient and the prosthetist time to make the prosthesis as comfortable as possible. Personally, I feel that this is the most crucial part of the prosthetic fitting and should not be neglected.
Because you have got a working prosthesis, you are able to get back on your feet and there is no need to rush. The comfort of the residual limb is the most important aspect of the entire prosthetic fitting.
Excessive pressure and pain will cause the skin to break down, which will lead to infection and ultimately to stump revision surgery. This will set you back and delay your progress for several weeks. This must be avoided at all costs.
During this process of fitting a test socket, it is important to also check the alignment – the second most important aspect of your prosthesis. Incorrect alignment and leg length could cause the following:
- Lower back and neck pain;
- Excessive pressure on your stump;
- Skin breakdown;
- Excessive pain and pressure on your sound leg and foot;
- Balance difficulties and instability;
- Difficulty walking up or downhill;
- Toe scuffing on the floor and ultimately injuries due to falling.
Because you are born with natural balance, your body will accommodate a leg that is not 100 percent aligned. You might be able to walk, but, somewhere in the near future, a complication will surface. Experienced prosthetists can visually pick up alignment deviations, but they cannot feel the pressure underneath your feet.
Professional, computerised, real-time alignment equipment with pressure plates to stand on and multiple cameras throwing images of virtual weight, load and torque bearing lines on a computer screen is highly recommended and the only way to accurately assess alignment.
During your rehabilitation, you should receive a certain amount of gait training. Physiotherapy with a therapist who specialises in the field is highly recommended. A patient should not be sent home with a prosthesis if this aspect has not been addressed. It is a recipe for disaster.
When your final prosthesis is being manufactured, please enquire whether the socket is fully adjustable. There are ways to manufacture a socket so that it will accommodate future pressure points and volume fluctuations.
Regarding leg components, the most expensive don’t guarantee the most functional prosthesis. Components are but a small part of the entire prosthetic experience. You can always upgrade components later. Rather focus on socket comfort first.
Last, pain is usually an indication that something is wrong. The stump has to desensitise a bit and a certain amount of pressure is to be expected. However, if the pain is the main theme of your prosthetic experience, something definitely is wrong. Prosthesis shouldn’t hurt!
Read the first part of the series here. To get access to the article, subscribe to ROLLING INSPIRATION today by clicking here.
Heinrich Grimsehl is a prosthetist in private practice and a member of the South African Orthotic and Prosthetic Association (SAOPA).