641

Upper Limb Prosthetics for Sports and Recreation

Chapter 24

UPPER LIMB PROSTHETICS FOR 

SPORTS AND RECREATION

ROBERT RADOCY, MSC*

INTRODUCTION

ADVANCES IN PROSTHETIC TECHNOLOGY

THE BALANCE BETWEEN PHYSICAL, PSYCHOLOGICAL, AND PROSTHETIC 

REHABILITATION

PREPROSTHETIC EXERCISE

BIOMECHANICS AND HUMAN MOVEMENT

PROSTHETIC DESIGN FOR SPORTS AND RECREATION

Archery and Weight Training

Golf and Baseball

Canoeing and Kayaking

Basketball, Volleyball, and Soccer

Swimming

Steering, Vehicle Control, and Other Activities with Similar Upper-Extremity Demand

Fishing

Firearms

Hockey 

Water-Skiing

Snow Skiing and Snowboarding

Windsurfing

Scuba Diving

Mountaineering and Technical Climbing

SUMMARY 

*Chief Executive Officer and President, TRS Incorporated, 3090 Sterling Circle, Studio A, Boulder, Colorado 80301
642

Care of the Combat Amputee

INTRODUCTION

the 1970s. In 1970, only a couple of simple adaptations 

were available for baseball and bowling. Today, a 

growing selection of adaptive prosthetic accessories are 

available that enable combat amputees to participate 

competitively in sports and task-specific activities. 

Most of today’s combat veterans dealing with the challenges of a traumatic upper limb amputation are 20 to 

30 years old and have the same dreams, drives, and 

needs as others their age. Through comprehensive rehabilitation, these amputees can participate in the same 

sports and recreational activities they enjoyed before 

they were injured. As survival rates continue to rise 

for traumatically injured service members, so will the 

demand for activity-specific prostheses. Knowledge 

of prosthetic sports and recreation equipment that is 

currently being developed in active military medical 

centers will eventually be incorporated into the care at 

national Veterans Administration hospitals, ensuring 

that combat amputees will continue to pursue specialized high-performance activities into the future. 

The expansion and sophistication of technology, 

services, and communications in the 21st century is 

creating many new lifestyle opportunities for adults. 

Improved lives and lifestyles resulting from this expansion provide additional leisure time that can be 

directed at sports and recreational endeavors. Experts 

from the Centers for Disease Control and Prevention 

report that both physical and mental well-being are 

enhanced by physical activity.1 In January 2007, the 

US government established the first federal medical 

classification code for upper limb prosthetic attachments for sports and recreation.2

 Sports and recreation 

activities have been linked to successful rehabilitation, 

and games and sports encourage socialization within 

selected micro and macro-social systems.3 Therapeutic 

recreation and adaptive physical education programs 

help implement these avocational components into 

comprehensive rehabilitation programs. 

There has been a growing demand for sports-specific (activity- or task-specific) prosthetic devices since 

ADVANCES IN PROSTHETIC TECHNOLOGY

The last 25 years have given rise to significant improvements in prosthetics materials and designs. Aerospace materials, such as carbon fiber and titanium, are 

now commonly incorporated into high-performance 

prosthetic limbs. High-strength resins and innovative 

suspension designs (with more intimate anatomical 

interfaces), combined with high-efficiency, bodypowered systems or electromechanical components, 

provide better control, energy transfer, and delivery of 

biomechanical forces through prostheses. Roll-on silicone liners can augment suspension for better control 

throughout greater ranges of motion. Silicone liners 

excel in aqueous environments, where water lubricity makes it difficult to secure adequate suspension; 

however, they are not appropriate for all patients or environments. Myoelectric and electromechanical arms 

are not used in sports and recreation activities as often 

as traditional body-powered prostheses, probably because of the myolimb’s inherent construction and more 

fragile, environmentally sensitive components. An 

externally powered arm is best used for activities and 

in environments that ensure its prolonged function and 

lifespan. The high impact and environmental exposure 

that result from many sports and recreational activities 

dictate that only a very durable, reliable, and functional 

prosthesis be constructed and used for these purposes.

Improved self-suspending socket designs4 and 

a variety of new thermoplastics and thermoplastic 

elastomers are available to build uncompromising, 

strong, and comfortable prostheses. These improved 

suspension systems and strong, lightweight materials 

allow for the use of terminal devices, or “end effectors” 

(ie, accessories specifically designed to accomplish 

particular activities). The approach that appears to 

be the most successful focuses on activity-specific 

prosthetic attachments that are designed to emulate 

the biomechanics of the human hand and arm in that 

particular activity. This has led to the development of 

products that allow many amputees to perform not 

only recreationally but competitively with their twohanded peers. The pursuit of rigorous sports activities 

may further advance prosthetic science, bringing about 

new conditions or requirements that drive prosthetic 

revision and innovation. 

THE BALANCE BETWEEN PHYSICAL, PSYCHOLOGICAL, AND PROSTHETIC REHABILIATION

Today’s combat amputee may be faced with multiple amputation injuries compounded by tissue damage from explosions and burns. Patient assessment is 

comprehensive and includes efforts to evaluate future 

sports and recreation demands. The rehabilitation 

process can be significantly improved when amputee 

patients realize that sports and recreational pursuits 

are real possibilities for their futures. 
643

Upper Limb Prosthetics for Sports and Recreation

It is important for the rehabilitation team serving the 

combat amputee in both the inpatient and outpatient 

settings to provide the most comprehensive rehabilitation program possible. Physical, psychological, and 

prosthetic rehabilitation must be balanced in order to 

foster success. Amputees cannot expect high performance from a prosthesis if they do not exhibit adequate 

range of motion, muscle hypertrophy, and strength. 

Conversely, they cannot be expected to perform at 

a high level if the prosthetic technology they receive 

does not complement their physical capabilities. Additional therapeutic intervention may be useful at this 

point in rehabilitation. The rehabilitation team should 

always endeavor to instill a positive attitude in the amputee and set realistic goals for accomplishing higher 

performance tasks. The combat amputee needs to be 

aware of the rehabilitation balance to focus perspective and direct rehabilitation. A direct involvement in 

rehabilitation decision making helps patients visualize 

the goals that need to be achieved. Specialty prostheses 

are prescribed and applied later in the rehabilitation 

cycle, following preliminary training and successful 

use of myoelectric and basic body-powered prostheses. 

Sports and recreation challenges are incorporated into 

the combat amputee’s rehabilitation goals as soon as 

is realistically possible. 

PREPROSTHETIC EXERCISE

Preprosthetic exercise should be considered in all 

cases where a definitive prosthesis cannot be applied 

or tolerated because of the severity of the injuries, tissue damage, skin grafts, or the like. In these cases, a 

padded, weighted harness may provide the patient 

with the ability to stimulate the muscles of the arm and 

shoulder, improving strength and range of motion. On 

a weighted harness with a transradial design, a triceps 

cuff is attached with flexible hinges to a padded cuff. 

The padded cuff is equipped with D-rings and a strap 

onto which disc weights can be added. The triceps cuff 

should strap above and below the biceps to prevent the 

harness from slipping off without inhibiting flexion. The 

padded cuff helps reduce abrasion to the tissues of the 

forearm while it supports the weights. The cuff should 

be placed as distally as possible to maximize resistance, 

but should not slide off the end of the arm. A weighted 

harness with a transhumeral design should replicate 

a standard figure-eight harness, padded as necessary 

to help reduce abrasion. Instead of terminating into a 

triceps cuff on the affected arm, a padded cuff, similar 

to that described for the transradial vest, can be applied. 

Weights can be added, and the therapist can create a 

variety of exercises to stimulate the musculature of the 

shoulder and remnant upper limb. A padded, weighted 

harness is an alternative to elastic-band or rubber-tube 

resistance exercise systems and can offer physiological 

benefits that those systems cannot provide. 

BIOMECHANICS AND HUMAN MOVEMENT

In the past decade, there have been significant 

improvements in the design and function of activityspecific prosthetic devices. A focus on human movement and biomechanics has led to the development 

of prosthetic devices that integrate with the human 

body’s biomechanics, allowing for improved movement and energy transfer through the torso and into 

the prosthesis. This is important for activities that 

require the dynamic (gross motor) use of the upper 

body, such as golfing and baseball. Improved range of 

motion throughout the forearm and at the wrist allow 

for two-handed function, more accurate control, and 

higher performance with a prosthesis than before. 

Altering the design focus away from “one-modelfits-all” to activity specific has allowed for an evolution of products that may only excel in particular 

tasks and environments. Because of their specificity in 

function, these products harmonize with the physical 

demands of a particular activity, providing amputees 

with improved potential for performance and success. These new “focused” designs can help combat 

amputees meet the challenges of being actively involved and competitive in sports and recreation in a 

two-handed world. 

PROSTHETIC DESIGN FOR SPORTS AND RECREATION

Understanding the biomechanics involved in performing a particular sport is the first step in providing 

a prosthetic solution. Certain activities, such as basketball, volleyball, and soccer, rely on bilateral hand 

function (volar hand surface control) that essentially 

ignores traditional opposed thumb (three chuck pinch) 

prehension. Other activities, such as baseball and golf, 

are successfully accomplished only when there are 

multiple degrees of freedom in the torso and arms and 

when efficient energy transfer is possible. The hand 

prehension aspects that may be required for a sport 

are not as important for performance; thus, analyzing 
644

Care of the Combat Amputee

and understanding an activity’s demands is the primary concern, followed by an effort to duplicate those 

characteristics in a prosthesis. In certain circumstances, 

it is not feasible to easily duplicate what is required 

and innovative solutions are developed.

Another important element that must be considered 

is safety. Sheathing the hard exterior shell of a prosthesis with a stretchable, soft, padded cover helps protect 

the user and other players from injury. A 5-mm thick 

neoprene wetsuit material (fabric both sides or a variant) can be made into a sports cover that looks good 

and provides a safety cushion from impact. A variety of 

new sports-specific prosthetic accessories are designed 

to minimize or eliminate the potential for injury.

Archery and Weight Training

It may appear odd to group these two radically 

different activities together, but they have prosthetic 

design commonalities. Most prostheses are designed 

with a preflexion angle between the socket’s center line 

and the forearm center line, so the face can be reached 

with a terminal device, prehensor, or hand. This type 

of preflexion alignment is counterproductive to many 

sports activities because it inhibits full arm extension 

when compared to an anatomical limb. 

In archery and weight training, proper prosthetic 

alignment is critical to performance. A neutral alignment that allows for even loading of distally applied 

forces is necessary for control and performance. An 

improperly aligned prosthesis under load would be 

difficult to control, especially for the amputee with a 

short- to medium-length forearm (much like balancing 

a heavy weight on the end of a long stick). A preflexed 

socket inhibits performance in these activities because 

the alignment creates forces in and on the prosthesis 

that cannot be easily controlled.

In archery, the successful drawing of the arrow 

and its accurate release and true flight are impacted 

by prosthetic alignment (Figures 24-1 and 24-2). An 

improperly aligned prosthesis makes it impossible 

to accurately draw and release an arrow, especially 

when dealing with bows that have a draw weight in 

excess of 45 lb. Custom attachments have been developed to connect to a bow or attach to the bow string. 

Voluntary closing terminal devices with a prehensile 

configuration conform to most bow risers when a soft 

cushion is wrapped around the handle. The cushion 

allows the handle and bow to center in the device’s 

grasp, helping eliminate torque when the arrow is 

released. Simple locking systems allow the bow to be 

held without concentration on cable tension (Figure 

24-3). Another prosthetic accessory is designed to allow an archer to clip on to the bowstring and release 

it mechanically with a lever that can be triggered by a 

chin nudge or other movement (Figure 24-4). Shooting 

a bow involves eye and hand dominance, so in many 

cases it is best to develop a solution that conforms to 

existing eye dominance traits.

Some other techniques and devices make archery 

accessible to those with hemiplegia or high-level limb 

absence. Mouth tabs and chest-suspended or chestsupported triggering systems help single-handed 

archers effectively and accurately shoot a bow and 

arrow. 

The proper alignment of a prosthesis may dictate a 

user’s ability to safely control weights while performing some weight-lifting exercises, such as bench press 

or dumbbell flies (Figures 24-5 and 24-6). Without a 

properly aligned and securely suspended prosthesis, 

an amputee with a medium or short residual limb will 

struggle to balance and control a barbell or dumbbell 

throughout the exercise’s range of motion. A prosthesis 

built with a neutral (not preflexed) alignment is best 

for weight lifting. Carbon fiber can be added into the 

socket and forearm for strength. A self-suspending 

design may prove useful when combined with a 

roll-on liner and integral locking system for added 

suspension. If a thin roll-on liner is used, an additional 

partial liner of foam fabricated into the prosthesis will 

provide protection for the olecranon and elbow condyles (Figure 24-7). Such padding helps mitigate the 

pressure points created when the prosthesis sustains 

torque from a heavy load. Harnessing should be kept 

at a minimum because it typically restricts range of 

motion. Depending on the activity and the design of 

the prosthesis, a harness may not be necessary.

Conventional voluntary opening, split-hook technology, commonly used in prosthetics for simple 

ADLs, has proven ineffective for these types of highperformance activities. The prehension requirements 

of the activities, especially weight lifting, supersede 

the capabilities of almost all split-hook designs. Certain voluntary closing prehensors are designed and 

constructed to perform in both archery and weight 

lifting. The prehensile configuration includes opposed 

thumb grasp, which conforms to cylindrical shapes 

and handles, improving stability and control. These 

devices operate best when they are modified with a 

simple accessory locking system that eliminates the 

need to maintain cable tension in the body-powered 

harness for grasping and holding (Figures 24-8 and 

24-9). 

One system designed specifically for weight training is intended for light or moderate weight exercise 

(Figure 24-10). Another system includes two models. 

One is capable of withstanding extreme loads, including those used in Olympic events. The second model is 
645

Upper Limb Prosthetics for Sports and Recreation

more compact, lighter, and is designed for general gym 

weight training and conditioning (Figures 24-11 and 

24-12). Both provide solid, stable control of barbells, 

dumbbells, and other weight-training equipment.

Golf and Baseball

Golf club and bat swinging require prostheses that 

provide appropriate degrees of freedom and control 

to allow for the efficient transfer of energy from the 

torso and body through the arms and prosthesis into 

the club or bat. Traditional or conventional prosthetic 

wrist components and terminal devices do not provide 

these capabilities.

Additionally, the site of the hand absence (right or 

left) and hand and swinging dominance dictate different solutions. There are a variety of prosthetic golf 

accessories; in the 1980s, most were custom made, 

single-use designs (devices built for use by a single 

individual and not intended for mass manufacturing). 

Experimentation was conducted to design a device 

that could duplicate the biomechanics in the wrist 

and forearm and produce a smooth swing and energy 

transfer. A flexible power coupling has evolved to be 

the best solution that fits the needs of most golfers. 

The length and stiffness of the coupling varies based 

on hand absence, swing-side dominance, and level 

of amputation. One golf device is designed primarily 

for right-handed individuals with left hand absence 

(Figure 24-13). The device can also be used by righthand amputees who golf left handed, but a crossover 

grip is required. Although a second hand with normal 

gripping capability is required to use it, the device is 

versatile and can be easily adjusted to fit onto any golf 

club, adapting to the grip’s diameter and taper.

Another alternative prosthetic golf system has 

models for both right and left hands to accommodate 

the differences (Figures 24-14 and 24-15). It uses a flexible coupling design similar to the device previously 

described, but the coupling stiffness is variable and 

the club attachment designs are different, dictating that 

uniform club grips be used. These devices are suitable 

for golfers with compromised strength, dexterity, or prehension in their second hand; they require only minimal 

assistance from another hand for club engagement. The 

application for bilateral amputees is viable. Typically, 

it is best to apply this device to the natural leading arm 

and allow the amputee golfer to experience and develop 

a controlled, one-handed swing using the prosthesis 

or residual arm for guidance and stability. Unique and 

individual solutions evolve for the second prosthesis, 

if required, as experience grows.

It is also possible, with the help of custom golf clubs 

modified with adapters, to directly and rigidly attach a 

golf club to a prosthesis. Although it is less convenient, 

this alternative may solve some control problems for 

amputee golfers. 

Golf prostheses for individuals with transhumeral 

absence have evolved significantly since the 1990s. 

High-performance designs now use short sports 

prostheses that terminate in a wrist component, which 

is mounted anatomically close to where the normal 

elbow exists. A custom, lightweight, energy-storing, 

power-coupling device can entirely eliminate the need 

for a traditional prosthetic elbow or forearm.These 

couplings are designed to terminate into one of the previously described attachments. Prosthetic suspension 

can take advantage of roll-on locking liners to ensure 

unrestricted range of motion or use more traditional 

harnessing. Lightweight, carbon-reinforced prosthetic 

sockets help ensure that these short sports prostheses 

can tolerate the loads involved in the activity.

Swinging a bat has many of the same biomechanical challenges as swinging a golf club. In the past, 

many amputees batted single-handed, but being able 

to swing a bat two-handed using a prosthesis can 

improve performance. An innovative device for bat 

swinging is molded entirely from a strong, energystoring, flexible polymer and is designed to quickly pry 

on and off the bat handle for convenience and safety 

(Figure 24-16). It uses a threaded mounting stud to fit 

any standard screw in a friction or disconnect wrist, 

and is designed to be grasped with an overhand grip 

from the sound hand. The device is versatile enough 

to allow function for either right or left hand absence 

and right or left hand swing preference.

Catching a ball adds additional challenges and 

choices for the amputee. Some prefer to play single 

handedly, transferring the glove on and off the sound 

hand as required. Others prefer to function with a 

prosthesis. Catching a ball below the waist requires 

that the forearm and glove are supine; catching above 

the waist requires pronation. For mid- or short-transradial amputees, these movements are impossible; 

merely placing a baseball glove on a prosthesis does 

not account for all the dynamic action involved. One 

prosthetic device made for baseball is designed to fit 

into a first-baseman’s glove (Figure 24-17). The device 

is cable operated and functions like a large, voluntary 

opening split hook that is pulled and held open, then 

released to catch. Manual pronation and supination 

are required using the sound hand.

Another design replaces the traditional glove with a 

large mesh pocket so a ball can be caught forehanded 

or backhanded, eliminating the need to pronate or 

supinate the forearm (Figure 24-18). This lightweight, 

high-performance alternative meets the surface area 

requirements for gloves in regulated play. 
646

Care of the Combat Amputee

Canoeing and Kayaking

Canoeing and kayaking require full range of motion 

and upper body coordination and strength. Manipulating handles and shafts requires different hand grasping 

configurations. Canoeing typically involves alternating paddling from starboard to port, complicating the 

situation for the amputee canoeist using a prosthesis 

because of the different grasps required. 

A prosthetic finger or thumb can be inserted 

into a large-diameter hole drilled through a canoe 

handle. The improved articulation created with this 

modification is usually sufficient to allow the paddle 

to be controlled through a wide range of motion. 

The shaft is usually easy to grasp with a voluntary 

closing prehensor. Voluntary opening split hooks do 

not perform well because of their configuration and 

limited prehension, and have a tendency to pry off 

paddles under load. Padding or wrapping the shaft 

can improve control with most devices. Myoelectric 

prostheses can be useful for general recreational paddling; however, accidental immersion is a factor and 

must be considered. These factors usually preclude 

the use of myoelectric prostheses in river and whitewater boating.

A new kayak and water sports prosthetic accessory attempts to meet the performance demands of 

river and whitewater kayaking, but also functions in 

flat water environments (Figure 24-19). It employs a 

quick connect and disconnect power strap to secure the 

kayak paddle shaft or canoe oar. The power strap stores 

energy as it is stretched from side to side, duplicating 

a radial–ulnar type of wrist articulation. A standard 

prosthetic wrist provides the additional adjustable, 

rotational friction needed for smooth paddling. The 

energy storage and return action allow for comfortable, forceful propulsion with a double-ended kayak 

or canoe paddle.

Basketball, Volleyball, and Soccer

Duplicating the volar (palmar) surface of the hand 

is important for activities that require coordinated 

bimanual function. A flexible interface that conforms 

to the large spherical surfaces of soccer balls, volleyballs, and basketballs also enhances control, improves 

performance, and provides some protection and 

safety. Several prosthetic accessories were specifically 

designed to emulate these hand characteristics and 

provide function and performance in these activities 

(Figures 24-20, 24-21, and 24-22). They are constructed 

of strong and flexible polymers that store and return 

energy, which helps duplicate certain wrist-like functions for improved ball handling and control.

Swimming

Swimming also requires the use of the volar hand 

surfaces, but for propulsion rather than manipulation. 

Prosthetic paddles or fins can enhance resistance during the power phase of a swimming stroke, improving 

propulsion but possibly impeding efficiency because 

often the amputee cannot pronate or “feather” the 

paddle or fin while swimming. This drag can be 

eliminated with a flexible or folding fin system. One 

swimming accessory with a folding fin is designed to 

be used on a custom, lightweight, short sports prosthesis specifically built for the water environment (Figure 

24-23). Polypropylene, polyethylene, or copolymer 

materials are appropriate for use in the socket. A roll-on 

locking liner counteracts the water’s natural lubricity, 

improving suspension for better control and higher 

loads during the power stroke. The fin collapses during retrieval, reducing or eliminating the water drag 

that a flat, rigid fin would create. 

Amputees can swim without a prosthesis, but a 

prosthesis provides better propulsion and performance. The added resistance of a swimming fin or 

paddle is also therapeutic to the muscles of the upper 

arm, shoulder girdle, and upper torso, creating stimulation for growth and hypertrophy.

A prosthetist can use a kit to fabricate a flexible 

swimming paddle that is designed to fit directly onto a 

residual limb (Figure 24-24). This device can be a good 

introductory aid for therapeutic physical exercise before an amputee is fit with a prosthesis, or for amputees 

who cannot tolerate a normal prosthetic limb.

Steering, Vehicle Control, and Other Activities 

with Similar Upper Extremity Demands

Bimanual capability and rapid and reflexive grip 

and release are functions that enable safe and effective 

vehicle control, whether the vehicle is body powered 

or motor driven. Road and mountain bicycles, motorcycles, all terrain vehicles, watercraft, and automobiles 

emphasize the need for coordinated bimanual function. High grasping forces may be required for control 

in certain circumstances. Quick release may also be 

required to avoid or mitigate injury. Manipulating handlebars, steering wheels and other steering controls, 

shifts, and levers requires accurate, variable prehension from a prosthesis and is enhanced by the natural, 

directly proportional feedback generated by active or 

positive-grasping, voluntary closing prosthetic prehensors. Devices equipped with polymer gripping surfaces provide better control in these types of activities 

than devices with smooth metal or serrated surfaces. 

Driving and steering usually involve glenohumeral 
647

Upper Limb Prosthetics for Sports and Recreation

flexion, and voluntary closing devices harmonize with 

that biomechanical motion (Figures 24-25 and 24-26). 

Myoelectric hands and control systems also perform 

well and are reliable for activities that involve driving 

and steering, although direct positive feedback is not 

available with this technology. 

Split hooks are actuated and controlled by a body 

harness in such a way that gripping control and stability can be compromised while driving or riding. Additionally, the split-hook configuration does not lend 

itself to handling the cylindrical shapes and curved or 

rounded surfaces that are often encountered with these 

activities. Split hooks produce a gripping feedback that 

is inversely proportional and therefore counterproductive to progressive gripping control.

Handlebars can be padded or cushioned to improve 

their frictional coefficients for better handling. Controls 

can be clustered together for easier, safer one-handed 

operation. Motorcycle controls can be grouped and 

integrated. The motorcycle twist throttle grip is easily combined with a lever action clutch and can be 

controlled simultaneously with the sound hand while 

the prosthesis is used primarily for handlebar control. 

Front and rear hydraulic brake systems can be integrated together to be operated independently with a 

single foot pedal or lever.

Similarly, front and rear mountain bike brake cables 

can be integrated to operate off a single lever, freeing 

the prosthesis to be used for handlebar stability and 

control (Figure 24-27). The progressive and powerful 

gripping capabilities of the voluntary closing prehensor easily withstand the bouncing and jarring conditions typical in off-road terrain. Should a fall occur, 

relaxation of cable tension in the system automatically releases the voluntary closing device from the 

handlebars, freeing the rider from the bike. Myoelectric 

prostheses also have the gripping capacity and control 

to meet these riding challenges. Rough off-road use creates significant shock and vibration that can be harmful 

to the function of electromechanical prostheses. 

Two models of recreational-grade prosthetic bicycle 

accessories are available to suit different ages, abilities, 

and riding styles (Figure 24-28). These devices are constructed of flexible polymers and operate like rubber 

cleats, snapping on and off the handlebars. They are 

safe, lightweight, and easy to use. 

Fishing

Handling fishing reels and rods for sport fishing 

requires bimanual function and coordination. It is 

important to manipulate handles and gears with a 

terminal device that provides controlled and adequate 

grasp. A simple, functional approach is to hold and 

control the fishing rod when possible with the sound 

hand and reel with the prosthesis (Figure 24-29). Accurately controlling a fishing rod in an activity like 

casting requires wrist action that prosthetic wrists do 

not provide.

One alternative prosthetic accessory consists of a 

rod system directly attached into the prosthesis (Figure 

24-30). Another adapter is used to cradle and stabilize 

the rod in the prosthesis, but is not practical for casting (Figure 24-31). These systems are appropriate for 

anglers who prefer to use a prosthesis for rod handling 

or who cannot control a fishing rod with a sound hand 

and limb.

Most fishing reels can be easily modified to be more 

functional with a prosthetic terminal device. Slip-on 

rubber grips can stretch over most reel handles, making 

them easier to grasp with a prosthetic device (Figure 

24-32). Myoelectric hands and externally powered 

hooks, as well as voluntary closing prehensors, can be 

used for reeling. Split hooks do not typically provide 

enough grasping force to be effective and tend to pry 

off the fishing reel handle under load. Most standard 

bait-casting and spinning reels, either open or closed 

face, can be easily manipulated. Reeling-specific prosthetic devices are also available (Figure 24-33). However, these products leave the angler single-handed for 

performing the other activities that are required while 

fishing (ie, changing lures, flies, and bait; netting fish; 

handling boating equipment; etc). 

Fly-fishing requires coordination, bimanual dexterity, and gross motor upper limb involvement. The 

prosthesis should be capable of handling the fly line 

or the fly rod. Controlling the rod with the prosthesis 

is difficult in most cases because of the lack of freedom 

in most prosthetic wrists. Fly-fishing requires that 

the line be cast (instead of just the lure or fly). The fly 

line can be handled accurately with a prosthesis that 

provides controlled gripping force and some type of 

sensory feedback (eg, a voluntary closing prehensor 

with polymer gripping surfaces provides traction to 

control the line without damaging it; Figure 24-34). 

Fly-fishing is different than other types of fishing in 

that the line is not usually retrieved by reeling, but is 

pulled in by hand when a fish is caught and reeled up 

after the fish is netted. An individual who has experience with a voluntary closing prosthesis can potentially 

develop the technique, dexterity, and control to fly-fish. 

A few general accessories that help with holding small 

flies, dealing with fine leaders, and tying knots are also 

useful tools for creating a positive, successful fly fishing experience. Advances in myoelectric technology 

may make it possible to fly-fish with an electric hook 

prosthesis. The myoelectric hand will not have the 

dexterity to control the fly line, but the electric hook 
648

Care of the Combat Amputee

with narrow, rubber-lined, hook fingers can meet these 

challenges. Water immersion is a risk to consider when 

using a myoelectric limb for fly-fishing.

Firearms

Firearms expertise is an integral part of any military experience and rehabilitation program. Service 

members and veterans with an amputation may find 

it rewarding to return to shooting as a pastime or for 

sport. Firearms Training Simulation facilities have been 

created to help amputee soldiers regain and retune 

their firearms skills during rehabilitation and prepare 

for live-fire experiences. Firearms Training Simulation 

facilities feature laser-fired weapons and simulated 

combat scenarios.

Safely handling and controlling a firearm with a 

prosthesis is the primary concern when engaging in 

shooting activities. Most pistols can be modified and 

retrofit with oversized, compliant grips that improve 

control (Figure 24-35). If myoelectric prostheses are 

used, the shock and stress that result from firing guns 

with high recoil must be considered. Some voluntary 

closing prehensors and myoelectric hands have an 

opposed thumb design that conforms to the shape 

of a pistol handle and can generate the level of gripping force required to safely control the firearm. An 

overhand grip is typically used with the sound hand 

to help aim and trigger the pistol. 

Long guns, such as rifles, carbines, and shotguns, 

can be safely controlled with prostheses. The shooter 

must decide whether or not to modify the firearm. A 

variety of pistol grip attachments can be added to the 

fore end of a gun to allow for improved control (Figures 

24-36, 24-37, and 24-38). Prosthetists should rely on 

trained, certified gunsmiths for modifications instead 

of doing them themselves. In certain cases, a simple 

military strap added to the gun provides enough flexibility to shoot with a prosthesis. A stainless steel or 

brass ring can also be added to a gun’s fore end and 

attached into a modified post used for a normal gun 

sling. The ring can be grasped by a prosthetic finger 

or thumb.

Another alternative avoids modifying the firearm 

altogether (Figures 24-39, 24-40, and 24-41). This 

device, designed initially to safely handle an M-16 

firearm, is versatile enough to shoot almost any rifle, 

carbine, or shotgun, including pump-action and sideby-side double barrel guns. A flexible, strong, polymer 

yoke contains tapered rubber fins that allow the fore 

end of the gun to be snapped down into place. Pulling 

the firearm back towards the shoulder tightens the 

gripping action of the yoke so that the firearm can be 

locked onto the shoulder for stability and control. The 

device has a friction-lockable, stainless steel ball and 

socket, and a friction-adjustable swiveling mechanism 

allows for a broad range of motion. The barrel can 

be carried up or down, and the firearm can easily be 

swung to the shoulder for tracking, aiming, and firing. 

The device’s yoke firmly grasps the gun’s fore end 

but will not mar even finely checkered walnut stocks. 

The gun can be loaded and reloaded while secured in 

the prosthesis’s hold. However, this type of a device 

is only useful for handling firearms, leaving shooters 

single-handed for other activities. 

Another option is a plastic-covered steel yoke, into 

which the fore end of a gunstock can be positioned 

for support (Figure 24-42). This device offers another 

simple alternative to the amputee shooter, but provides 

less total control over the firearm.

Depending on eye dominance, the shooter may 

wish to fire a gun with the prosthesis. This takes a lot 

of practice to be safe and proficient. The lack of tactile 

finger sensation and fine dexterous movement in 

prostheses make triggering a firearm with a prosthetic 

finger problematic. Additionally, when a human hand 

triggers a gun, it also operates safety mechanisms and 

provides support for the stock, functions that are difficult to perform with a prosthesis while triggering.

Hockey

Ice and street hockey require bimanual upper extremity involvement and coordination. A jointed or 

flexible coupling at the end of the prosthesis connected 

to a hockey stick is important for safety. A 4-ft long 

hockey stick will create forces of leverage that can be 

transferred back into the prosthesis and injure the 

player’s residual limb if some type of flexible linkage 

is not used.

Handedness and playing style (right or left) can 

dictate whether an amputee wishes to control the stick 

with the prosthesis at the top or down on the shaft 

(trial and error may help determine the best solution). 

A variety of custom prosthetic attachments attempt to 

make handling a hockey stick easy and efficient; some 

try to meet the needs of either stick-handling situation 

(Figure 24-43). The flexible coupling on these attachments bends enough to help eliminate injury when 

a player is forced into the rink’s walls or falls. The 

coupling is stiff enough to allow handling the puck 

with just the prosthesis when necessary. 

Water-Skiing

Water-skiing, especially slalom skiing, singlehanded without a prosthesis is possible but tiring and 

physically demanding on the muscles of the remain-
649

Upper Limb Prosthetics for Sports and Recreation

ing arm. Custom quick-detach mechanisms can be 

incorporated into a water-ski rope, but they must be 

controlled by the skier. A custom plastic water-ski hook 

used in conjunction with a floating, self-suspending 

prosthesis can be helpful. The hook creates enough 

grip to engage the rope handle so the skier can ski even 

single-handedly with a prosthesis. If the hook fails to 

twist off the handle during a fall, the skier can twist 

out of the prosthesis, avoiding injury. 

A simpler alternative is to modify the ski rope 

handle. A small cup or tube (sized to slide over one end 

of a ski rope handle) and flexible line can be attached 

to the prosthesis or directly to a body harness. The attachment provides leverage so the arm and prosthesis 

can be used to resist the pulling load of launching and 

control the ski rope handle. When the sound hand releases the handle, the tube pops off the other end and 

releases the skier. Another way to use this technique 

is to attach a strip of polypropylene webbing (1.5–2 in. 

wide) securely to the end of the prosthesis, removing 

the standard terminal attachment. Six to eight inches 

of webbing should be left loose off the end of the prosthesis and can be wrapped once or twice around the 

rope handle and over-grasped with the sound hand. 

During a fall or to release the rope, the sound hand 

drops the handle and the web strap pulls free, releasing 

the prosthesis from the tow-rope handle. 

Snow Skiing and Snowboarding

Snow skiers usually rely on ski poles, while snowboarders depend primarily on their upper limbs for 

balance. The snowboarder or rider can use almost any 

type of prosthesis that provides this function and is safe 

to wear, considering the rider might unexpectedly fall 

onto the prosthesis. A prosthesis often pulls heat from 

the residual limb, decreasing circulation and leaving 

the limb colder than the rest of the body. Wearing a 

thin, moisture-transferring liner sock under a woolblend sock helps keep the residual arm dry and at a 

more consistent temperature.

One commercially available snow skiing tool is a 

skiing and fishing terminal device that operates without a cable (Figure 24-44). It is fabricated from flexible 

silicone polymers and accepts a pole that has been 

stripped of the standard grip. The ski pole is forced 

into the device and held in place by friction. The skier 

thrusts the pole forward using glenohumeral flexion 

(arm extension), and the pole rotates forward with a 

pendulum action. The natural elastomeric action of the 

device returns the pole to its original position. 

Another device can be either cable driven or used 

like a simple pendulum, depending on the user’s 

preference (Figures 24-45 and 24-46). The ski pole’s 

grip is removed and the bare tube fits into a cylindrical receiver attached to a shock-absorbing mounting 

system. An elastic retraction system keeps the pole 

flexed back out of the way until it is needed. The pole 

is easily removed. Natural glenohumeral flexion is 

used to pull on the cable, rotating the pole forward 

for a pole plant. A shock-absorbing module is built in 

to absorb the torque and stress created by using a ski 

pole. The device transfers upper limb power into the 

pole and provides the propulsion needed for Nordic 

skiing, yet is responsive enough to be used in moguls 

and for downhill pursuits. 

Windsurfing

Windsurfing is a demanding activity for amputees. 

Windsurfers must be capable of quickly grasping and 

releasing the boom, sail, and control ropes. The grip 

required to engage and hold on is significant, and 

spontaneous release is important to avoid injury. A 

modified voluntary closing prehensor provides sufficient gripping force to control the mast and boom, 

and streamlined inner gripping surfaces allow for the 

prosthesis to be released smoothly or twisted off the 

boom when necessary during sailing. 

The prosthesis needs to be waterproof and constructed with corrosion- and salt-resistant hardware. 

Leather will not survive long when repeatedly exposed 

to water. Roll-on silicone or similar liners, if used, 

should employ only strong plastic or stainless locking components. Cables have a tendency to foul with 

repeated exposure to saltwater; rinsing and flushing 

the cable system is important for efficient, reliable function. Synthetic cables constructed of polyethylene with 

an ultra-high molecular weight may be useful because 

they are strong, flexible, and naturally lubricious.

Scuba Diving

A prosthesis is not required for scuba diving and 

most amputee divers can become skilled enough to 

pass mandatory diver’s certification courses singlehanded. However, a prosthesis can be useful when 

handling gear and equipment underwater, and significantly aids climbing out of the water via a ladder. A 

scuba prosthesis should be designed to operate in both 

freshwater and saltwater environments. A voluntary 

opening split hook equipped with enough elastic bands 

will operate under a tight wetsuit, providing grasping 

function. The hook shape helps the diver climb ladders, 

get back onto the boat, and handle equipment and gear. 

Shorter, specially designed, lightweight prostheses 

that are passive and not cable operated may also be 

considered. A simple, strong, plastic terminal device 
650

Care of the Combat Amputee

can be designed to assist with basic functions, including ladder climbing and manipulating weight-belt 

buckles and other gear. 

Mountaineering and Technical Climbing

Mountaineering and technical climbing require 

participants to be in top physical condition, possessing both strength and endurance. Good upper limb 

coordination, range of motion, and positive gripping 

force are necessary to handle equipment and meet the 

rigors of these activities. A stainless steel, voluntary 

closing device with an opposed thumb design can 

be used for mountaineering and climbing activities 

(Figure 24-47). Custom modified split hooks have 

also been used (Figure 24-48). Two custom climbing and mountaineering devices were designed and 

built with the input of amputee climbers and several other experienced able-bodied climbers (Figures 

24-49 and 24-50). These designs use standardized, 

chromium molybdenum (“chrom-moly”) climbing 

aids integrated into custom pedestals designed to fit 

onto a prosthesis. They are specific to an individual 

climber’s requirements and capabilities, and therefore 

have not been made commercially available. These 

devices represent an example of what an amputee 

climber might consider using to succeed in this challenging sport. 

SUMMARY

Research in upper limb prosthetics is advancing as 

a result of funding from the federal government. The 

majority of this research is oriented toward high-tech, 

mostly externally powered, solutions to sophisticated 

problems and objectives. These solutions and technology have not historically been successfully applied 

to sports and recreation. Performance in sports and 

recreation for those with upper limb prostheses has 

improved with sports-specific mechanical designs and 

innovative materials. Future developments in upper 

limb prosthetics for sports will most likely continue to 

arise from engineered, mechanical solutions that focus 

on duplicating the sometimes complex biomechanics involved in the performance of a specific activity. 

Applying energy-storing elastomers and other lightweight yet strong materials into sports-specific prostheses will improve performance. Focusing designs 

on the specific limitations created by various levels 

of amputation will also improve the capabilities and 

performance for a broader range of consumers. Future 

research and product development will be enhanced 

and accelerated by new financial input and resources 

that can be directed into this specific area of prosthetics. These resources, complemented by the innovative 

thinking, input, and demands of a new, young population of prosthetic users, will drive ideas and improve 

technology for even better performance in sports and 

recreation activities.
651

Upper Limb Prosthetics for Sports and Recreation

Figure 24-3. TRS GRIP 2S Prehensor with locking pin holding 

recurve bow and arrow.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-1. Incorrect prosthetic alignment. An improperly 

aligned prosthesis makes it impossible to accurately draw 

and release an arrow. 

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-2. Correct prosthetic alignment, allowing for accurate arrow draw and release.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
652

Care of the Combat Amputee

Figure 24-7. Weight-lifting prosthesis with partial liner 

padding.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-6. Biceps curls with dumbbells using a weightlifting prosthesis.

Photograph: Courtesy of TRS Inc, Boulder, Colo. 

Figure 24-5. Bench press with dumbbells using a weightlifting prosthesis.

Photograph: Courtesy of TRS Inc, Boulder, Colo. 

Figure 24-4. Quick Release Gripper archery trigger with NAbler (Texas Assistive Devices LLC, Brazoria, Tex).

Photograph: Courtesy of Texas Assistive Devices LLC, 

Brazoria, Tex.
653

Upper Limb Prosthetics for Sports and Recreation

Figure 24-8. Prehensor with locking pin being used on weight 

equipment handle.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-9. Prehensor with locking pin modification for 

weight lifting.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
654

Care of the Combat Amputee

Figure 24-12. Weight-lifting devices.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-11. Heavy-duty weight-lifting device.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-10. Weight-lifting device.

Photograph: Courtesy of Texas Assistive Devices LLC, 

Brazoria, Tex.

Figure 24-13. Golf prosthesis.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
655

Upper Limb Prosthetics for Sports and Recreation

Figure 24-16. Baseball bat prosthesis.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-14. Golf prosthesis, left model.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-15. Golf prosthesis, right model.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
656

Care of the Combat Amputee

Figure 24-17. Baseball glove adapter split hook.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-18. Baseball catching prosthesis.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
657

Upper Limb Prosthetics for Sports and Recreation

Figure 24-20. Basketball accessory.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-19. Kayak accessory. (a) Closed. (b) Open. (c) In use.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

a

c

b
658

Care of the Combat Amputee

Figure 24-21. Volleyball handling device.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-22. Soccer ball handling device.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-23. Freestyle swimming prosthesis.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
659

Upper Limb Prosthetics for Sports and Recreation

Figure 24-24. Swim fin kit (assembled).

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-25. Prehensor used with a steering wheel.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-26. Prehensor used with stick shift.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-27. Dual bike brake lever.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
660

Care of the Combat Amputee

Figure 24-29. Prehensor with spinning reel.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-30. Fishing rod prosthetic adaptor.

Photograph: Courtesy of Texas Assistive Devices LLC, 

Brazoria, Tex.

Figure 24-28. Bicycle accessory.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
661

Upper Limb Prosthetics for Sports and Recreation

Figure 24-33. Crank adaptor.

Photograph: Courtesy of Texas Assistive Devices LLC, 

Brazoria, Tex.

Figure 24-32. Rubber slip-on reel handle grip accessories.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-31. Universal Handle Holder (fishing rod application; Texas Assistive Devices LLC, Brazoria, Tex).

Photograph: Courtesy of Texas Assistive Devices LLC, 

Brazoria, Tex.
662

Care of the Combat Amputee

Figure 24-34. Prehensor with fly fishing rod, reel, and line.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-35. Prehensor with 44-magnum pistol.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
663

Upper Limb Prosthetics for Sports and Recreation

Figure 24-36. Over and under shotgun with fore-end modification and prehensor.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-37. Pump style shotgun fore-end modification.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-39. Gun turret prosthesis with over-and-under 

shotgun.

Photograph: Courtesy of TRS Inc, Boulder, Colo. 

Figure 24-38. Side-by-side style shotgun with fore-end 

modification.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
664

Care of the Combat Amputee

Figure 24-42. Tool/gun cradle adaptor.

Photograph: Courtesy of Texas Assistive Devices LLC, 

Brazoria, Tex.

Figure 24-41. Gun turret used with a carbine.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-40. Gun turret used with an M-16.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
665

Upper Limb Prosthetics for Sports and Recreation

Figure 24-46. Nordic and alpine ski prostheses.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-45. Ski accessory (extended for pole plant).

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-43. Prosthetic hockey accessories.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-44. Ski/fishing prosthesis.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
666

Care of the Combat Amputee

Figure 24-47. Prehensor used for technical climbing.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-48. Modified split hook for climbing by Pete Davis, 

accomplished amputee climber.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
667

Upper Limb Prosthetics for Sports and Recreation

Figure 24-49. Mountaineering device custom built for Aron 

Ralston, who gained notoriety after amputating his lower 

arm that had become trapped by a boulder while he was 

climbing in Blue John Canyon, Utah.

Photograph: Courtesy of TRS Inc, Boulder, Colo.

Figure 24-50. Technical climbing prosthesis custom built for 

Aron Ralston.

Photograph: Courtesy of TRS Inc, Boulder, Colo.
668

Care of the Combat Amputee

REFERENCES

1. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. Recommendation from the Centers for Disease 

Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273(5):402–407.

2. DMECS Durable Medical Equipment Coding System. Code: L6704: Terminal Device, Sport/Recreational/Work Attachment, 

Any Material, Any Size. Available at: www.hcpcs@cms.hhs.gov. Accessed June 11, 2009.

3. Rarick GL. Physical Activity, Human Growth and Development. New York, NY: Academic Press; 1973: 257–332.

4. Miguelez JM, Lake C, Conyers J, Zenie J. The Transradial Anatomically Contoured (TRAC) Interface: design principles 

and methodology. J Prosthet Orthot. 2003;15(4):148–157.