581

Lower Limb Prosthetics for Sports and Recreation

Chapter 21

LOWER LIMB PROSTHETICS FOR 

SPORTS AND RECREATION

JOHN R. FERGASON, CPO*; and PETER D. HARSCH, CP†

INTRODUCTION

WHEN TO PROVIDE A SPORTS-SPECIFIC PROSTHESIS

GENERAL-USE UTILITY PROSTHESIS

SKIN TOLERANCE TO HIGH ACTIVITY

GENERAL ALIGNMENT CONSIDERATIONS FOR SPORTS

GENERAL COMPONENT CHOICES FOR FORCE REDUCTION IN SPORTS

TRANSTIBIAL RUNNING 

TRANSFEMORAL RUNNING

CYCLING 

ROCK CLIMBING 

WATER SPORTS

WINTER SPORTS

GOLF

HIKING

INJURIES AND LONG-TERM EFFECTS

OTHER CONSIDERATIONS

SUMMARY

*Chief Prosthetist, Department of Orthopaedics and Rehabilitation, Brooke Army Medical Center, 3851 Roger Brooke Drive, Fort Sam Houston, Texas 

78234

†Chief Prosthetist, C5 Combat Care Center Prosthetics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, Building 3, San Diego, California 

92134
582

Care of the Combat Amputee

INTRODUCTION

reported stress, pain, and depression, as well as a 

general increase in the quality of life.8 Participation in 

physical activity has shown a positive relationship with 

improved body image for many amputees.9 For many 

active duty service members, the desire to continue in 

the Armed Forces is correlated to their physical ability to return to their previous military occupational 

specialty. Amputation of a lower limb does indeed 

constitute a major disability that can lead to functional 

and professional incapacities.10 A commonly referenced 

survey (Kegel, 1985)11 revealed that lower limb amputees had a strong interest in participating in sports and 

recreation. A majority of respondents indicated that 

their quality of life could be enhanced if the prosthesis 

did not limit their ability to move quickly and run.11

A more recent survey showed that the 20- to 39-yearold age group had a similar distribution of interests 

between high-, moderate-, and low-energy-level activities; the survey reported a high ability to perform these 

activities while using a prosthesis.12 This information 

suggests that the prosthesis is no longer the primary 

limiting factor when participating in desired activities. 

Given the opportunities for participation in sports 

that are currently offered to injured service members, 

the demand for new, innovative prosthetic designs is 

challenging the clinical and technical expertise of the 

prosthetist.

No artificial limb can replace what is lost in the 

trauma of conflict. However, aggressive rehabilitation 

and appropriate prosthetic provision will enhance the 

ability of injured individuals to pursue athletic activities once again. Understanding the biomechanics of the 

sport and the physical characteristics of the remnant 

limb are the first steps in determining what a prosthesis 

can provide. The following sections present principles 

involved in the design of prostheses suitable for sports 

and recreational activities.

The value of sports and recreation continues to be a 

primary motivational factor for many service members 

with newly acquired lower limb amputations. Whether 

they were competitive prior to their amputations or 

not, they will become competitive to overcome their 

current physical limitations. The background and demographics of an active duty service member differ 

from the demographics of the majority of new civilian 

amputations that occur each year. Unlike the general 

population, every service member is preconditioned 

to train and work to pass mandatory physical fitness 

tests. Contrary to an elective amputation secondary to 

disease, trauma amputees have no time to prepare or 

process what it will be like to function with limb loss. 

They must be encouraged to challenge themselves 

to achieve new skills in activities that are unfamiliar 

to them that may be more appropriate to their new 

body, as well as continue to participate in their favorite 

sports. An informative survey conducted with disabled 

competitors in the 1996 Paralympic Games showed no 

mean differences in the results obtained in Goal Orientation, Competitiveness, and Desire-to-Win Scales 

when comparing men and women, onset of disability, 

adolescents and adults, and severity classifications.1

This may suggest that the healthcare team does not 

have reliable predictors for who will excel; therefore, all 

competitors should be given the same opportunities. 

Participation in sports and recreation is universally 

beneficial not only for the demographic of an active 

duty service member, but also for the general population. Several publications2–4 have made recommendations regarding the efficacy of regular physical activity 

to reduce disease concerns. Inactivity also increases the 

risk of many physical pathologies5,6 and is the second 

most costly risk factor in cardiovascular disease.7

Physical activity has many specific benefits for 

the disabled population, including a decrease in selfWHEN TO PROVIDE A SPORTS-SPECIFIC PROSTHESIS

Because of the unique, comprehensive nature of 

military rehabilitation programs, high expectations 

are instituted early. Goal setting can be started by 

using the physical training fitness test as standard if 

the patient wants to remain on active duty. Encouragement from other patients with similar injuries can 

also be a significant motivating factor in the pursuit 

of recreational activity.

In addition, the general public has a heightened sense 

of awareness of the challenges involved in disabled 

sporting activities. Competition such as that seen in the 

Paralympic Games has gained wider exposure and has 

demonstrated that high-activity goals are attainable. 

Although world-class athletes seen in the Paralympic 

Games are true inspirations, most individuals will not 

pursue this level of activity. Exposure to a variety of 

sporting activities is a more effective method to peak 

the interest of the injured and even to open up new 

possibilities for recreation or competition. 

The prosthesis optimized for recreation is finely 

tuned both to the specific function required and to 

the capabilities of the user. Realistic goals should be 

set in context to the overall physical capabilities of the 

individual. It is more encouraging to reach a small goal 
583

Lower Limb Prosthetics for Sports and Recreation

quickly and then set more ambitious goals as incremental steps are attained. During performance of the 

physical evaluation and patient history, two of the most 

important considerations include (1) the mechanism 

of amputation and (2) the physical factors associated 

with the injury (eg, if the patient has experienced prolonged bed rest, rehabilitation must begin with a focus 

on the deconditioned status). The polytrauma nature 

of military injury often complicates the intensity of the 

rehabilitation because the patient has not experienced 

any significant activity since the injury. For example, 

in patients with compromised skin and associated 

diminished sensation, excessive skin loading in early 

weight bearing can lead to ulcers and an interruption 

in the ability to progress in ambulation skill. 

While weight-bearing capability is being established, a comprehensive program of physical rehabilitation should be in progress. In one study on physical fitness, amputee test subjects were significantly 

deconditioned when demographically matched to 

able-bodied subjects. After an endurance training 

program was completed, there was no significant difference from the able-bodied subjects, showing that 

individuals with limb loss are able to recover from a 

poorly conditioned state.13 The patient must be educated to understand that the primary key to successful 

participation in sports is a combination of preparatory 

physical training and appropriate prosthetic design. 

The prosthesis is merely a tool that plays an increasingly important role in maximized performance once 

strength, stamina, and skill progress. 

Depending on individual choice, patients can opt to 

participate in sports without a prosthesis. Swimming is 

one example of an activity in which use of a prosthesis is 

not always desired. The prosthesis can be used to reach 

the water and then removed on entry (Figure 21-1). In 

competition, the International Paralympic Committee 

Figure 21-1. Exiting the water using short, nonarticulated 

prostheses provides stability and function during the triathlon transition. 

Photograph: Courtesy of Terry Martin.

Figure 21-2. Bilateral transtibial amputee preparing for 

competition in the 2004 Paralympic Games.

Photograph: Courtesy of the US Paralympics, Colorado 

Springs, Colorado.
584

Care of the Combat Amputee

governs the use of assistive devices in the water. All 

prosthetics are removed prior to competition (Figure 

21-2). The International Amputee Soccer Association 

requires that participants use bilateral forearm crutches 

with at least one amputated limb without a prosthesis. 

In these instances, it would be counterproductive for 

high-level competition to train with a prosthesis when 

it cannot be used in the competition. In contrast, the 

Paralympic alpine disciplines allow athletes with single 

leg amputations to choose use of a single ski, outriggers, 

or prostheses; however, athletes with arm amputations 

usually compete without using poles.

When prostheses are not worn, it is advisable that 

amputees wear some form of protection on the residual 

limb. It can be as simple as using the liner that is worn 

with the prosthesis. If increased protection from highimpact falls is needed, a custom limb protector can be 

fabricated. 

GENERAL-USE UTILITY PROSTHESIS

Although the residual limb is undergoing expected shape and volume changes, it is important to 

consider using the prosthesis for as many activities 

as possible. In most instances, prostheses that allow 

the amputee to participate in a wide range of activity, 

including selected sports, can be designed. Current 

options—such as elastomeric gel liners that provide 

socket comfort and skin protection—required during 

everyday ambulation can suffice for many recreational 

activities. Careful choice of the prosthetic foot allows 

the amputee to walk faster and achieve a more equal 

step length on both sides, thus facilitating recreation 

and routine walking.14 The foot that has been aligned 

for comfort and efficiency during walking can still 

function adequately for intermittent, moderate bouts 

of higher activity. Although it has been shown that 

amputees find it difficult to accurately report their activity level versus measured activity level, the clinician 

does not have to rush into sports-specific limbs during 

the early stages of rehabilitation.15 Once the amputee 

commits to participation and training for a particular 

sport, a specific prosthesis or component may be 

necessary. When a single use prosthesis is provided, 

the optimized design facilitates full and potentially 

competitive participation in the desired activity.

Another approach is to utilize the current daily use 

socket with additional foot and/or knee combinations. 

The socket can be coupled with interchangeable distal 

components that have been selected to facilitate different tasks. A quick-release coupler can be provided 

to permit interchanging knee and foot/ankle components. This alternative, when appropriate, can be 

more time- and cost-effective than multiple individual 

prostheses. 

SKIN TOLERANCE TO HIGH ACTIVITY

Identification of the functional demands the activity 

will place on the residual limb will help determine the 

design of the prosthetic socket. A prosthesis cannot 

fully replace complexities of the human leg, such as 

providing dynamic shock absorption, adaptation to 

uneven terrain, torque conversion, knee stabilization, 

limb lengthening and shortening to diminish the arc of 

the center of gravity, transfer of weight-bearing forces, 

and reliable weight-bearing support.16 The significant 

difference in the activity is the nature and amount of 

impact and shear that will be placed on the residual 

limb. Long-term monitoring of ambulatory activity has 

indicated that our assumptions about the definition of 

high-activity level may not be correct.17 Some sports 

(eg, running) require quick movement and many steps 

for a limited amount of time, whereas other sports (eg, 

golf) require many more steps over a period of several 

hours. The sports of running and golf could be considered high-activity levels, although with different durations. Understanding the functional demands is even 

more important. The runner’s prosthesis must absorb 

the impact of loading response, support body weight 

through midstance to allow a long stride length on the 

sound side, and provide a measure of propulsive thrust 

at the end of stance. The golfer using a prosthesis endures long time periods of standing; maintains overall 

stability when twisting during swings; and ambulates 

safely over uneven terrain, slopes, and inclines.

Once the demands of the activity are understood, 

a careful evaluation will identify the weight-tolerant 

regions, as well as the skin sensitivity of the limb. A 

simple 10-g monofilament used to test foot sensation 

can be used to identify regions of the limb that lack 

protective sensation. This information should be relayed to the patient so that the individual has a full 

understanding of the importance of periodic visual 

skin evaluation during at-risk activity. 

The greater the shear forces generated with a prosthesis, the lower the pressure required to cause tissue 

breakdown.18 The cyclic shear stress that inevitably 

occurs within a prosthetic socket can cause a blister 

to form within the epidermis or can create an abrasion on the skin surface. When there is adherent scar 

tissue present, which is common following traumatic 
585

Lower Limb Prosthetics for Sports and Recreation

amputations, shear stress adjacent to the area results 

in skin tension that can cause blanching or even cell 

rupture.19 Investigation of an instrumented patella 

tendon-bearing prosthetic socket demonstrated that 

maximal pressure and resultant shear stresses shifted 

locations between the loading phase of stance and the 

latter phases of the gait cycle.20 This is a result of the 

dynamic movement of the residual limb within the 

socket. The planar force coupling that results in these 

measurement differences will be increased as directional activity changes with variations in movement 

of the prosthesis during sports.

As the individual’s activity level increases, the 

pressure and shear forces can easily rise to levels that 

cause soft-tissue damage. An increase in activity can 

also be associated with a rise in the incidence of skin 

problems.21 Common skin problems associated with 

prosthetic use include ulcers, irritations, inclusion 

cysts, calluses, contact dermatitis, hyperhidrosis, and 

infections.22,23 When these complications occur, medical management and prosthetic adjustments are often 

necessary. Controlled prosthetic use while treating 

ulcerations, for example, can still allow the patient to 

be ambulatory and the ulcer to heal satisfactorily.22

GENERAL ALIGNMENT CONSIDERATIONS FOR SPORTS

Several studies demonstrate that alignment is not 

as critical as volume change in affecting skin stress on 

the residual limb.24–26 In the context of this evidence, 

it still remains a critical aspect of optimal sports 

performance. Alignment of the socket and shank of 

a lower limb prosthesis critically affects the comfort 

and dynamic performance of the person it supports 

by altering the manner in which the weight-bearing 

load is transferred between the supporting foot and 

the residual limb. Furthermore, alignment of the 

lower extremity prosthesis for sports activities may 

be significantly different than what is optimal for 

other activities of daily living. Water and snow skiing are good examples of sports requiring increased 

ankle dorsiflexion. However, when the prosthesis is 

optimally aligned for these sports, it will not function well for general ambulation (Figure 21-3). In 

these instances, either a special-use prosthesis or 

interchangeable components will be necessary. If the 

user intends to interchange components, education 

must be instituted carefully to protect the limb from 

misalignment. 

Figure 21-3. Upright control while surfing is enhanced when 

using straight pylons on the transfemoral prosthesis. 

Photograph: Courtesy of Joseph Gabunilas.

GENERAL COMPONENT CHOICES FOR FORCE REDUCTION IN SPORTS

When the multidirectional forces that give rise to 

pressure and shear stresses are expected to increase 

because of athletic activity, a socket liner made from 

an elastomeric gel is often recommended. Patients with 

conditions such as skin grafts or adherent scars will 

have a reduced tolerance for shear.27 For transfemoral 

limbs, special consideration should be given to the 

ischial tuberosity area and the proximal tissue along 

the socket brim. Patient comfort can be increased by 

the use of a flexible plastic inner socket supported by 

a rigid external frame. This combination maintains 

the structural weight supporting the integrity of the 

socket while increasing the range of hip motion from 

the flexibility of the proximal socket.

The heels of prosthetic feet can dissipate significant 

amounts of energy during loading.28 Feet were shown 

to be capable of dissipating up to 63% of the input 

energy. Once a running shoe was added, the dissipation capacity increased to 73%. Even with the encouraging capability of the foot to absorb energy, once it 

has reached its limit, the forces are transferred to the 

socket and then ultimately the limb. Shock-absorbing 

pylons can be added between the socket and foot if 

additional impact reduction is desired. They may be 

an independent component or part of a foot/ankle/

shin integrated system. Some shock-absorbing pylon 

systems are pneumatic and easily adjusted by the user; 

other systems must be adjusted by the prosthetist to 

provide the optimal amount of vertical travel. The 

addition of a shock-absorbing pylon may show few 
586

Care of the Combat Amputee

quantitative kinetic or kinematic advantages in how 

someone walks, but pylons do show a force reduction 

during loading response and a report of increased comfort, particularly at higher speeds.29,30 It is important to 

consider that, when negotiating stair and step descent, 

the transfemoral amputee may gain added effect from 

an energy-absorbing pylon because of the increased 

lower extremity stiffness secondary to a lack of shockabsorbing knee flexion of a mechanical knee. 

A prosthetic torque absorber component can be 

provided that will allow up to a 40-degree range of 

internal and external rotation between the socket and 

foot. Although multiaxial ankles offer some rotational 

movement, a separate torque-absorbing component 

performs this most effectively. There are many torqueabsorber options commercially available, but none can 

effectively match or be adjusted to the asymmetrical 

internal and external torque seen in able-bodied 

individuals.31 Given the importance of minimizing 

transverse plane shear stress on vulnerable soft tissue, this component should still be considered even 

though it can match exactly to characteristics of the 

sound side.

Hafner et al32 suggest that the development and 

recommendation of prosthetic feet without supporting evidence of their performance may be the result 

of conflicting or inconclusive results in the reported 

literature. There is a missing link between the scientific 

evidence and clinical experience of the medical providers. Although subtle changes in gait and performance 

parameters are not statistically significant, these differences are perceived by amputees to affect their 

preferences and perception of foot performance. Later 

studies do suggest that variations in prescription may 

allow for benefits such as greater propulsive impulses 

by the residual leg that contribute to limb symmetry.33,34

TRANSTIBIAL RUNNING

Prior to performing running activities, it is helpful to 

understand the running goals of the service member. If 

the primary desire of the individual is to jog for cardiovascular endurance, a slow jog occurs at about 140 m/

min. At this speed, the heel has minimal effect because 

the middle portion of the foot becomes the primary initial contact point. Because the heel is minimally used or 

virtually eliminated as speeds increase to approximately 

180 m/min in running, a specific running foot without 

a heel component may be advantageous (Figure 21-4).35

Prosthetic limb kinematics have been shown to mimic 

this able-bodied data.36 The running foot is very light 

and highly responsive. There is a significant amount 

of deflection on weight bearing that adds to the shockabsorbing qualities. A running shoe tread is adhered 

to the plantar surface to further reduce weight. If a 

Figure 21-4. Running-specific foot modules are used to mimic 

natural running biomechanics.

Photograph: Reproduced with permission from ASI PHOTOS, Fort Worth, Texas.

Figure 21-5. Track-and-field sprint-specific feet are used for 

quick acceleration and high cadence speed. 

Photograph: Courtesy of Peter Harsch.
587

Lower Limb Prosthetics for Sports and Recreation

decrease in speed occurs (eg, when jogging with intermittent walking), the heel will become more important 

and a more versatile utility foot should be chosen. If 

the amputee desires to sprint and short bursts of speed 

are the goal, a sprint-specific foot should be considered 

(Figure 21-5). In general, the sprint foot is designed with 

a much longer shank that attaches to the posterior of 

the socket. This gives a longer lever arm for increased 

energy storage and return. For sprinting, the socket/

limb interface should be a more intimate fitting that will 

maximize the transfer of motion from the limb to the 

socket. As with any running, use of gel liner interfaces 

is recommended. Choosing a thinner, 3-mm-thickness 

liner will reduce the motion of the tibia in the socket. If 

jogging, the liner should be 6-mm thickness or 9-mm 

thickness to maximize the shock-absorbing capabilities 

over a longer duration of the activity. Because suspension is a key factor in movement and shear reduction 

on the limb, an airtight sleeve and expulsion valve can 

give the best limb stability.37

Figure 21-7. Transfemoral runner exhibiting a knee flexion 

running gait using a hydraulic single axis knee, sprint foot, 

and 20-degree angle bracket.

Photograph: Courtesy of Prosthetic Innovations LLC, Eddystone, Pennsylvania. 

TRANSFEMORAL RUNNING

Design of a transfemoral running limb follows 

the same guidelines as previously discussed for the 

transtibial running limb. Component choices are 

based on defining the goal of jogging and sprinting. 

Foot choices and use criteria are identical for both 

transtibial and transfemoral limbs. The next decision 

involves whether to incorporate a knee or begin with 

a nonarticulated limb. Beginning without a knee is 

Figure 21-6. Transfemoral runners can use a nonarticulating 

limb with a circumducted gait to increase stance stability 

and energy efficiency.

Photograph: Courtesy of Thomas F. Martin, Jr, and Anderson 

Independent-Mail, Anderson, South Carolina.
588

Care of the Combat Amputee

a viable option when stability is a concern or when 

suitable cardiovascular endurance has not yet been 

attained. Training begins with a circumducted gait to 

allow foot clearance in swing. If a patient intends to 

participate in distance running, a nonarticulated system eliminates the mental concern of inadvertent knee 

flexion and seems to be significantly less demanding 

for a longer run (Figure 21-6). When sprinting is the 

goal, use of a knee is generally recommended. There 

are several good choices available that use hydraulic 

control of flexion and extension resistance and that 

interface well with the sprint feet (Figure 21-7). The 

knees and overall alignment must be fine-tuned to 

the individual needs of the patient. Interlimb asymmetry has been shown to increase significantly when 

the transfemoral amputee runs. Therefore, special 

attention to alignment, component adjustments, and 

training is particularly important.36,38 Maximum sports 

performance may require modified or even specialized 

components or significant deviations from standard 

alignment techniques to help improve interlimb symmetry and running velocity.39

Figure 21-9. Transfemoral amputee exhibiting free swing 

from a seven axis knee with a direct attached carbon foot 

system. 

Photograph: Courtesy of Coyote Design, Boise, Idaho.

CYCLING

Cycling is an excellent exercise that is nonweight 

bearing and indicated for those who may have closedchain impact restrictions. Once proper fitting of the 

bicycle has been completed, the prosthesis will need 

some accommodations if more than recreational cycling 

is intended (Figure 21-8). For the transtibial amputee, 

knee flexion restriction must be minimized. Suspension systems that cross the knee, such as suction with 

gel sleeves, can be replaced with distal pin-and-lock 

options. If the sleeve is still preferred by the patient, 

choosing one that is preflexed and just tight enough 

to maintain a suction seal is adequate. The posterior 

socket brim is typically restrictive in full knee flexion. 

Providing an adequately low posterior brim to allow 

full knee flexion often will not comfortably support 

the limb during ambulation. This can be overcome by 

Figure 21-8. Paralympic cyclist with a direct attached carbon fiber foot and shin system to enhance aerodynamic efficiency.

Photograph: Reproduced with permission from Brightroom, 

Inc, Fort Worth, Texas.
589

Lower Limb Prosthetics for Sports and Recreation

designing a posterior brim that is removable for biking 

and replaced for ambulation. 

The transfemoral amputee must be provided adequate clearance between the ischial tuberosity and 

the cycle seat. Careful socket adjustments in this region 

can usually provide a limb that is comfortable for limited ambulation and extended seat time (Figure 21-9). 

The knee choice will be based on the type of cycling 

that is intended. Typically, a knee that allows free 

motion on the bike will be easier to use. Choosing a 

knee component that is safe to walk on in a free swing 

mode will be helpful. For both levels of amputation, 

the foot stiffness can be increased to ensure maximum 

transfer of energy to the pedal. This will leave the foot 

excessively stiff for comfortable ambulation, but more 

efficient for cycling. The sole of the biking shoe can be 

removed and attached directly to the prosthetic foot if 

additional weight and control are needed. Unilateral 

transtibial amputee cyclists have been shown to exhibit more pedaling asymmetry than the able-bodied 

population. This may be also related to foot stiffness, 

but was not shown to be statistically significant in 

preliminary data (Childers WL, Kistenberg RS, Gregor 

RJ, unpublished data, 2007).

Figure 21-11. Wake boarding is made possible with sportsspecific knees that provide stability with flexion- and 

extension-assisted support.

Photograph: Courtesy of Ed Rosenberger.

ROCK CLIMBING

Rock climbing has increased in popularity in the past 

years. No longer does one have to travel to the natural 

outdoors to enjoy the exhilaration of this experience. Local indoor and outdoor climbing systems are available 

in many locales. Commercially produced prosthetic feet 

are unsuitable for rock climbing because the toe must 

be rigid enough to support the full body weight when 

only that portion of the prosthesis is in contact with the 

rock face (Figure 21-10). The foot should be shortened to 

decrease the torque and rotation that occur with a longer 

lever arm. The shape of the foot should be contoured to 

Figure 21-10. Custom foot module with spikes and Kevlar 

(Du Pont de Nemours and Company, Wilmington, Delaware) is used to increase traction while scaling an indoor 

rock-climbing wall.

Photograph: Courtesy of College Park Industries, Fraser, 

Michigan.
590

Care of the Combat Amputee

take advantage of small cracks, crevices, and contours 

of the climbing surface. Once an acceptable shape has 

been obtained, completely covering the foot with the 

soling from climbing shoes will give the texture needed 

for optimum performance. Making the prosthesis easily height adjustable allows the user to optimize limb 

length for different types of climbs. If no prosthesis is 

used, limb protection should be provided. 

Figure 21-13. Adaptive ski poles for the downhill skier replaces the need for a sports-specific prosthesis.

Photograph: Courtesy of Byron Hetzler.

Figure 21-12. Advanced dynamic sport knee builds energy 

during flexion and returns energy in extension to provide 

superior control for the transfemoral skier.

Photograph: Courtesy of SymbioTechs, USA LLC, Amity, 

Oregon.

WATER SPORTS

After running sports, water sports are the next most 

popular activities. Depending on geographical location, 

water sports may be more or less a part of the culture. 

Most prostheses will tolerate occasional and nominal 

exposure to moisture, particularly when protected under a layer of clothing. The everyday prosthesis should 

be made resistant to splashes that occasionally occur, 

especially when living in a wet climate. A specialized, 

waterproof design is necessary when the amputee will 

have regular exposure to salt water or freshwater, especially if complete immersion is intended (Figure 21-11). 

For the bilateral transfemoral patient, prosthetic devices 

are usually bypassed in favor of specialty seating systems that allow participation at the highest levels.40

WINTER SPORTS

The amputee interested in winter sports currently 

has an unprecedented opportunity for participation. 

For those interested in downhill skiing, most individuals with unilateral transtibial amputation continue to 

use a prosthesis (Figure 21-12). Although a walking 

limb can be adapted and used, a ski-specific alignment should be performed for the duration of the 

activity. Additional foot dorsiflexion and external 

knee support should be added. For advanced users, 

specialty feet that eliminate the boot are available. 

The plantar surface of the ski foot is modeled after the 

boot sole and will attach directly to the ski bindings, 

thus eliminating the boot altogether. This eliminates 

excess weight, but, more importantly, enhances energy 

transfer to the sporting equipment for more efficient 

performance. Unilateral transfemoral skiers will 

usually opt to use a single ski with bilateral forearm 

outriggers (Figure 21-13). The immense popularity of 

snowboarding has accelerated developmental designs 

for the transfemoral amputee. A recently released knee 

has been designed specifically for sports that require 

a loaded, flexed knee position. Snowboarders are in 

bilateral dynamic hip, knee, and ankle flexion as they 

negotiate the hill (Figure 21-14). This knee is adjustable 

and produces the weighted knee flexion necessary to 

snowboard successfully. The transtibial snowboarder 

needs additional dorsiflexion range and flexibility in 

the prosthetic foot. 
591

Lower Limb Prosthetics for Sports and Recreation

GOLF

can be introduced (Figure 21-15). Amputee golfers 

report that these components can help them achieve 

a smooth swing and follow-through, and can reduce 

the uncomfortable rotational shear that would otherwise occur between the skin of the residual limb and 

the socket. Studies have confirmed this fact and show 

improved hip and shoulder rotations, particularly in 

the left-sided amputee.41,42

Figure 21-15. Torsion control systems allow for proper swing 

mechanics for the amputee golfer.

Photograph: Courtesy of Michael Pack, Artificial Limb Specialists, Phoenix, Arizona.

The longevity of potential participation in this 

sport may be a major factor in its popularity. Golf 

is a sport that can be entered into when one is quite 

young and often followed throughout a lifetime. A 

correct golf swing requires triplanar movements at 

the ankle, hip, and shoulder joints. Because prosthetic 

feet cannot duplicate the three-dimensional movement 

of the ankle, torque absorbers or rotational adapters 

Figure 21-14. No additional adaptive gear is necessary for 

this transfemoral snowboarder when using this energystoring prosthetic knee. 

Photograph: Courtesy of Symbiotechs, USA LLC, Amity, 

Oregon.

HIKING

Activity that includes traversing uneven terrain 

(eg, hiking) requires consideration of a multiaxial 

ankle. This type of ankle allows the prosthetic foot to 

conform to irregular surfaces, thus reducing the forces 

transferred to the residual limb.

As the amputee enters midstance on the prosthesis, the foot should accommodate uneven terrain and help control advancement of the tibia. 

If tibial advancement is too abrupt, the amputee 

will resist this knee flexion moment, increasing 

the forces on the residual limb within the socket. 

When aligning and adjusting a new prosthesis, the 

amputee should be evaluated on surfaces similar 

to those that will be encountered in the athletic 

activity limb. Perhaps even more significant than 

multiaxial feet and torque absorbers is the recent 

release of a motorized ankle. This type of ankle 

does not generate propulsive power, but rather 

senses electronically when the user is on an incline 

or decline. The ankle requires two strides to sense 

the orientation, then it will consequently plantarflex or dorsiflex the foot to ease the moments that 

are induced on the knee and the forces that act on 

the residual limb.
592

Care of the Combat Amputee

INJURIES AND LONG-TERM EFFECTS

intact limb injuries are also common to the amputee.44

Additional attention must be focused on the issue of 

depressive symptoms that are seen so commonly in 

conflict amputations. A correlation has been noted between depression and prediction of pain intensity and 

bothersomeness.45 Amputees have also been shown 

to suffer from various comorbidities associated with 

biomechanical abnormalities.46–49

With this focus on sports as an aspect of rehabilitation for the limb amputee comes an inherent increased 

risk of injury. Injuries for the disabled sporting community are similar to those for athletes without disabilities. Locations of the injury seem to be sports- and 

disability-dependent. Ambulatory amputee athletes 

more commonly have lower extremity injuries (eg, 

abrasions, strains, sprains, and contusions).43 Spine and 

OTHER CONSIDERATIONS

Prescribing component recommendations that 

facilitate higher activities is typically based on the 

experience of the prosthetist primarily because of 

the lack of conclusive scientific evidence on these 

applications.18 It is useful to clearly understand 

the functional and biomechanical demands of a 

specific sport when forming a prescription recommendation so that the functional characteristics of 

the components match these criteria. Participation 

in most sports can be facilitated by adaptations of 

conventional socket designs combined with commercially available components, but some activities 

are best accomplished with unique custom-designed 

components. 

SUMMARY

The needs and preferences of the amputee should 

be clearly understood, and the functional demands of 

the activity should be determined prior to generating 

the prescription. Physical training status should be 

evaluated before intensive participation, particularly 

in sports unfamiliar to the participant. Early in the 

rehabilitation process, the prosthesis can usually be 

adapted to the activity and still be used effectively in 

therapy. As the amputee progresses and the demands 

of participation increase, a specialized prosthesis can 

be provided. A properly designed prosthesis can substantially expand the opportunities for participation in 

sports and augment the overall goals of the rehabilitation plan for each patient. 

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