NCPO LaTrobe University

PREPARING AMPUTEE ATHLETES:

THE AUSTRALIAN APPROACH

compiled by Joellen McPhan

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TABLE OF CONTENTS

TABLE OF FIGURES.............................................................................................. VI

ACKNOWLEDGEMENTS ....................................................................................VII

INTRODUCTION........................................................................................................1

SECTION 1 – BACKGROUND TO AMPUTEE RUNNING .....2

CHAPTER 1 - BIOMECHANICS OF AMPUTEE RUNNING............................3

RUNNING............................................................................................................3

TEMPEROSPATIAL CHARACTERISTICS......................................................4

KINEMATICS .....................................................................................................5

JOINT MOMENTS..............................................................................................8

ENERGETICS......................................................................................................8

CHAPTER 2 - AMPUTEE SPECIFIC CONSIDERATIONS.............................12

PHYSICAL CONSIDERATIONS.....................................................................12

PROSTHETIC CONSIDERATIONS ................................................................13

PSYCHOLOGICAL CONSIDERATIONS .......................................................13

CHAPTER 3 - AMPUTATION LEVEL CONSIDERATIONS............................14

CONGENITAL AND ACQUIRED AMPUTEES.............................................14

UPPER EXTREMITY AMPUTEES .................................................................14

THROUGH KNEE AMPUTEES.......................................................................15

ABOVE KNEE AMPUTEES.............................................................................15

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CHAPTER 4 - THE MULTI-DISCIPLINARY TEAM APPROACH .................17

DOCTOR............................................................................................................18

PHYSIOTHERAPIST ........................................................................................19

PROSTHETIST..................................................................................................19

COACH ..............................................................................................................19

SECTION 2 - THE MULTI-DISICPLINARY TEAM...................20

CHAPTER 5 - THE ROLE OF THE PHYSIOTHERAPIST .............................21

INITIAL ASSESSMENT...................................................................................21

GAIT ANALYSIS ............................................................................................22

PHYSICAL ASSESSMENT.............................................................................22

• Residual Limb.......................................................................................23

• Posture .................................................................................................23

• Strength ................................................................................................23

• Range Of Motion ..................................................................................24

• Core And Joint Stability And Activation ..............................................24

PHYSICAL UPGRADING................................................................................25

GAIT RE-EDUCATION.................................................................................25

CORE PROGRAM .........................................................................................26

MODIFIED GYM PROGRAM.......................................................................27

POOL WORK.................................................................................................29

SPORT SPECIFIC TRAINING ......................................................................29

ONGOING MANAGEMENT............................................................................29

LIASE WITH TEAM.......................................................................................29

INJURY PREVENTION AND MANAGEMENT ............................................29

ELIGIBILITY FOR A RUNNING PROSTHESIS............................................30

COMMON EXERCISES AND PROGRAMS...................................................30

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CHAPTER 6 - THE ROLE OF THE PROSTHETIST........................................31

INITIAL ASSESSMENT...................................................................................31

RUNNING PROSTHESIS .................................................................................32

BELOW-KNEE COMPONENTRY.................................................................32

• Foot ..................................................................................................32

• Liner .................................................................................................36

• Socket type .......................................................................................36

• Suspension........................................................................................38

• Trimlines ..........................................................................................40

BELOW KNEE ALIGNMENT........................................................................40

Below Knee Bench Alignment ...................................................................41

Below Knee Static Alignment ....................................................................42

Below Knee Dynamic Alignment...............................................................42

ABOVE KNEE COMPONENTRY..................................................................42

• Foot ..................................................................................................43

• Socket ...............................................................................................44

• Liner/suspension ..............................................................................45

• Knee Units........................................................................................46

ABOVE KNEE ALIGNMENT ........................................................................47

Above Knee Bench Alignment ...................................................................47

Above Knee Static Alignment ....................................................................48

Above Knee Dynamic Alignment...............................................................48

EDUCATION.....................................................................................................49

CHAPTER 7 - THE ROLE OF THE COACH .....................................................51

INITIAL ASSESSMENT...................................................................................52

DEVELOPING A TRAINING PROGRAM......................................................54

INDIVIDUALISM ..........................................................................................54

INJURY PREVENTION AND MANAGEMENT ............................................55

COMMUNICATION ......................................................................................55

SPORT SPECIFIC FITNESS .........................................................................56

SPORT SPECIFIC SKILL DEVELOPMENT ................................................57

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MODIFICATIONS TO EXERCISES................................................................60

STRENGTHENING PROGRAMS..................................................................60

PLYOMETRIC EXERCISES ..........................................................................60

SECTION 3 - TROUBLE SHOOTING .................................................62

CHAPTER 8 - INJURIES.......................................................................................63

RISK FACTORS................................................................................................63

INJURY MANAGEMENT................................................................................63

INJURY PREVENTION....................................................................................64

COMMON INJURIES .......................................................................................65

CHAPTER 9 - GAIT ANALYSIS: DEVIATIONS AND MANAGEMENT......69

GAIT ANALYSIS..............................................................................................69

PHYSIOTHERAPIST .....................................................................................70

PROSTHETIST ..............................................................................................71

COACH ..........................................................................................................72

GAIT DEVIATIONS .........................................................................................73

GENERAL DEVIATIONS ..............................................................................73

BELOW KNEE SPECIFIC DEVIATIONS .....................................................86

ABOVE KNEE SPECIFIC DEVIATIONS .....................................................87

REFERENCES...........................................................................................................88

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SECTION 4 - APPENDICIES.....................................................................91

APPENDIX I – AMPUTEE CLASSIFICATIONS.................................................92

APPENDIX IIA – IMPAIRMENT SPECIFIC SCREENING FORM .................94

APPENDIX IIB – EXPLANTORY NOTES............................................................98

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TABLE OF FIGURES

Figure 1 - The Running Gait.. ........................................................................................4

Figure 2 - Joint Angle Times During Able-Bodied Running. .......................................5

Figure 3 - Knee Joint Angular Kinematics ....................................................................6

Figure 4 - Energy Absorption During Stance ..............................................................10

Figure 5 - Energy Generation During Stance ..............................................................11

Figure 6 - A Below Elbow Running Prosthesis ...........................................................15

Figure 7 - The Multi-Disciplinary Team .....................................................................18

Figure 8 - Gait Re-Education.......................................................................................26

Figure 9 - Core Strengthening......................................................................................27

Figure 10 - Modified Gym Program ............................................................................28

Figure 11 - Modified Gym Program ............................................................................28

Figure 12 - The Flex-Sprint III ....................................................................................33

Figure 13 - The Flex-Sprint III and Attachments ........................................................34

Figure 14 - Positioning and Attaching the Lamination Connector ..............................35

Figure 15 - Hydrostatic Sockets...................................................................................37

Figure 16 – Running Prosthesis Compenentry ............................................................39

Figure 17 - Running Prosthesis Componentry.............................................................39

Figure 18 - Bench Alignment of the Flex-Sprint III. ...................................................41

Figure 19 - The Flex-Sprint Series...............................................................................43

Figure 20 - The Quadrilateral and Ischial Containment Sockets.. ...............................44

Figure 21 - The Flex-Sprint I and Attachments ...........................................................46

Figure 22 - Bench Alignment of an Above Knee Running Prosthesis ........................47

Figure 23 - Strength Testing ........................................................................................53

Figure 24 - Relative Strength Training ........................................................................56

Figure 25 - Bend Running............................................................................................58

Figure 26 - Take-Off....................................................................................................59

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ACKNOWLEDGEMENTS

Harvey Blackney - Advanced Prosthetic Centre

David Howells – prosthetist, Advanced Prosthetic Centre

Cathy Howells – consultant physiotherapist, Advanced Prosthetic Centre

Colin Wright – coach of a number of successful Paralympians

Stephen Wilson – dual gold medallist and world record holder, Sydney 2000

Paralympic Games

Chris Nunn - head coach athletes with disabilities, Australian Institute of Sport

Dr Tim Bach – supervisor, Head of NCPO, Latrobe University.

Les Barnes – co-supervisor, NCPO, Latrobe University.

Staff at the Advanced Prosthetic Centre, Sydney

Fellow honours students

Sydney Athletics Centre, Homebush Bay

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INTRODUCTION Australian amputee runners have been extremely successful in international

competition. The training approach taken in the preparation of the athletes has been

identified as a major contributor in achieving such success. The ability to obtain

information relating to the Australian methods of training amputee runners is limited.

There are no current publications that investigate or discuss the training approach of

the Australian amputee track team.

The success of the Australian amputee track team was demonstrated at the

Sydney 2000 Paralympic games. As a result of the increased exposure of the abilities

and successes of amputee athletes it is anticipated this will inspire others to develop

their sporting skills. Increased participation provides a higher competition standard

and as a result produces more competitive athletes. It also increases the demand for

improvements in prosthetic and other disabled sport technology and increases the

demand for amputee running related resources, which are already limited.

The Australian method of training amputee athletes involves a multi-

disciplinary team approach. This provides expertise and specialist knowledge in every

aspect relating to amputee running. The multi-disciplinary team approach is

applicable in training disabled athletes in general, although this manual demonstrates

the approach in relation to amputee running.

The manual is aimed to educate and guide the multi-disciplinary team on ways

of managing amputee runners when they initially present. The manual includes sports

specific knowledge (biomechanics of amputee running), discusses the roles of each

member of the multi-disciplinary team and includes a trouble-shooting guide that

reviews gait deviations and amputee specific injuries. Case studies are also included

to provide examples of successful coaching and physiotherapeutic programs and

prosthetic management. The manual addresses the management of athletes at the early

stages of running, to the more experienced, elite athlete. It also caters for all levels of

amputation, with the main emphasises throughout the manual being the multi-

disciplinary team approach.

The manual will provide an updateable resource for people interested in any

aspects relating to amputee running. It provides guidelines to assessing athletes, the

basic principles of designing individual amputee specific training programs and

options for prosthetic prescription.

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SECTION 1

BACKGROUND TO AMPUTEE

RUNNING

BIOMECHANICS OF AMPUTEE RUNNING

AMPUTEE SPECIFIC CONSIDERATIONS

AMPUTATION LEVEL CONSIDERATIONS

THE MULTI-DISCIPLINARY TEAM APPROACH

It is important for the members of the multi-disciplinary team to have good

knowledge of the biomechanics of running as it provides an understanding of the

limitations and adaptations necessary to enable amputees to run. This section provides

a brief summary of below knee and above knee amputee running, discussing the

temperospatial characteristics, kinematics, joint moments, energetics and joint

powers.

This section also briefly discusses the amputee specific considerations that a

professional managing an amputee athlete should understand. This includes the

physical, prosthetic and psychological issues that the amputee faces.

The types of amputation (congenital and acquired) are reviewed as too the

basic considerations necessary for each amputation level. Finally, the multi-

disciplinary team is introduced as it forms the basis of the manual. The relationship

between the major contributors of the amputee running multi-disciplinary team (the

physiotherapist, prosthetist, coach and athlete) is identified.

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CHAPTER 1

BIOMECHANICS OF AMPUTEE RUNNING

Understanding the biomechanics of normal running is important in identifying

the limitations and compensations that occur during amputee running. Research is

further enhancing our understanding of the adaptations required of amputees to run

(Czerniecki, 1996). The adaptive processes of the amputee must coordinate prosthetic

limb motion with those of the intact limb. This increases the demand in muscle work

and increases the energy expenditure of amputee running gait (Sanderson and Martin,

1996). When discussing amputee running, it is important to distinguish between

swing and stance phases and the movement of the intact and the residual limbs.

The main biomechanical deficits of amputee running are insufficient power

generation at prosthetic push-off, increased impact forces on the intact limb and

interlimb asymmetry (Brouwer, Allard and Labelle, 1989; Smith, 1990; Czerniecki,

Gitter and Beck, 1996). Compensatory mechanisms are adopted to overcome these

limitations particularly on the intact limb during swing phase and the prosthetic limb

during stance phase (Czerniecki, 1996). It is important for each team member to

understand the biomechanics of running and the compensations and adaptations

employed to enable amputees to run as it influences the implementation of a training

program and the prosthetic prescription

RUNNING As a person increases their speed from walking to running, the proportion of

stance phase decreases, swing phase duration increases and double support is

eliminated. The running cycle consists of a stance phase and a swing phase, which

includes a period of flight where there is no contact with the ground (FIGURE 1). The

stance phase can be further divided into absorption and propulsion phases and the

swing phase into initial and terminal swing phases (Thordarson, 1997).

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Figure 1 - THE RUNNING GAIT. This figure illustrates the various positions of the body during

running gait at (A) take-off, (B) flight and (C) initial contact (as cited by Lees in Durward, Baer and

Rowe, 1999).

(A) (B) (C) (A)

TEMPEROSPATIAL CHARACTERISTICS The stride length, stride time and impact loads of the intact and prosthetic

limbs are common asymmetries (Macfarlane, Nielsen and Shurr, 1997). Interlimb

asymmetries result in an energy expensive gait compared to normal (Macfarlane,

Nielsen and Shurr, 1997).

In above knee prosthesis, excessive heel rise causes a delay in the forward

acceleration of the distal shank. This is a major contributor to interlimb asymmetry

and can cause a number of gait deviations (Sabolich, 1987). In an attempt to quicken

the follow through of the distal shank (foot) during running, the hop-skip method of

running was previously adopted by above knee runners. The hop-skip method

involves two intact stance phases to one prosthetic swing phase with a period of

double support (Mensch and Ellis, 1986). The feet are closer together at initial

contact and assist in decreasing the knee flexion moment and impact loads of the

intact limb at initial contact.

In recent years, through prosthetic componentry developments, particularly

knee units, has enabled above knee amputees to run with a more efficient step-over-

step style.

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KINEMATICS In able-bodied jogging, initial contact is with the heel. At heel contact,

dorsiflexion occurs and the foot pronates. Pronation and dorsiflexion, along with hip

and knee flexion, assists in absorbing impact loads (Thordarson, 1997). As speed

increases, initial contact occurs with the midfoot/forefoot. Consequently the foot is

plantarflexed at initial contact. The ankle then quickly dorsiflexes to reflect the

movement of the body over the foot and plantarflexes again for push-off (FIGURE 2)

(as cited by Lees in Durward, Baer and Rowe, 1999).

Figure 2 – JOINT ANGLE TIMES DURING ABLE-BODIED RUNNING. The ankle, knee and thigh

angle times during able-bodied running are shown below (as cited by Lees in Durward, Baer and Rowe,

1999).

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At initial stance during able-bodied running, the knee maintains a slightly

flexed position to absorb loads and assist in push-off. Alternatively, the transtibial

amputees often walk and run with a ‘locked-knee’ gait. This refers to a gait where the

amputee maintains their knee in extension or limits their knee flexion, particularly

during swing on the intact limb and initial –mid stance on the prosthetic limb (Miller,

1987; Sanderson and Martin, 1996). FIGURE 3 illustrates the limited flexion of the

prosthetic knee during initial-mid stance and the limited flexion of the intact knee

during swing.

Limited knee flexion on the prosthetic side occurs for a number of reasons.

Decreased quadriceps strength and manipulation of the knee joint moment to limit

knee flexion maintains the prosthesis in a vertical position. Maintenance of a vertical

position is an attempt to reduce the impact loads applied to the residual limb and is a

safety mechanism used to prevent the knee from collapsing (Brouwer, Allard and

Labelle, 1989; Sanderson and Martin, 1996).

Figure 3 - KNEE JOINT ANGULAR KINEMATICS. The knee angle during stride is illustrated for

‘normal’ (solid line), the intact (dotted line) and the prosthetic sides (broken line). Stance phase

comprises the first 40% of stride duration (Sanderson and Martin, 1996).

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As rapid acceleration occurs, during and after prosthetic push-off, the

prosthesis can give the amputee the sensation that their leg is pulling off. However, by

restricting knee flexion and maintaining the prosthesis in a vertical position the

elongation on the distal end of the residual limb is eliminated.

Knee flexion can also be limited as a result of the prosthesis’ design. The

patellar tendon bar in particular designs apply pressure on the patella ligament when

the knee is flexed. If this pressure is excessive, the amputee maintains their knee in

extension to avoid discomfort (Miller, 1987; Enoka, Miller and Burgess, 1982;

Brouwer, Allard and Labelle, 1989).

The intact limb limits the amount of knee flexion in an attempt to gain

symmetry with the prosthetic limb. The decreased knee flexion maintains the intact

foot close to the ground and as a result the step length is reduced (Sanderson and

Martin, 1996). It has been suggested that the reduced step length on the intact side is

in an attempt to match the step length of the prosthetic side and hence gain symmetry

between the intact and prosthetic limbs.

The knee flexion angle of the intact leg is also manipulated in an attempt to

gain symmetry between the prosthetic and intact limbs. By manipulating joint

moments, the sum of all the joint moments on the intact leg is similar to the sum of

those on the residual limb.

The rigidity of the extended knee at initial contact reduces the shock absorbing

characteristics of the limb and places further stress on the knees and hips of both legs

and the vertebral column (Enoka, Miller and Burgess, 1982; Brouwer, Allard and

Labelle, 1989). Such stresses can result in degenerative changes at these joints

(Czerniecki, 1996; Macfarlane, Nielsen and Shurr, 1997).

It is important for the above knee amputee to maintain knee stability and

prevent the knee buckling (Czerniecki, 1996). To achieve this, above knee amputees

use their hip extensors to maintain stability. The hip is maintained in extension for a

longer period compared to able-bodied athletes for stability reasons and is also held at

approximately 0o-5o extension to assist in maintaining a vertical limb for the reasons

mentioned previously. However, by maintaining the hip in extension, the impact

forces are not absorbed efficiently. To effectively absorb impact forces it is necessary

to have hip and knee flexion, although knee flexion encourages knee instability

(particularly in above knee athletes). Ideally, the prosthetic knee unit should replicate

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the quadriceps in early stance and the hamstrings in late stance in their energy

absorption roles and abilities (Czerniecki, 1996).

JOINT MOMENTS During swing in below knee amputee running there is an increased hip flexor

moment on the intact and prosthetic sides (Czerniecki and Gitter, 1996; Sanderson

and Martin, 1996). Sanderson and Martin (1996) found that both the intact and

prosthetic limbs have an increased hip flexor moment compared to normal. The intact

leg increases its hip flexor moment in an attempt to provide symmetry between the

limbs during running. As mentioned previously, this may be an attempt to gain

symmetry between the limbs by making the sum of the joint moments on each leg

similar values.

Czerniecki and Gitter (1996) found an increased hip flexor moment on the

intact side during swing contributes to energy transfer mechanisms. By increasing the

concentric hip flexor and eccentric knee extensor contractions during swing, there is

an increase in the mechanical work done and the energy available to transfer. Energy

transfer is adopted in amputee running to provide an alternate power source to

compensate for the insufficient push-off on the prosthetic side.

The knee and ankle moments are also manipulated on the intact side in an

attempt to gain symmetry between the intact and prosthetic limbs. The joint moments

are manipulated to allow the sum of the joint moments on the intact limb to equal the

sum of joint moments on the prosthetic limb (Sanderson and Martin, 1996). Although

the knee joint may contribute a different joint moment to the summed figure of each

limb, the addition of all the joint moments on each limb will be approximately the

same.

ENERGETICS At initial contact in able-bodied running, pronation and dorsiflexion, along

with hip and knee flexion, assists in absorbing impact loads (Thordarson, 1997). The

foot is dorsiflexed as the body moves over the foot and during the absorption phase,

following initial contact, the hip and knee extend and remain extended until just prior

to push-off (Throdarson, 1997). At push-off the ankle plantarflexes and the hip and

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knee flex to generate energy to propel the body forward (as cited by Lees in Durward,

Baer and Rowe, 1999).

In below knee amputee running, similarly to able-bodied running, all joints of

the lower limbs assist in energy generation and absorption. However, they each

contribute differently compared to able-bodied running and as a result of the loss of

the plantarflexors in the amputee. In comparison to able-bodied running, the intact leg

has increased impact loads and the prosthetic leg has decreased impact loads

(Brouwer, Allard and Labelle, 1989; Prince, Allard, Therrien and McFadyen, 1992;

Czerniecki and Gitter, 1996). There is also an overall reduction in the work done on

the prosthetic stance phase limb in below knee amputee running, irrespective of

prosthetic foot type (Czerniecki, Gitter and Munro, 1991). Some studies have found

that up to 50% less work is done on the prosthetic stance phase limb compared to

normal (Czerniecki and Gitter, 1992). This is attributable to the reduced energy

generation provided by both the plantarflexors and knee extensors. The prosthetic side

knee extensors absorb significantly less energy than normal and as a result the

prosthetic hip extensors absorb more energy than normal (FIGURE 4) (Czerniecki,

Gitter and Munro, 1991; Czerniecki, 1996). The hip extensors on the prosthetic side

actually have increased work demands and generate more energy than normal during

stance phase (FIGURE 5). Czerniecki and colleagues (1992) found that the prosthetic

side absorbed two-thirds the energy and the hip extensors generated three times more

energy than non-amputees. The intact limb in below knee athletes during stance does not increase muscle

work to compensate for the power deficits associated with prosthetic push off

(Brouwer, Allard and Labelle, 1989; Smith, 1990; Czerniecki, 1996). However,

during swing, the total mechanical work done on the intact limb is 69% more than

normal (Czerniecki and Gitter, 1992; Czerniecki, Gitter and Beck, 1996). This

influences the energy levels of the limb and energy transfer mechanisms.

Energy transfer assists in accelerating the prosthetic limb into swing and

accounts for more than 50% of the total work done (Gitter, Czerniecki and Miender,

1997). Typically, energy is transferred into the prosthetic limb in early swing and as

the limb decelerates toward the end of swing, energy is transferred out of the limb.

This energy transference co-insides with prosthetic push-off (Czerniecki, Gitter and

Beck, 1996).

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The intact limb of the transfemoral amputee experiences higher impact loads

and higher work demands compared to the prosthetic and normal limbs (Czerniecki,

1996). Increased mechanical work by the intact limb compensates for the inability of

the prosthesis to provide push-off power. The intact hip extensors, during the

concentric contraction phase in stance, produce 270% more mechanical work than

normal and the intact plantarflexors generate 30% more (Serroussi, Gitter, Czerniecki

and Weaver, 1996). The increase in mechanical work by the intact hip musculature

increases the energy levels of the limbs and contributes to energy transference. Energy

transfer mechanisms are incorporated into transfemoral running gait similarly to

transtibial amputees, to assist in prosthetic push-off and to assist the acceleration of

the prosthesis into swing (Gitter, Czerniecki and Beck, 1996).

There is also an increase in hip flexor power on the prosthetic side to

accelerate the transfemoral prosthesis into swing. The increased hip flexor power

produces a ‘pull-off’ effect, lifting the prosthesis into swing, rather than pushing off

with the prosthesis (Serroussi, Gitter, Czerniecki and Weaver, 1996). The value of the

prosthetic hip flexor power is similar to normal. However, the prosthetic limb weighs

approximately 30-40% of the normal limb. In context, more power is produced to

propel the lighter prosthetic limb into swing compared to a ‘normal’ leg (Serroussi,

Gitter, Czerniecki and Weaver, 1996).

Figure 4 - ENERGY ABSORPTION DURING STANCE. This figure illustrates the distribution of total

stance phase eccentric muscle work (energy absorption) of the hip extensors, knee extensors and ankle

plantarflexors (Czerniecki, Gitter and Munro, 1992).

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Figure 5 - ENERGY GENERATION DURING STANCE. This figure illustrates the distribution of

total stance phase concentric muscle work (energy generation) of the hip extensors, knee extensors and

ankle plantarflexors (Czerniecki, Gitter and Munro, 1992).

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CHAPTER 2

AMPUTEE SPECIFIC CONSIDERATIONS The recreational desires of the lower limb amputee are not entirely considered

during the initial rehabilitation stages (Enoka, Miller and Burgess, 1982; Czerniecki

and Gitter, 1992). The initial rehabilitation team should discuss the patient’s

expectations beyond gait re-education in regard to long-term functional outcomes.

Ideally, rehabilitation programs should not regard walking as the ultimate objective

for fit and active lower extremity amputees. Running forms the basis of many

recreational activities and running related issues should be addressed and incorporated

in the rehabilitation programs for active amputees, especially if they intend to pursue

recreational activities (Czerniecki and Gitter, 1992).

When managing an amputee athlete (either lower or upper extremity) there are

a number of factors to consider. The amputee pursuing recreational desires is faced

with various challenges including physical, prosthetic and psychological issues.

Clearly a multi-disciplinary team is required in the management and preparation of

these athletes to address each challenge.

PHYSICAL CONSIDERATIONS Physically, amputee athletes have increased work demands compared to able-

bodied athletes during walking and running. Amputee athletes often tire quicker due

to the increased work demands and have thermoregulatory issues. Amputees tend to

perspire more as there is less surface area for heat dissipation. As a result of wearing a

prosthesis, the perspiration cannot evaporate and the full cooling benefits associated

with evaporation are not gained.

Muscular imbalances may also be present as a result of surgical management.

Consequently, compensatory measures to overcome the original deficiencies may

further influence the development of other muscular imbalances.

Pain and phantom pain also requires consideration when managing amputee

athletes. Pain influences the ability of the athlete to fully weightbear and impairs their

ability to walk and run.

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PROSTHETIC CONSIDERATIONS Prosthetically, there is a need for a recreational or sporting prosthesis that is

designed for the particular sport chosen by the athlete. This will be discussed in the

prosthetist’s management of the athlete.

PSYCHOLOGICAL CONSIDERATIONS Congenital and acquired amputees must continuously attend to various

psychological issues, amongst many includes the acceptance of amputation, body

image, self-pity and frustration. It may be necessary to employ experts in psychology

to delicately handle the situation.

The amputee’s ability to cope with such issues and to maintain a healthy

psychological state is influenced by the amputee’s attitude and their ability to pursue

goals to control their negative feelings. Amputees often engage in sport as a result of

observing role models and to prove their abilities and functional capacity as an

athlete. Sport itself provides a number of psychological benefits including enhancing

self-confidence and increasing motivation.

The amputee athlete may find it difficult not only re-integrating back into

society but also into able-bodied sports. The commitment and effort required to

achieve an elite level of competitiveness is also difficult in amputee sports. The

athlete may face setbacks during their training and as a result need to be prepared to

modify their outlook, goals and performance expectations.

Most amputee athletes are active prior to their amputation and often believe

they are unable to further practice and develop their sporting abilities. Role models

indirectly encourage the amputee to pursue their sporting desires and are commonly

used as a tool for managing amputee psychological issues. Role models provide a

good resource in the area of amputee psychology however their contribution is often

underestimated.

Role models increase the awareness of the abilities of amputees and provide a

foundation from which other amputees can base themselves in terms of achievable

goals. They give the amputee perspective as they begin to consider their amputation in

‘relative terms’. That is, the amputee does not allow their amputation to provide an

obstacle in achieving their goals and objectives. Through this, the amputee learns the

ability to adapt their goals to certain conditions.

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CHAPTER 3

AMPUTATION LEVEL CONSIDERATIONS

CONGENITAL AND ACQUIRED AMPUTEES In most cases, congenital amputees have a shorter proximal section (i.e.,

humerus or femur) and therefore their lever arm is reduced. In particular lower limb

congenital pathologies (i.e., proximal femoral focal deficiency – PFFD), where a short

femur causes the knees to be at different heights, creates technical problems with leg

exercises and drills (e.g., squats).

The neuromuscular pathways that the congenital amputee athlete has

developed since childhood often make it difficult to modify the athlete’s style. For

example, congenital arm amputees naturally adopt their intact limb as their dominant

side. It is difficult to train the neuromuscular pathways of congenital arm amputees to

drive and propel with their affected side and to avoid compensating and balancing

with their dominant side.

UPPER EXTREMITY AMPUTEES The upper limbs provide balance, propulsion and drive during running. If only

one arm is present, often the athlete presents with decreased strength on their affected

side and associated scoliosis due to the difference in muscle strength.

Upper extremity amputees often hold their intact arm out as a compensatory

measure to maintain balance. Ideally, the arm should move straight up and down and

not swing out and around.

Prosthetic management of upper limb amputees is mainly to assist with a

crouch/block start (FIGURE 6). It allows the athlete to gain full momentum and drive

from the blocks. It is difficult for a congenital arm amputee to incorporate and use the

prosthesis in their running style, however traumatic below elbow athletes may utilise

and prefer weighting of their prosthesis.

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Figure 6 - A BELOW ELBOW RUNNING PROSTHESIS. This type of prosthesis assists crouch/block

starts for below-elbow amputees.

THROUGH KNEE AMPUTEES Knee disarticulation amputees have an advantage over transfemoral amputees

as a result of a longer residual limb length. The length of the lever arm means the

muscles are longer. Resulting in a powerful lever arm that increases the amputee’s

ability to generate power. The increased muscle mass also provides increased

proprioception, provides better control of the knee unit and provides the amputee with

a good idea of their foot placement. Through-knee athletes can often tolerate distal

weightbearing; as a result they have shorter sockets that do not require loading the

pelvis.

ABOVE KNEE AMPUTEES Above knee amputation surgery has a huge impact on the stability and strength

of the residual limb. Above knee amputees often lose muscle strength as a result of

reduced muscle mass, muscle atrophy and muscular imbalances.

Again, the stump length influences the lever arm, power and muscle

attachments of transfemoral athletes. The length of the femoral remnant determines

the attachment of the adductor musculature and hence their adducting ability and

strength. In most cases, the shorter the stump the more abducted it is. The reason for

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this is that the adductor musculature is not attached to its correct anatomical position.

The abductor musculature and the gluteus medius and minimus over power the

adductors of the residual limb and hold the limb in an abducted position. Often, with

shorter residual limbs, hip external rotation occurs as a result of no opposition of the

abductors and external rotators.

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CHAPTER 4

THE MULTI-DISCIPLINARY TEAM APPROACH

A multi-disciplinary team approach has assisted Australian amputees achieve

the successes of recent times. The team approach is successful in the rehabilitation

management of amputees immediately post-operatively and is also applicable to

training amputee athletes. A multi-disciplinary team approach provides the athlete

with expertise in every aspect related to amputee running. The success of the multi-

disciplinary team is dependent on the qualifications, interest and abilities of each team

member and their capacity to communicate and work within a team environment.

The immediate post-operative multi-disciplinary team educates and

rehabilitates the patient on all facets relating to their amputation. The basic team

involves; the doctor/orthopaedic surgeon, physiotherapist, prosthetist, social worker

and psychologist, although this may differ between hospitals and rehabilitation

facilities. The recreational desires are not entirely considered in the initial

rehabilitation phase, however the multi-disciplinary team approach is successful and

the principles can be applied to training amputee athletes.

The amputee running multi-disciplinary team is similar to the immediate post-

operative rehabilitation team, however of particular interest and significance is the

relationship between the physiotherapist, the prosthetist, the coach and the amputee

athlete (FIGURE 7). With minor but important contributions from the biomechanist and

other sport related professionals (e.g., orthopaedic surgeon/sports physician, sports

psychologist etc). The goal of the ‘team’ is to work together to assist the athlete in

achieving their maximal functional potential, which in this situation, is to become a

competitive amputee runner. Each member plays an important role in assisting the

athlete to produce an efficient running style, in an attempt to minimise the energy

expenditure and metabolic cost associated with amputee running gait (Nunn, 1992). It

is essential each member understand their individual role as well as the roles of the

other members. It is important to note that each member of the multi-disciplinary

team plays an equally important role and the co-ordination of these disciplines

determines the success of the preparation of amputee athletes.

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Figure 7 - THE MULTI-DISCIPLINARY TEAM. This figure demonstrates the relationship of the

multi-disciplinary team involved in preparing amputee athletes.

DOCTOR The doctor/orthopaedic surgeon plays a small but important role in the multi-

disciplinary team. The doctor/surgeon supervises the medical and surgical

management of the athlete, monitors the general health of the athlete and plays an

important role in diagnosing injuries and injury management. Ideally they should have

sport specific knowledge and/or have previous experience in managing amputees.

COACH

AMPUTEE

PHYSIOTHERAPIST PROSTHETIST

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PHYSIOTHERAPIST The physiotherapist, through a physical assessment, determines the current

physical status of the athlete. In conjunction with the coach, the physiotherapist

develops and supervises a general fitness program. The physiotherapist focuses on the

general strength, flexibility, stability and endurance of the athlete and introduces and

provides basic education on sport specific skills. The physiotherapist must be satisfied

with the condition of the athlete, including their walking gait, before the athlete is

eligible for a running prosthesis.

PROSTHETIST The prosthetist determines the componentry for the running prosthesis

including the suspension and interface and fabricates and aligns the prosthesis to

running specifications. The prosthetist is concerned with the effects of the prosthesis

on movement and the athlete’s utilisation of the prosthesis’ characteristics.

COACH After the introduction of the basic sport specific skills by the physiotherapist,

the coach formulates a training program and technically evaluates the athlete’s

performance. Generally, the coach is interested in the general movement of the

athlete, their style and progress.

As demonstrated, the multi-disciplinary approach can be applied to any type of

amputee management. This may include other sports or other aspects relating to

rehabilitation and recreation. The success of the team is determined through the ability

of the team to work together and communicate.

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SECTION 2

THE MULTI-DISICPLINARY TEAM THE ROLE OF THE PHYSIOTHERAPIST

THE ROLE OF THE PROSTHETIST

THE ROLE OF THE COACH

This section discusses the roles and management of below-knee and above-

knee amputee runners by each multi-disicplinary team member. The physiotherapist

assesses the athlete as they initially present to a clinic. Based on the results of the

athlete’s walking gait and various tests the physiotherapist can design and determine

an individualised physical upgrading program. Once the athlete has improved in these

areas they are introduced to the sport specific skills necessary to run. The

physiotherapist also determines when the athlete is eligible for a running prosthesis

and plays a further role in the ongoing management of the athlete.

Once the athlete has fulfilled the criteria necessary, the running prosthesis can

be fabricated and aligned by the prosthetist. When determining the prosthetic

componentry, the prosthetist must consider the foot, socket-stump interface, socket

shape and type, suspension, trimlines and the relationship of the componentry.

Ultimately the athletes’ preference determines the prosthesis to be fabricated and the

prosthetist aims for the amputee to control the prosthesis, not the prosthesis control

the amputee.

Following the introduction of the sport specific skills by the physiotherapist,

the coach takes over to further define these skills. The coach moulds the athlete to run

to a technical model. To achieve this, the coach implements a sport specific training

program that encourages strengthening the cardiovascular system and the sport

specific musculature used in running.

The coaching strategies used to train able-bodied athletes are applicable to

training amputee athletes. However, there are a number of factors the coach needs to

consider when designing a training program for amputee athletes. These factors and

modifications to exercises will be discussed in this section.

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CHAPTER 5

THE ROLE OF THE PHYSIOTHERAPIST

The physiotherapist assesses the athlete in their ability to become a runner.

Generally, the role of the physiotherapist is to provide gait re-education and gait

training for amputees in both their everyday and sporting prostheses, maintain general

body condition and prevent and manage injuries (Nunn, 1992). To achieve this, the

physiotherapist implements a training program that involves general strengthening

and flexibility exercises, focussing on the weaknesses and deficiencies identified

when the amputee initially presents.

It is important that the physiotherapist has a full understanding of the

biomechanical principles of amputee running as it influences the information they

require during their initial assessment and also affects the implementation of an

appropriate training program.

The management of the physiotherapist involves a number of steps. They first

complete an initial assessment of the athlete including gait analysis and a physical

assessment. This provides the basis for the physical upgrading program. Physical

upgrading includes a core program, weights and pool programs and is implemented in

an attempt to gain general fitness, strength and endurance. This period also involves

gait re-education and the introduction of running skills.

Finally, the physiotherapist maintains an ongoing role in managing the athlete,

including injury management and must also liase with the multi-disciplinary team as

much as possible.

INITIAL ASSESSMENT The approach taken by the physiotherapist follows the same fundamental

principles at each amputation level. However, some modifications to testing

procedures and exercises are required to allow for the different amputation levels. In

any case, the basic procedures and protocols are the same.

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The initial assessment by the physiotherapist involves an in-depth analysis of

the individuals’ walking gait and a thorough physical assessment of the athlete’s

posture, mobility, strength and stability.

GAIT ANALYSIS

It is important to complete a thorough investigation of the athlete’s walking

gait. The athlete wears their walking prosthesis during the analysis, as their running

prosthesis is aligned to different specifications. These specifications are not suited to

walking and promote asymmetry, making it difficult to accurately assess the walking

gait and posture of the athlete.

The assessment identifies the functional strength, stability and mobility of the

athlete. The gait deviations present demonstrate the functional weaknesses of the

athlete and should be managed appropriately, as any deviations in walking gait will be

amplified in their running gait. A detailed report on the observations should be

documented, as it is a useful tool in gauging the progress of the athlete over a certain

period.

The physiotherapist should follow the same amputee gait analysis procedures

and guidelines as they would at any other time. They look at the basic pattern of

movement and determine the reasons for any compensations that are present.

PHYSICAL ASSESSMENT

A full physical assessment should be carried out on the athlete. This includes

assessing the residual limb condition, posture, joint ranges of motion, muscle strength,

muscle control and muscle activation and recruitment patterns. It is assumed the

physiotherapist has knowledge in the basic testing positions and procedures. There are

no amputee specific tests necessary to assess the strength, range of movement and

muscle control. Modifications may be necessary depending on stump length and

amputation level, however the same principles apply as for able-bodied patients. Of

particular interest is the strength, range of movement, stability and activation of the

hips and abdominals (the ‘core’). The core plays a critical factor in amputee running

in relation to posture, pelvic movement and energy generation and absorption.

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• Residual Limb

The condition of the residual limb is assessed and follows assessment criteria

as for the initial presentation for an everyday prosthesis. The stump characteristics

including musculature, scarring, length, shape, sensitivity, abrasions, redundant tissue,

pain and phantom pain should be considered.

The physiotherapist should also consider the impact and tolerance of sporting

activities on the level of pain and phantom pain experienced by the amputee.

• Posture

The postural assessment assists in management and prevention of back injuries

and reflects compensations adopted by the amputee to overcome the biomechanical

deficits they encounter during gait. Maintenance of a good posture influences the

performance and technique of the athlete (Nunn, 1995).

The posture of the athlete should be assessed with the walking prosthesis

donned. With the athlete looking straight ahead, ensure the feet are level and weight is

evenly distributed between both feet. If the weight is unevenly distributed, the

alignment of the prosthesis may need to be modified. There should be no need for the

athlete to exert effort to maintain a comfortable and symmetrical static alignment.

• Strength

Initial strength tests assist in identifying the weaknesses and imbalances the

athlete has. From this, the physiotherapist can establish the most appropriate training

program, taking into account these deficiencies. This includes designing a modified

gym program where the exercise is adapted to the amputee and is bias towards

strengthening weak musculature and avoids strengthening its strong antagonist. For

example, the program may be biased towards strengthening weak hip flexors and

exclude strengthening the overpowering hip extensors.

The procedures to follow are the basic strength tests used in everyday

physiotherapy management. However, some positions and tests may need to be

modified to assist in identifying the strengths of amputees.

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• Range of Motion

Range of motion tests provide information regarding the mobility of particular

joints. All joints of the lower and upper limbs should be tested as they all influence

the running ability of the athlete. Similarly to strength training, a stretching program is

prescribed to assist in stretching out tight muscles and joint structures (e.g., joint

capsule), increasing flexibility and increasing the movement of the joint.

Restrictions in joint movement influence the ability of the athlete to run

efficiently as compensations are usually adopted to overcome any limitations.

• Core and Joint Stability and Activation

Core and joint stability and activation are important as these influence the

athlete’s ability to recruit the appropriate muscles at particular times during the gait

cycle. Employing inappropriate muscles to do work during running gait is considered

a compensatory mechanism and should be addressed. The compensations adopted

influence the efficiency and energy expenditure of the athlete's running gait.

To test the posture, mobility, strength and stability of the athlete, two forms

have been developed to guide the assessor (the physiotherapist) through the process.

The tests should be performed at each joint on both the intact and prosthetic sides and

on the upper limbs.

The impairment specific screening form assists in identifying weaknesses and

provides examples of common deviations. However, it is still important to determine

the severity of the weakness. The results of the tests provide an insight of the

strengths and weaknesses of the athlete and provide the basis from which an

appropriate training program can develop. The forms are found in APPENDIX II A and

the explanatory notes in APPENDIX IIB.

Once the results of each test have been obtained, the information should be

analysed to determine the strengths and weaknesses of the athlete. This forms the

basis for the development of an individual physical upgrading program.

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PHYSICAL UPGRADING The physical upgrading component of the physiotherapist's management

includes gait re-education, core maintenance, general fitness work that comprises of a

core program, weights program and pool work and the introduction of basic running

skills. Achieving a satisfactory level of fitness (i.e., strength, mobility, stability and

endurance) is a criterion that must be fulfilled before the athlete is eligible for a

running prosthesis. It is vital the athlete has good hip and abdominal (core) strength,

stability and range of movement to maintain a good posture and to achieve the

benefits mentioned previously.

GAIT RE-EDUCATION

Gait re-education aims to attain a precise walking gait with no gait deviations,

as any deviations will be more pronounced in running gait. It involves a number of

steps including:

- Strengthening or activating weakened or inhibited muscle groups, usually the

hip extensors, abdominals and knee extensors.

- Inhibiting compensatory measures to overcome deficiencies and stretching of

tight structures as a result of these compensations, commonly the iliopsoas as

it influences hip and knee flexion throughout stance phase.

- Improving muscle control especially eccentrically; for example, in transtibial

athletes it is important to enhance the control of the knee extensors to ensure

shock absorption, or enhance control of the hip extensors in transfemoral

athletes.

- Re-introducing correct movement patterns into gait (i.e., activation of

appropriate muscle synergies, adequate upper body rotation (FIGURE 8) etc).

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Figure 8 - GAIT RE-EDUCATION. A Swiss ball is used in gait re-education for a number of reasons,

in this case to encourage adequate trunk movement.

CORE PROGRAM

The body core is the lumbopelvic-hip complex. Lumbopelvic-hip (core)

stability is an important component in rehabilitation and gait re-education. A core

stabilisation program aims to develop an optimal level of functional strength and

dynamic stabilisation (FIGURE 9). Core stabilisation also improves dynamic postural

control, neuromuscular efficiency and enhances the power and endurance of the core

musculature. A core program further facilitates muscle balance by encouraging the

activation and strengthening of functional synergies, whilst simultaneously inhibiting

inappropriate activity.

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Figure 9 - CORE STRENGTHENING. A Swiss ball can also be used to assist in core strengthening (as

seen here).

MODIFIED GYM PROGRAM

The weights program should: -

- Target weakened muscle groups as identified during testing, in an attempt to

decrease imbalances and prevent the adoption of compensations.

- Have a functional emphasis where most of the limb is against resistance

requiring stabilisation of the core and attention to joint positions in relation to

the activity you are training for (FIGURE 10). This strengthens the functional

range of the muscle while simultaneously recruiting core stability muscles to

reinforce and improve their roles in core stability.

- Include exercises that can be modified to adapt to the individual amputee (e.g.,

squats and bench press) (FIGURE 11). The program should be modified as the

athlete improves their sport specific strength and skills. Squats need to be

modified so the intact leg does not bear an increased proportion of the load.

Each limb should therefore be strengthened individually. Upper limb amputees

will find it difficult to maintain a horizontal bar in bench press. To overcome

this the Smith machine (assisted bench press) should be used to avoid injury

and allow for correct technique. It also permits the athlete to perform the

exercise independently.

- Be supervised and monitored to ensure the correct technique is used.

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Figure 10 - MODIFIED GYM PROGRAM. Exercises should have a functional emphasis with

simultaneous stabilsiation of the core (courtesy of the Australian Institute of Sport).

Figure 11 - MODIFIED GYM PROGRAM. Modifications to exercises are necessary to allow the

athlete to gain the maximum benefits from the exercise. This figure shows a modified squat (courtesy

of the Australian Institute of Sport).

Page 29

POOL WORK

Pool work is an important component in amputee training, particularly in

bilateral amputee management. It provides a non-weightbearing exercise and assists in

injury prevention, as the limb is not constantly loaded as in walking and running. It

enhances cardiovascular fitness and involves core stability work. Pool work may also

be used as an alternative training method if an injury has occurred.

No modifications to exercises are necessary as the water assists the amputee

maintain balance. This allows the athlete to gain the full benefits of each exercise. It is

important to monitor the exercise technique to ensure it is being executed

appropriately.

A pool program may also include the use of a specially designed aquatic

training prosthesis for the residual limb in an attempt to involve the residual limb in

the pool workout.

SPORT SPECIFIC TRAINING

The physiotherapist also assists the athlete in acquiring the basic skills of their

sport. The process of developing sport specific skills is similar to gait re-education. As

the athlete develops basic running skills the coach takes over the sport specific

training of the athlete.

ONGOING MANAGEMENT LIASE WITH TEAM

As the physiotherapist is a member of the ‘team’ they maintain contact with

the athlete throughout their prosthetic and athletic lives. The physiotherapist provides

further sporting analysis and monitors the progress of the athlete. The program

requires constant modifications as the athlete develops their sport specific strength

and skills.

INJURY PREVENTION AND MANAGEMENT

The physiotherapist also plays a major role in injury prevention and

management. They introduce the initial sport specific skills and techniques to the

Page 30

athlete and ensure that the exercises are practised correctly. Close monitoring of the

athlete's running style identifies any weaknesses in their technique. Prompt

identification and management of technical errors by the physiotherapist (and coach)

prevents injury development. The physiotherapist should also be aware of previous

injuries and the current status of the affected areas. It is important to monitor the

previously injured area for the recurrence of pain, limitations in movement, oedema

and heat.

The physiotherapist designs and implements a rehabilitation program that aims

to return the athlete to previous training levels as quickly and smoothly as possible.

During this period it is important to maintain the general fitness levels of the athlete

and to educate the athlete on injury management.

ELIGIBILITY FOR A RUNNING PROSTHESIS To be eligible for the fabrication of a running prosthesis, the amputee must

fulfil a number of criteria. The athlete should have:

- A sound gait with no deviations as any deviations in walking are more

pronounced during running

- Achieved a good level of general fitness, including strength, flexibility,

stability and endurance

- Demonstrated commitment through adhering to the initial fitness program for

a minimum of approximately three months.

- Joined a sporting association and have commenced competition at a local

level.

COMMON EXERCISES AND PROGRAMS It is difficult to define a ‘common’ training program from a physiotherapist’s

perspective. In the initial management of the athlete, the physiotherapist aims to gain

strength and endurance through the physical upgrading program. The prescription of

exercises is entirely based upon the findings of the initial assessment. The strengths

and weaknesses identified in the initial assessment may differ between athletes;

therefore the training program should be based on the athlete’s personal needs and

progression.

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CHAPTER 6

THE ROLE OF THE PROSTHETIST

The prosthetist plays a major role in the multi-disciplinary team approach

when managing amputee runners. It is necessary for the prosthetist to have sport

specific knowledge and current knowledge in prosthetics, as minor developments can

improve the athlete's performance.

The athlete will have an additional prosthesis for their recreational and

sporting activities. The prosthetist conducts an initial assessment to determine the

most appropriate componentry for the sporting prosthesis for the athlete. This requires

consideration of not only the prosthetic componentry but the demands of the sport,

componentry relationships, muscular imbalances and patient/athlete preference.

Ideally, when the athlete presents for their running prosthesis they will have fulfilled

the criterion for a running prosthesis as stipulated by the physiotherapist.

In the initial assessment, the prosthetist aims to determine the componentry to

be used in the running prosthesis, in particular the interface material. In any case all

the prosthetic options available should be presented to the athlete as inevitably their

personal preference plays a major role in determining the prosthesis to be fabricated.

The prosthetist then fabricates the prosthesis and aligns it to running

specifications. It should be emphasised that the maintenance of the prosthesis should

be attended to by the prosthetist.

The prosthetist plays a further role in education and it is important for the

prosthetist to remain in constant contact with the other members of the multi-

disciplinary team to discuss the management of the athlete.

INITIAL ASSESSMENT For the initial assessment to occur, the athlete will have fulfilled the eligibility

criteria for a running prosthesis as specified by the physiotherapist. This requires the

athlete to have a good walking gait, demonstrated commitment and has improved their

strength, range of motion and stability (for more detail refer to physiotherapy section).

Page 32

It should be noted that prior to this assessment, the amputee will have been

running on their everyday prosthesis, which is not aligned to running specifications.

The results of this maybe reflected in the stump condition of the athlete.

The initial assessment of the amputee for a running prosthesis follows the

same principles and guidelines as the assessment for a new walking leg. The

prosthetist will most likely have seen the athlete previously and has an understanding

of the athlete’s stump characteristics and individual alignment. In any case it is

important to examine the residual limb characteristics in relation to skin quality, scar

line and general stump condition. These characteristics influence the selection of

interface for the running prosthesis and the main aim of the initial assessment is to

determine the most appropriate interface for the athlete.

RUNNING PROSTHESIS With constant prosthetic developments it is important the prosthetist presents

the athlete with all the prosthetic options available. Emphasis must always be placed

on the athlete’s preference as they must be comfortable and secure with their

prosthesis.

BELOW-KNEE COMPONENTRY

• Foot

Energy storing feet are designed to more closely replicate the normal

biomechanics of the foot and ankle. They store energy upon loading and later release

this energy, as the foot is unloaded (push-off). During sprinting, the prosthetic foot is

in contact with the ground for a shorter period of time and can incur loads up to five

times bodyweight. The energy storing/releasing characteristics provide numerous

benefits to the athlete and are recommended for running prosthesis.

Other prosthetic feet, including the SACH, single axis and multi-axial feet are

based on different design principles. They do not return the energy absorbed at initial

contact as effectively as energy storing feet although this does depends on the type of

energy storing foot (e.g., Vari-Flex, Flex-Walk etc).

The Flex-Sprint series are energy-storing feet and are recommended for

running. They consist of a flexible, lightweight carbon fibre keel that runs the entire

Page 33

length from the socket to the ground (FIGURE 12). They have no heel counter and a

drop-toe design to promote toe running (FIGURE 13). The Flex-Sprint III keel has an

inverted question mark shape that allows the prosthesis to be aligned with the weight

line passing through the toe without plantarflexing the foot. The keel shape also

enables the foot to vertically compress and simulate dorsiflexion at initial contact.

This accounts for the symmetry seen in amputees running with these feet. It limits the

vertical displacement of the centre of mass and in turn decreases the impact loads

incurred by the intact limb.

Figure 12 - THE FLEX-SPRINT III. This figure shows the Flex-Sprint III runs the entire length from

the socket to the ground (courtesy of the Advanced Prosthetic Centre).

Page 34

The distal end of the Flex-Sprint III curves up and requires a build-up/filler

underneath. The build-up should extend from the distal tip of the toe to the point of

contact between the foot and the ground. This build-up aims to increase the surface

area of the ‘toe’ in contact with the ground. Attached to this build-up are running

spikes from a spiked running shoe to assist in traction etc.

To select the most appropriate Flex-Sprint III it is important to determine the

‘category’ of the foot. The category of the foot relates to the stiffness and the

compressibility of the carbon fibre keel and is determined by the individual

characteristics and preference of the athlete. The category of the foot is always a

consideration when using an energy storing foot in a prosthesis and it is necessary to

determine the correct category otherwise the athlete will be unable to utilise their

prosthesis effectively. Gait deviations including knee hyperextension (in both BK and

AK athletes) may result if the category selection is incorrect. The higher the category,

the stiffer the foot and the less compression.

Figure 13 - THE FLEX-SPRINT III AND ATTACHMENTS. The Flex-Sprint III can attach to the

socket by a pylon connector or a lamination connector (courtesy of Flex-Foot).

Page 35

The Flex-Sprint III can be attached to the transtibial socket in two ways, either

by a pylon connector (FIGURE 17 & 18B) or a lamination connector (FIGURE 14). The

pylon connector is the preferred method. It is laminated into the socket and the

connector is exposed distally (below the socket). The Flex-Sprint III is bolted to the

exposed portion of the attachment plate and this allows for easy adjustments to be

made. The position of the pylon connector to the socket is dependent on the athlete’s

stump characteristics (i.e., stump flexion, abduction/adduction). The pylon connector

should be strongly adhered to the socket and often requires carbon fibre

reinforcement.

The lamination connector is also laminated into the socket. However, there is

no distal section and the Flex-Sprint III attaches directly to this connector plate,

posterior to the socket (FIGURE 14). If alterations are necessary or if problems occur

with the lamination connector (i.e., screw cross-threading) the entire plate must be

removed from the socket.

The position of the adaptor plates should be as precise as possible before the

lamination. However, if a slight alignment adjustment is necessary, bias wedges are

available to adjust the position of the Flex-Sprint feet.

Figure 14 - POSITIONING AND ATTACHING THE LAMINATION CONNECTOR. It is important

to have the lamination connector in the correct position before it is laminated into the socket.

Page 36

• Liner

The interface between the residual limb and socket should protect the stump

from shear and frictional forces. Depending on the interface, the forces are either

absorbed and/or transferred from between the skin-liner to the liner-socket. The

ability of the interface to distribute or eliminate these forces is also determined

through the interface materials and the socket fit. Socket fit and the liners abilities are

highly inter-related. However, patient/athlete’s preference determines the interface as

their comfort and security is of the upmost importance.

Polyurethane and silicon liners are popular amongst active athletes (FIGURE

16). They are worn directly against the skin providing total contact. This minimises

shear and frictional forces as no movement can occur between the skin and liner.

As the amputee athlete runs, their stump shape changes. The urethane liner

adapt to this as the gel 'flows' from areas of high concentration to areas of low

concentration. Although silicon and polyurethane liners are indicated for highly active

(running) amputees, a pelite liner may still be preferred by some athletes. However,

the pelite can ‘bottom out’ and lose its shock absorbing characteristics. A pelite liner

also necessitates the use of stump socks. The frictional forces produced between the

sock and residual limb can cause skin breakdowns. It is also necessary to change

stump socks regularly as they absorb perspiration. Silicon impregnated stump socks

are also available and provide similar benefits to the silicon liners although to a lesser

magnitude.

Hard sockets with no liners are also contraindicated as forces are dissipated

directly to the residual limb causing skin breakdown and other overload injuries.

• Socket type

A good prosthetic socket should permit efficient energy transfer from the

residual limb to the prosthesis and not impinge on movement. The socket fit is

determined by casting techniques, socket design/shape and the socket materials.

Carbon fibre laminated sockets are lighter and stronger than fibreglass

laminated sockets. The socket lamination procedure follows the same guidelines as a

general lamination, however the position and direction of the carbon fibre influences

the strength characteristics of the socket.

Page 37

Patella tendon bearing sockets focuses loads on particular areas of the residual

limb. For example, the patella tendon bar loads the patella ligament. This can cause

discomfort during knee flexion if there is a large patella tendon shelf.

Similarly, the supracondylar suspending socket (PTK socket) loads proximally

to the femoral condyles for suspension. To achieve this, the mediolateral dimension of

the socket is reduced above the femoral condyles. Although this provides suspension

it causes the quadriceps to atrophy. The athlete then relies on the socket for stability

rather than their muscles alone. This can cause a vicious cycle where the tighter the

ML dimension the less control the muscles have over the prosthesis and the further

they atrophy, then the tighter the ML dimension.

A total surface-bearing, hydrostatic socket is necessary with the use of

urethane and silicon liners (FIGURE 15). Total surface bearing sockets reduce socket

forces as pressure is distributed over the entire residual limb with no specific weight

bearing areas. Hydrostatic socket designs utilises the compression of fluids in the liner

to distribute and eliminate forces. In any case the socket should not compensate for

muscle weakness or instability.

Figure 15 - HYDROSTATIC SOCKETS. Hydrostatic sockets apply pressure equally over the residual

limb (Fergason and Smith, 1999).

Page 38

• Suspension

The athlete’s confidence in the suspension of the prosthesis is important.

Athlete preference is emphasised in the choice of suspension, as the athlete needs to

feel assured that their prosthesis is secure and not going to detach.

As mentioned previously, supracondylar suspension causes the knee extensors

to atrophy and the athlete relies on the prosthesis for stability rather than their

muscles.

Negative pressure suspension requires an intimate fitting total surface bearing

socket. It necessitates a silicon sleeve to be donned over the socket to maintain the

negative pressure and to suspend the prosthesis (FIGURE 16). Unlike the supracondylar

suspending socket (PTK), it does not rely on high trimlines to maintain suspension or

stability. The suspension sleeve does not restrict knee movement and the knee

musculature is fully utilised for stability. This increases the knee muscle’s control of

the prosthesis. An expulsion valve is also necessary to evacuate/expel any air within

the system. Air within the socket/suspension sleeve causes the suspension to be

ineffective. Similarly, if there is a tear in the silicon sleeve the suspension will be

ineffective. Therefore, it is important that the prosthetist is educated on correct casting

and fabrication techniques and the athlete on the correct donning and maintenance

procedures.

Shuttle lock systems are used with silicon or urethane liners. However, they

can elongate on the distal end of the residual limb. This milking effect can be

uncomfortable and give the athlete a feeling of insecurity.

Suprapatellar straps are still used in running prosthesis (FIGURE 17). They are

not necessarily the most suitable suspension for running but athlete's using this type of

suspension have produced world records. The suprapatellar strap can be attached to an

elastic waistband for auxiliary suspension. The elastic strap only provides suspension,

particularly during swing and does not assist weak musculature.

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Figure 16 – RUNNING PROSTHESIS COMPENENTRY. A negative pressure suspending prosthesis

requires a urethane line, spikes, a Flex-Sprint III attached to a total contact socket via a lamination

connector, an explusion valve and a suspension sleeve).

Figure 17 - RUNNING PROSTHESIS COMPONENTRY. A pelite liner with a suprapatellar cuff

attached to a waistband (www.advancedprosthetic.com.au).

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• Trimlines

The suspension influences the trimlines of the socket. Ideally, they should be

kept to a minimum to avoid restricting movement, especially knee flexion.

The posterior trimlines of the socket should not impinge on knee flexion. If the

athlete has a reasonably long residual limb, the height of the posterior trimline can be

reduced. When treating athletes with shorter residual limbs the centre of the posterior

trimline should be maintained as proximal as possible without impinging on the

medial and lateral hamstrings.

The medial/lateral trimlines of a transtibial socket should also be kept to a

minimum. Prostheses using negative pressure suspension minimise the height of the

trimlines. This allows the athlete to have good muscle control over the prosthesis.

As the athlete’s knee musculature strengthens and the muscles have increased

control of the prosthesis, the trimlines can be lowered. Lowering mediolateral

trimlines further strengthens the knee musculature. Increased strength also results in

increased muscle control of the prosthesis.

BELOW KNEE ALIGNMENT

Alignment of the prosthesis describes the relationship between the socket and

foot. There are no exact optimal dynamic alignment specifications however the static

alignment of the prosthesis does provide a foundation for dynamic alignment.

Athletes have their own individual dynamic alignment that is influenced by their

personal running technique and stump characteristics. However the basic aim of

alignment is the same, to minimise gait deviations, to gain the maximum out of the

prosthesis and to produce an energy efficient gait

Core stability (as mentioned in the physiotherapy section) and prosthetic

alignment are significantly interrelated. The ability of the athlete to control their

lumbopelvic complex influences their prosthetic alignment. The better core stability

the athlete possesses, the more precise the alignment. This enables the athlete to

utilise the characteristics of the prosthesis more efficiently.

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Below Knee Bench Alignment (Flex-Sprint III)

• Position the socket in neutral (i.e., 0o flexion) in relation to the foot. This

allows the weightline to fall through the toe without plantarflexing the foot

(when the pylon connector is vertical).

• From the side (sagittal view) with the socket in neutral, the weightline

should fall from the midpoint of the socket through the midpoint of the

Flex-Sprint keel (FIGURES 11 a &b).

Figure 18 - BENCH ALIGNMENT OF THE FLEX-SPRINT III. This figure illustrates the bench

alignment of a Flex-Sprint III attached with a (A) lamination and (B) pylon connector (courtesy of

Flex-Foot). The weight line should fall from the mid-point of the socket through the mid-point of the

Flex-Sprint III keel.

weightline weightline

ground contact ground contact

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Below Knee Static Alignment

Static alignment provides a foundation from which dynamic alignment can be

determined. Generally, the height of the transtibial running prosthesis is

approximately ½” - ¾” longer than the intact side, depending on the category/stiffness

of the foot. This encourages toe running and allows for vertical compression of the

Flex-Sprint III in an attempt to achieve a level pelvis during stance. The height of the

prosthesis has a significant effect on the trunk movement/core stability of the athlete

and is discussed further in the gait deviations section of this manual.

Below Knee Dynamic Alignment

The dynamic alignment aims to eliminate gait deviations and achieve a

symmetrical running gait. Initial dynamic alignment is based on restoring symmetry

between the intact and prosthetic limbs during running. Depending on the adjustments

made, it may indicate muscle weakness. From this the physiotherapist and coach can

work on strengthening these particular muscles and return the athlete to a more

symmetrical running gait.

The dynamic alignment of the prosthesis changes significantly, as the athlete

becomes more efficient in using their running prosthesis. As their ability to control the

energy storing characteristics of the foot develops, the alignment is adjusted to force

the athlete to use their musculature for stability, rather than relying on the prosthesis.

To encourage the athlete to fully utilise their skills and the prosthesis’ characteristics,

the prosthesis is aligned to have as much foot in contact with the ground as possible.

This should enable the athlete to have total control of the energy stored without being

out of control.

As mentioned previously, if the alignment of the connector plate is incorrect or

alignment alterations are necessary, bias wedges are used to reposition the Flex-Sprint

III in relation to the socket.

ABOVE KNEE COMPONENTRY

In the above knee amputee athlete the stump characteristics have more of an

influence on prosthetic prescription. More components are required in above knee

prosthesis and as a result there is a stronger relationship between the componentry. An

increased number of components increases the chance of breakdown and increased

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maintenance needs, highlighting the need to maintain constant contact with the

prosthetist and have regular maintenance assessments.

• Foot

Based on athlete feedback and success, the foot used in above-knee amputee

runners is the Flex-Sprint I or II. The Flex-Sprint I is based on the Modular III, which

is an energy storing foot. It consists of a carbon fibre keel that extends from the knee

unit to the toe. However, the Flex-Sprint I has no heel counter and is more

plantarflexed than the Modular III design. The Flex-Sprint I and II have a straighter J-

shaped keel rather than the Flex-Sprint III’s inverted question mark shape (mentioned

in trantibial prosthetic feet options) (FIGURE 19).

As a result of their straighter shape, the Flex-Sprint I and II have less vertical

compression than the Flex-Sprint III. In above-knee running, if the category of the

foot is too soft it allows excessive compression of the foot. As the prosthesis is loaded

the athlete will hyperextend their knee. This produces interlimb asymmetry as the

athlete spends more time on their prosthetic side during stance phase. Compression

also causes malalignment of the height of the prosthetic and intact knee axes.

Figure 19 - THE FLEX-SPRINT SERIES. This figure shows (from left) the Flex-Sprint I, II and III.

The Flex-Sprint I and II are used in above-knee running and the Flex-Sprint III in below knee running

(courtesy of Flex-Foot).

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• Socket

Transfemoral amputees have the option of two sockets, the quadrilateral

socket and the more recent ischial containment socket design. The ischial containment

socket is preferred over the quadrilateral socket for a number of reasons; it is more

energy efficient at higher speeds, contours better to the residual limb, has a bony lock

that eliminates ischial rotation within the socket and lateral stabilises the femur in

adduction (FIGURE 20).

Figure 20 - THE QUADRILATERAL AND ISCHIAL CONTAINMENT SOCKETS. This figure

compares the ischial containment socket with its bony lock and counter force to the quadrilateral socket

that has no bony lock and pressure on the distal femur (Sabolich, 1985).

Flexible inner plastic sockets with a rigid outer socket framework are common

above knee socket designs. The inner socket provides the interface for suction

suspension while the outer socket provides the structural framework and is fabricated

from a more rigid plastic or carbon fibre laminate. Windows may also be cut in the

outer socket, providing the main structural support is maintained.

On the posterior distal aspect of the above-knee socket there is often a flexion

bumper (FIGURE 26 – Earle Connor). This is in an attempt to limit heel rise. The foot hits

the flexion bumper and returns the foot to extension earlier for initial contact. This

also assists in overcoming the delay of the prosthetic foot during swing phase.

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• Liner/suspension

Suspension is a major consideration in transfemoral athletes and is determined

by the athlete’s preference. It is important the athlete feels secure with their

prosthesis’ suspension. The suspension options for transfemoral athletes are shuttle

locks or suction suspension.

The forces the athlete uses to extend the knee can cause terminal impact and

when using the shuttle lock system, can disengage the shuttle lock. Replacing the

spring with a more robust spring assists in overcoming this problem. Using a shuttle

lock is also dependent on stump length. A shuttle lock is contraindicated for long

residual limbs, as the shuttle pin will lower the position of the knee unit.

Suction suspension requires a total contact socket that is completely contoured

to the athlete's stump. The athletes pull themself into the prosthesis and the negative

pressure suspends the prosthesis on the residual limb. As mentioned previously, this

form of suspension is used in combination with a flexible inner socket.

Suction suspension is also suitable for through-knee athletes, although it may

be necessary to provide a build up proximal to the femoral condyles so a more

cylindrical shaped socket can be produced. This allows for easier donning.

Through-knee athletes have an extra suspension option available. This is

supra-condylar suspension. The residual limb is loaded proximally to the femoral

condyles and benefits athletes who have distal weightbearing.

Similarly to transtibial suspension, transfemoral amputees may also use

auxiliary suspension for additional security. This can include the use of a neoprene

sleeve or TES (total elastic support). When using a silicon suction suspension system

a neoprene sleeve limits the amount of elongation of the silicon liner on the distal end

of the residual limb.

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• Knee Units

There is an increased demand on the knee as a result of the faster and

increased loading associated with increased speeds. As a result, the prosthetic knee

used should be more responsive in running than walking. Commonly, hydraulic four

bar linkage knees are used in above knee (and through knee) running prosthesis.

The hydraulic four-bar linkage knee unit provides stability in stance and good

toe clearance during swing. The hydraulic mechanism adapts to changes in speed and

the four-bar linkage component effectively creates a longer lever arm.

The knee units attach to the socket by a lamination adapter plate or a male

pyramid. An L-bracket is attached to the distal connector of the knee and is the

attachment for the foot (FIGURE 21).

The friction of the running knee joint is also increased, so when the athlete

walks they are unable to break the knee. However, with the forces produced during

running the knee should flex accordingly.

Figure 21 - THE FLEX-SPRINT I AND ATTACHMENTS (courtesy of Flex-Foot). The Flex-Sprint I

attaches to the knee unit via a L-bracket adapter.

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ABOVE KNEE ALIGNMENT

(using a hydraulic four bar linkage and Flex-Sprint I or II)

Initially, the dynamic alignment aims to gain symmetry between the intact and

residual limbs. As the athlete becomes more experienced and has improved control of

their prosthesis the alignment is adjusted. The new alignment is dependent on the

athlete's ability to control the hydraulics of the knee unit and the energy storing

characteristics of the foot.

Above Knee Bench Alignment

Figure 22 - BENCH ALIGNMENT OF AN ABOVE KNEE RUNNING PROSTHESIS. These figures

demonstrate the alignment of above-knee running prostheses using a four-bar linkage knee unit and

Flex-Sprint I (courtesy of Flex-Foot).

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Bench alignment guidelines of the above knee running prosthesis using a four

bar linkage knee unit and Flex-Sprint I;

• Position the socket in slight extension and anteriorly to the knee unit. As a

result, the instantaneous centre of rotation moves posteriorly and

proximally increasing knee safety.

• In a sagittal view, the weightline should fall from the midpoint of the

socket through the knee axis and approximately six centimetres behind the

distal tip of the toe (FIGURE 22).

• In a frontal view, the weightline should fall from the midpoint of the

socket through the midpoint of the toe (FIGURE 22).

Above Knee Static Alignment

The height of the prosthesis should be as close to normal as possible. The knee

centre should be at the same height as the intact knee and the knee axis should be

horizontal to the ground.

Above Knee Dynamic Alignment

The knee should be aligned so that it is stable in hip extension with as little

energy required as possible for hip flexion to occur.

The angle between the knee unit and the L-bracket adaptor controls the

direction of the ground reaction force and alters the instantaneous centre of rotation of

the knee. Angling the knee unit and L-bracket adaptor is a useful alignment method

when determining the safety of the knee. The angle between the knee unit and Flex-

Sprint I L-bracket adaptor should direct the ground reaction force to a position that

allows the knee to break easily while maintaining stability. The exact angle between

the Flex-Sprint and knee joint is left to the discretion of the prosthetist, taking into

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account the athlete’s feedback and their ability to utilise their musculature and lever

arm to control the knee unit.

Angling the knee unit and positioning the foot back under the athlete

effectively shortens the toe lever. By shortening the toe lever the stride length is also

reduced. This results in faster loading and unloading of the foot. Consequently the

prosthesis is more responsive and the characteristics of the Flex-Sprint are utilised

more effectively. Shortening the toe lever also decreases the hip flexion required to

lift the prosthesis into swing.

However, these are just theories and there has been no valid research

undertaken to identify and justify the benefits mentioned.

EDUCATION The prosthetist plays a major role in the athlete’s education. The athlete should

have a basic understanding of prosthetic and stump management and care through

previous experience with their everyday prosthesis. The following issues should be

further emphasised as complications may occur. Things to address: -

- Hygiene management. Generally, amputees perspire more during walking

and running as a result of increased work demands. There is decreased

surface area for heat dissipation and as a result of not being exposed to the

ambient air; evaporation of the perspiration is difficult. It is important to

wipe the residual limb dry during training as perspiration can lead to

bacterial development and associated problems (detailed in injury section).

If the athlete uses stump socks then these should be changed regularly as

the socks absorb the perspiration. Cleaning/washing the liner is important

from a hygienic aspect and to ensure the longevity of the liner.

- Monitoring of the stump and education of what to look for. It is important

for the athlete to monitor the stump in an attempt to avoid injuries. Skin

breakdown or irritations and pressure areas are detrimental and usually

affect the athletes’ mobility. The inability of the athlete to wear their

prosthesis as a result of these injuries restricts the athlete to walking aids

and an alternate training program (i.e., pool work). Redness, swelling,

irritations and blisters are signs and may indicate a prosthetic or hygiene

issue.

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- Prosthetic management. Educate the athlete on the correct donning

procedure and the correct position of the running prothesis. Malalignment

of the prosthesis constitutes an ill-fitting socket and causes stump

problems. If the socket fit is inadequate or alignment inappropriate, the

earlier it is rectified the more comfortable training will become. It should

also be emphasised that any maintenance that the prosthesis requires

should be carried out by the prosthetist. The prosthetist is qualified and

experienced in prosthetics; they know what they are looking for in relation

to prosthetic management, the effect of the prosthesis on movement and

the alignment of the prosthesis.

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CHAPTER 7

THE ROLE OF THE COACH

After the initial fitness program of the physiotherapist is complete and the

athlete has starting running on their running prostheses, the coach becomes involved

in further developing the sport specific skills required for running.

The coach trains the athlete based on a technical model, or their interpretation

of the ‘ideal’ technique of running. The coach aims to teach the athlete to replicate

this model as closely as possible. The athlete’s ability to imitate this model is the

athlete’s individual ‘style’. When coaching amputee athletes, the coach needs to be

flexible with their model as slight modifications may be necessary. This requires the

coach to have a good understanding of the biomechanics of amputee running to

determine whether any deviations that present are technically related or are influenced

by the amputation.

By observing and interpreting the running technique of the amputee, the coach

can identify areas for improvement in comparison to the model. Modification of

existing techniques and the introduction of new techniques aid in producing the

fastest, most energy efficient running style and maximises the athlete’s performance.

The techniques and training programs used in coaching able-bodied athletes

can be applied to coaching amputee athletes although some exercises may require

modifications. Training with able-bodied athletes also provides a number of benefits

for the amputee athlete including improved performance, greater motivation and

increased self-discipline (Nunn, 1992). Training and competing with able-bodied

athletes also gives the coach an indication of the amputee’s style compared to other

styles that more closely replicate the technical model. There are however a number of

considerations that should be taken into account when coaching amputee athletes.

These include the individual characteristics of the athlete, injury prevention and

management, communication and sport specific fitness and skill development.

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INITIAL ASSESSMENT Similar to the physiotherapist and prosthetist, the coach assesses the physical

condition of the athlete. The coach conducts a personal assessment of the athlete and

structures a personal training program from the information obtained.

To begin, the coach will discuss the athlete’s ability and medical history with

the athlete, including current general health, previous injuries and any other issues

(e.g., scoliosis).

The coach then focuses on the technical assessment of the athlete during

walking. Ideally, the athlete will have a precise walking gait as a result of the

physiotherapist’s treatment and management. The athlete’s walking style provides an

indication of the way they will run (particularly if they are lower limb amputees).

Upper extremity amputees walk well and often show no evidence of deficiencies that

may present during running. It is difficult to make any assumptions between upper

extremity amputee walking and running.

The coach views the overall skeletal movement of the athlete. Skeletal

movement demonstrates muscle control. The coach begins the analysis at the hips

(analysing core function and stability) and assesses down the legs, then returns to the

hips and analyses the upper body. The coach then returns to an overall review of the

athlete.

It is important to fully assess the hips, as any deviations may be a reflection of

deviations present at the ankle and knees. The analysis involves assessing the amount

of pelvic/hip movement. There is a certain level of pelvic movement necessary in

running, however exaggerated pelvic movement indicates a structural problem or a

weak, unstable core. To further confirm this, the athlete should lie down and the coach

will check the position/alignment of the body segments in relation to the naval. This

identifies the natural alignment and symmetry of body segments.

With the athlete walking towards them, the coach analyses the lateral hip

movement. Looking more distally the coach should assess the inversion and eversion

of the prosthesis and foot. Any deviations that are present which are not a result of

muscular weakness suggest prosthetic issues and should be assessed by the

prosthetist.

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The coach should then focus on the upper body movement. Identifying the arm

movement during walking indicates the possible deviations that will present during

running.

After the technical evaluation is complete, the coach should have an

approximate idea of the strengths and weaknesses of the athlete, as it is possible for

technical faults to indicate functional weaknesses and deficiencies.

The assessment then moves to the gym to determine the extent of the athlete’s

strength and indicates where a weights program should begin and focus. The

physiotherapist (with the coach's input) will previously have introduced a

strengthening and flexibility program. However as the athlete improves, the coach

introduces a more defined gym program that addresses sport specific skills and

fitness. Squats and bench press are used as measurement instruments to quantify the

strength of the athlete (FIGURE 23).

Figure 23 - STRENGTH TESTING. Squats and bench press provide an indication of the strength of the

athlete (courtesy of the Australian Institute of Sport).

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Arm and trunk strength, stability and control are vital elements in running and

their necessity is evident in amputee running. The emphasis of the initial

strengthening program of the coach is to maintain general fitness levels and

strengthen the arms and trunk. It is important to strengthen and accentuate the arm

movement, as the legs will follow the arms. As the arm technique improves the

posture should then become the focus. Following from this the legs become the focus

of the strengthening program.

After the coach has implemented a strengthening program and the athlete has

progressed, the physiotherapist should assess the strength of the athlete to determine

any improvement from their perspective.

DEVELOPING A TRAINING PROGRAM When developing a training program for amputees, there a number of basic

principles the coach should consider. These include; individualism, periodisation,

injury prevention and management, communication, employment of other

professionals, general fitness, sport specific fitness and skills and variation within the

program. Essentially, these principles are the same for able-bodied running. However,

there is increased emphasis on particular principles and there are amputee specific

considerations to address.

Individual Characteristics

In any case, it is important that the coach designs a program that is suited to

the individual athlete. The coach should have good knowledge and understand the

specific considerations that relate to amputee running. Modifications to exercises are

adapted into the training program to cater for the amputation and allow the athlete to

gain the most out of each exercise. To avoid constantly loading the limb, the program

may include non-weight bearing exercises to maintain fitness levels (i.e., pool

sessions). Simultaneously implementing non-weight bearing exercise and increasing

the amount of recovery sessions assists in injury prevention and management.

Amputees often have thermoregulatory difficulties. Generally, amputees

perspire more as a result of the increased work demands and the decreased surface

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area for heat dissipation. The residual limb is not exposed to the ambient air due to

prosthetic use and makes evaporation of the perspiration difficult. This limits the

cooling effect of evaporation and the body overheats.

Fatigue is also a major factor to consider in amputee training programs. The

increased work demands and the need for increased energy generation, increases the

energy required during gait and increases the cardiovascular demands of the athlete.

Amputees tire quicker as a result of the increased work done and the increased energy

cost associated with amputee running. It is important to increase the recovery times

within and between training sessions, as amputees require increased recovery time to

return their body to homeostasis.

Injury prevention and management

The design of a training program must also be based on the athlete’s individual

characteristics, strengths and weaknesses. This includes accounting for the amputation

(i.e., modifications to exercises) and allowing sufficient recovery times between and

within training sessions.

Throughout the program implemented by the coach, injury prevention should

be a major consideration. Injury to an amputee athlete (particularly lower limb) is

extremely detrimental to their independence and mobility. Injury disrupts the training

program and limits the amputee to walking aids. This should be a high priority in the

coach's mind as the training program is designed. The training program must also be

periodised and individualised. Periodisation is the structure of a training program so

that the athlete will achieve the peak of their season at a particular time.

Communication

Communication is extremely important between the coach and the multi-

disciplinary team and in particular with the athlete themselves. Communication within

the multi-disciplinary team is important in achieving the most from the athlete

together. One aspect of management may indirectly influence other aspects and is

therefore necessary to determine the overall approach to training the athlete.

Management by one member of the team may indirectly influence other aspects of the

athlete’s management. Therefore, it is important to discuss management methods

within the multi-disciplinary team.

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Constant feedback from the athletes on their condition and how they feel is

important in modifying training programs. If the athlete is feeling lethargic,

inadequate recovery between training sessions may be indicated as a possible cause

and can predispose the athlete to injury.

Sport Specific Fitness

Relative strength training programs have similar benefits between able-bodied

athletes and disabled athletes. However, relative strength training is the most effective

way of stimulating the nervous system and increasing the strength of disabled athletes.

Generally, in maximum strength training, amputee athletes cannot handle as

heavy weights as able-bodied athletes. Relative strength training uses lighter weights

with a controlled stimulus, where the timing of the concentric and eccentric

contractions of the exercise is the focus (FIGURE 24).

Figure 24 - RELATIVE STRENGTH TRAINING. Relative strength training requires timing the

concentric and eccentric contractions of the exercise (courtesy of the Australian Institute of Sport).

Page 57

If the athlete struggles with an exercise due to a particular weakness, the

physiotherapist will implement supplementary exercises. Supplementary exercises are

co-ordinated within the training program to assist in overcoming specific weaknesses.

They strengthen weak muscles in isolation and ensure the athlete gains the maximum

from each exercise of the relative strength program. As a result, the relative strength

training program becomes more beneficial to the amputated side. This demonstrates

the co-ordination necessary within the multi-disciplinary team.

Sport Specific Skill Development

Explosive and reactive strength is the ability of the athlete to produce the

greatest amount of force in the shortest amount of time. Plyometric exercises are used

in the training program to assist in producing explosive and reactive strength and if

implemented correctly will aid in injury prevention. Plyometric exercises require

modifications to allow amputees to gain the full benefit of each drill and exercise.

Rather than modifying the actual exercise and losing the full effect of the drill, the

number of repetitions and sets undertaken during the training session is manipulated.

Particular exercises may also be gradually introduced into the training program (e.g.,

box jumps). Alternatively, plyometric exercises can be beneficial in a pool. It is not

necessary to wear the prosthesis in the water as the water in effect, stabilises the

athlete while they practice.

• BEND RUNNING

Sport specific skills development also involves teaching the athlete to run

bends. The inside (left) side drives and propels the athlete around the bends and the

main thrust is from the hips. The hips are also vital in changing direction in bend

running.

Using the outside/right leg to provide the drive around the bend is

contraindicated. It increases the stride length on that side and as a result the inside

leg’s hip movement is limited and stride length reduced. Limiting the hip movement

means the athlete cannot fully utilise both hips for the thrust necessary to powerfully

get around the bend. Leaning into the curve also limits the hip movement and stride

length of the inside leg.

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Figure 25 - BEND RUNNING. The inside arm and leg drive and propel the athlete around the bend

(www.advancedprosthetic.com).

Left-sided amputees (either upper or lower extremity) must use their affected

side to propel and drive themselves around the bend. This is a huge disadvantage in

comparison to right-sided amputees, who have their intact side for the drive and

propulsion (FIGURE 25). However, when running bends, right lower limb amputees

tend to contact the ground in an inverted position. The inverted orientation of the

prosthesis means less of the prosthesis is in contact with the ground. The athlete

pushes off the side of their toe and as a result the hip drops off and energy expenditure

increases. In an attempt to overcome this, the amputee may introduce hip/lumbar

rotation to increase the amount of prosthesis in contact with the ground, however the

athlete will still push off the edge of the prosthesis if it has a rounded toe.

Above knee amputee athletes also have difficulty in running bends. External

rotation of the hip causes internal rotation of the socket. As a result the prosthetic foot

does not track well and follows through with a lateral whip. This requires

strengthening of the hip internal rotators and adductors, in an attempt to minimise the

degree of hip external rotation and the resultant socket internal rotation and lateral

whip. It is difficult to make prosthetic alterations, as the bends are only a small

portion compared to the straights of the track.

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• TAKE-OFF/START

As in able-bodied take-offs and starts, the individual determines the best

method or style they will adopt. There are benefits of having the prosthesis as the

back foot or the front foot. With no real studies in this area, it is difficult to discuss the

most appropriate methods of training relating to take-off and starts. It should be

entirely based on the athlete’s personal preference. FIGURE 26 shows Earle Connor, an

above knee sprinter who holds the 100m world record (12.61 secs) in the above knee

amputee class (T42) practicing his start, note that his prosthesis is used on the back

block.

Bilateral amputees have a number of considerations regarding their take-off

style. A standing start does not provide any benefits other than they are balanced

when they take off. The bilateral lower extremity amputee has less proprioception and

less power generation through their prosthesis onto the blocks. Current theories are to

have a ‘leap style’ start where the blocks are of equal length and the athlete leaps off

the blocks and jumps into their take-off.

Figure 26 - TAKE-OFF. Pictured is an above-knee sprinter in a crouched starting postition

(www.healthcare.ottobock.com).

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MODIFICATIONS TO EXERCISES Exercises for amputee athletes do not require drastic modifications. Usually, if

the exercise is modified to suit the athlete the benefits and effects of the exercise

change. If an exercise appears dangerous it should be excluded from the athletes

program.

Often, the only modification to the exercises prescribed by the coach is the

number of repetitions and sets the athlete must complete. As the athlete becomes more

experienced at the exercises, the intensity of the program is slowly increased.

Strengthening Programs

During resistance training, there are a number of major muscle groups to

strengthen and there is a vast range of exercises to achieve this. A running resistance

strength training program should emphasise working on the legs and should assist in

the cyclic action required in running. With increased resistance these types of

exercises become particularly difficult for lower extremity amputees. If the athlete has

difficulty executing an exercise, a similar exercise providing the same benefits should

be prescribed. The introduction of different exercises for each major muscle group

also provides variation within the training program. For example, alternate leg

exercises in training sessions between squats and leg press. This prevents the athlete

becoming bored with their strengthening program while gaining similar benefits from

each exercise.

Plyometric exercises

Plyometric exercises can also be practised in a pool without a prosthesis. The

water stabilises the athlete and the full effects of the exercise are achieved. The non-

weightbearing environment aids in injury prevention, as the limb is not constantly

loaded and simultaneously the athlete gains the benefits of the exercise.

Lower limb amputees may require alterations to jumping exercises. The

residual limb is not as tolerant of the impact loads associated with jumping and as a

result these types of exercises need to be modified and gradually introduced into the

athlete’s training program.

Box jumps require both modifications and should be slowly introduced into

the athlete’s training program. The amputee athlete should first commence with

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vertical jumps. As the athlete progresses they are introduced to a low height to jump

from. The intensity (number of sets and repetitions) increases, as the athlete becomes

stronger and more efficient.

Above knee athletes have larger restrictions on their capacity to practice

particular exercises. When designing a program for above knee athletes the coach

should consider the athlete’s safety and their knee unit. The knee unit can pose a

problem in relation to stability and the athlete’s ability to control the knee unit during

drills. Some exercises for above knee athletes are unsuitable (i.e., bounding or split

squat jumps) and others require modifications. Step-ups for above knee amputee

athletes are difficult. With a height of 10-15 centimetres the athlete can step onto the

shelf and continue the movement over the box to the other side where they step down

off the box. This provides the same benefits and is as effective as step-ups. It is also

safer for the above-knee athlete.

Modifications to plyometric exercises for upper limb amputees are necessary

if the exercise requires the athlete to hold something in both hands. This includes the

use of a medicine ball during particular exercises.

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SECTION 3

TROUBLE SHOOTING

INJURIES

GAIT DEVIATIONS This chapter reviews a number of injuries that effect amputee athletes. This is

only a basic review and other injuries related to running in general (i.e., shin splints

etc) can be found in other references specialising in this area.

Injury to the intact or prosthetic limb is disruptive to the competitive amputee

athlete. The mobility of the athlete is restricted and at times walking aids are

necessary. It is important to understand the mechanism of injury to prevent further

recurrence. The identification, diagnosis and management of an injury influences the

rehabilitation period and the recovery process. It is imperative that injuries are fully

rehabilitated before the athlete returns to full training and any prosthetic modifications

should be attended to by the prosthetist.

It is important to understand the cause of the gait deviation to allow for the

correct modifications and alterations to be implemented. Gait deviations can be

attributable to muscle imbalances, the prosthesis, technique or a combination of these

factors.

Any deviations during walking gait are amplified in the athlete’s running style

and it is important for the athlete to have an ‘ideal’ walking gait before the fabrication

of their running prosthesis. The management of running and walking gait deviations

are similar. The speed at which gait deviations occur during running is fast and

difficult to identify to the untrained eye. Video analysis is a common tool in

identifying gait deviations during running.

This chapter discusses the running gait analysis of the physiotherapist,

prosthetist and coach in relation to what they look for. It provides a list of common

gait deviations, their causes and possible management methods.

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CHAPTER 8

INJURIES

As a result of the biomechanical deficits and the compensations adopted to

enable amputee’s to run, the prosthetic limb is predisposed to injury and the intact

limb is more susceptible to common able-bodied running injuries including plantar

fasciitis, shin splints, muscular sprains and strains and joint problems (please refer to

other resources that specialise in this area).

Risk factors The risk factors associated with able-bodied athletes are applicable to amputee

athletes. Amongst many these risk factors include; fatigue, training frequency and

training surface. Amputee specific risk factors include prosthetic fit and alignment,

training intensity and gait deviations. Inadequate recovery within and between

training sessions often predisposes the amputee athlete to overload injuries, on either

the intact or prosthetic side and is a major consideration in the design of a training

program. The coach and physiotherapist implement injury preventative techniques as

a component of a training program. These techniques include ensuring adequate

recovery and pool work (a non-weightbearing exercise).

Injury management The period the athlete will be limited in their training is influenced by the

initial management (immediately after the trauma), correct and accurate diagnosis,

specific treatment methods to allow healing and an extensive rehabilitation program to

return the athlete to their previous training levels.

Prosthetic modifications may also be required to assist in overcoming injury or

eliminating possible causes. For example, frictional and shear forces can occur

between the liner and residual limb requiring consideration of the socket fit and the

actual interface.

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Increased perspiration, inadequate stump care, poor hygiene and poor

maintenance and management of the prosthesis all contribute to injury (e.g., skin

irritations). To overcome skin irritations the athlete should doff the prosthesis

throughout the training session to wipe the perspiration from their residual limb and

liner.

Incorrect donning and inadequate socket fit can produce pressure areas on the

residual limb. With constant loading in these areas it can cause the skin to break

down. Further complications can develop (i.e., infection), however if the athlete

maintains constant contact with their prosthetist, the prosthetic derived injuries can be

minimised.

Massage is commonly used as an injury preventative and management

method. It provides both psychological and physical benefits. It is used in soft tissue

injury management as it increases blood flow to the muscles. As a result, this

increases the nutrients and oxygen delivered to the musculature. It also assists in

breaking down adhesive scars. This is particularly applicable to athletes with

excessive scarring on their residual limbs.

Injury prevention Introducing preventative measures into the athlete’s training program is the

preferred method of injury management. There are a number of factors that contribute

to minimising injury development and are briefly discussed in the coaching section

(training program considerations) section of the manual.

A well-designed training program allows adequate recovery within and

between training sessions. Insufficient recovery encourages overload injuries to

develop, as the musculature has not had enough time to adapt and repair itself from

the workload of the previous training session.

Education of the preventative aspects of injury is a major contributor in injury

prevention and management. Knowledge of prosthetic management, correct donning

procedures, socket positioning, stump care and hygiene aspects can all reduce the

amount of injuries sustained through poor stump and prosthetic management. For

example, most skin irritations are a result of increased perspiration and the best way to

manage this is to constantly doff the prosthesis and wipe the residual limb dry. It is

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assumed the athlete will have basic knowledge in stump and prosthetic care and

management from their previous experience with their everyday leg. As mentioned

previously the prosthetist should emphasise hygiene management (perspiration

issues), stump monitoring (for redness, breakdown, irritations) and prosthetic

management (donning, prosthetic maintenance) when the running prosthesis is

initially provided.

Injuries on the intact limb can sometimes be avoided through orthotic

intervention. Foot orthoses play a role in impact absorption and assist in maintaining

the structural integrity of the foot.

Although not discussed in detail, it is essential to understand the nutritional

requirements of an athlete, not only from an injury preventative and management

perspective but also in relation to improving performance. The nutritional

requirements of an amputee athlete follow the same guideline as able-bodied athletes.

Common injuries Amputee specific injuries usually involve the prosthesis. Such injuries are a

result of the forces produced and their distribution, poor socket fit causing movement

of the residual limb within the socket (i.e., pistoning, shear and frictional forces) and

gait deviations.

Amputee runners commonly incur back pain as a result of their spinal position

and muscular weaknesses. The spine adapts a scoliotic position to adapt to their limb

loss and to maintain balance. As a result, gait deviations and muscular imbalances

develop. This further emphasises the need for core strength and stability.

The increased loads and inadequate shock absorption on the prosthetic side

increases the incidence of joint degenerative conditions on the prosthetic and intact

limbs. Poor technique and inadequate prosthetic fitting and alignment also contribute

to excessive joint loading and joint degeneration.

The table below summarises amputee specific running/athletic injuries. It is

important that any injury is correctly diagnosed and sufficiently rehabilitated before

the athlete returns to previous training levels.

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Injury Signs and symptoms Mechanism of injury Management

Skin Irritations Rash on stump

Flakey or peeling skin

Dermatitis/eczema

Itchy

Redness of affected areas

Perspiration/heat

Reaction to liner

Shear/frictional forces at stump-

socket interface

Dry skin

Creams and moisturisers

Emphasise stump and prosthetic

care and management

Skin breakdown Broken skin

Scab

Painful

Shear or frictional forces at

stump-socket interface

Adhesive scar pulls skin tight

causing friction

Pressure areas

Insufficient management of

skin irritation

Pistoning within socket

Rest until healed

Emphasise stump monitoring

Assess and modify socket fit

Assess alignment

Massage to break up scar tissue

Verrucose

hyperplasia

Distal skin appears

roughened and warty

Loss of distal contact with

socket, as a result the blood

pools distally in the residuum

and the vessels burst

Assess and modify socket fit

New total contact socket

Infected hair

follicle

Pimply

Rash

Perspiration

Hygiene

Allow to heal

Emphasise stump and prosthetic

care and management

Stump pain General stump soreness

Stump pain on loading and

after training

Discomfort on loading

Muscle soreness

Stump intolerance to pressure

and loading

Hypersensitivity

Insufficient shock absorption

Socket fit

Medication (legal)

Massage (for hypersensitivity and

scar adhesions)

Acupuncture

Assess liner characteristics

Decrease foot category

Assess socket fit

Phantom pain Pain in the portion of leg

that has been amputated

Nerve impulses continue

through cut nerve giving the

athlete pain sensations in their

amputated leg

Medication

Massage

Acupuncture

Blisters Liquid filled mass

Shear and/or frictional forces at

stump-socket interface

Avoid loading

Rest until healed

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Injury Signs and Symptoms Mechanism of Injury Management

Calluses

(stump or intact

foot)

Hard, toughened skin

Can be painful

Constant blistering

Adaptation to loading

Friction

Remove (podiatrist)

Don’t soften as it will cause

breakdown

Ulcers Deep wounds (especially

on bony prominences)

Friction and shear forces

(particularly if athlete has frail

or thin skin)

Pressure on bony prominences

Pressure on desensitised skin

Constant skin breakdown

Assess interface/liner

Socket fit

Assess loading of socket

Close monitoring of stump

condition

Posterior knee

capsule

Posterior knee swelling

Posterior knee pain

Knee instability

Genu recurvatum

Constant knee hyperextension

during loading

Stretching of the synovial

capsule of the knee

Physiotherapy (ultrasound)

Walking gait re-education

Technique modifications

Knee Orthosis

Increase foot category

Back pain Constant lower back ache

Restrictions in movement

Awkward gait pattern

Spinal malalignment

Musculature weakness

Core instability and weakness

Gait deviations

Compensatory adaptations

Previous injury

Prosthetic socket fit, alignment,

height

Lack of shock absorption

Core stability and strengthening

work

Walking gait re-education

Running technique modifications

Suffice rehab post-injury

Rest

Prosthetic modifications (height,

alignment, socket fit)

Decrease category of foot

Joint pain

(intact or

prosthetic side)

Soreness at joint/s

Avoid loading joint

Increased impact loads

Inability to absorb shock (ie,

shoes, prosthesis)

Training surface too hard

Gait deviations

Joint degeneration

Increase flexibility (ROM)

Get suitable shoes

Add shock-absorbing materials to

prosthesis

Decrease foot category

Change training surface (ie, grass)

Gait re-education (walking and

running)

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It is important to note these injuries can be avoided. This is through constant

stump monitoring, stump care and management, prosthetic care and management and

maintaining contact with the prosthetist to assess prosthetic fit and function. It also

emphasises the necessity of a perfect walking gait and an ideal running style to avoid

back pain and other structural and muscular injuries. Often the muscular injuries are

overload injuries and are a result of inadequate technique or in suffice recovery. The

compensatory measures are adapted to avoid loading the limbs for various reasons,

including pain. This influences the alignment of body segments and predisposes the

athlete to further injury.

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CHAPTER 9

GAIT ANALYSIS: DEVIATIONS AND MANAGEMENT

GAIT ANALYSIS Similarly to walking gait analysis, during running gait analysis it is important

to get both frontal plane aspects and a sagittal view. Gait deviations during running

are more difficult to identify because of the speed of movement. To assist in

identifying gait deviations, it is important to look at the compensatory mechanisms

that are employed. The compensations accentuate the original deviation and direct the

assessor to the underlying cause.

Ideally, the athlete will have a good walking gait, as any deviations present

during walking will be amplified during running. This is one of the criteria (as

stipulated by the physiotherapist) that must be fulfilled before the athlete is eligible

for a running prosthesis. It is vital to have a balanced and solid walking gait

foundation to achieve an efficient running style.

It is important to address and manage any gait deviations as soon as possible.

Excessive gait deviations may cause long-term problems for the amputee including

pain, structural deformities and degenerative changes. Managing these deviations is

usually achieved through a multi-disciplinary team approach. If an individual

manages the deviation they should pass on their findings and management methods to

the other multi-disciplinary team members, as changes in one aspect can often

influence other aspects of the athlete’s management.

When assessing the athlete’s running gait, the athlete should run

approximately sixty metres a maximum of eight times. Exceeding this will produce

gait deviations that are a result of fatigue.

High speed video analysis of the athlete’s running gait is a common tool used

in recognising deviations and their cause. The speed of the video can be decreased

during playback and the movement of the athlete can be assessed slowly and in more

detail. It also enables the viewer to focus on certain aspects of the athlete’s gait

including stride speed and length, symmetry and the functional joint range of

movement.

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Viewing the footage with other members of the ‘team’ may also be useful in

determining a management plan to overcome the deviation and prevent the adoption

of compensations. This further highlights the need for communication within the

multi-disciplinary team.

PHYSIOTHERAPIST

The physiotherapist is particularly interested in the muscle efficiency and

muscle recruitment during running.

• Assess upper body rotation is sufficient and symmetrical.

Look for stiffness of the athlete during running.

Look whether the athlete has excessive trunk movement and/or upper

body rotation.

Note whether the arms are being used for drive.

Review core strength and stability.

• Check posture.

Look for excessive lumbar lordosis, anterior trunk flexion or lateral

trunk bending.

Check core strength and stability.

• Assess pelvic movement is sufficient (not excessive) in each plane.

Look for anterior pelvic tilt, pelvic drop and excessive pelvic shift.

Check core strength stability.

• Check knee stability.

Look for varus/valgus during loading, hyperextension and drop off

(excessive flexion).

• Check the width of the base of support.

Feet should be underneath athlete running in one line. Too wide

indicates an abducted gait.

• Assess symmetry.

Note stride length and duration, joint angles, rotational movements and

check the limbs are following the same movement pattern.

• Note whether muscles are being recruited efficiently and used effectively.

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PROSTHETIST

The prosthetist is particularly interested on the athlete’s use of the prosthesis

and the prosthesis effect on movement.

• Check the foot is flat on the ground with good ground contact.

Look for inversion or eversion of the prosthesis.

Look at amount of toe on ground.

• Assess whether feet are evenly loaded and are fully weightbearing through

their prosthesis.

Ensure prosthesis is not being used as a prop and is being used

appropriately.

• Assess symmetry.

Check for symmetry (approximately) between stride length, stride

width, swing and stance phase duration, joint angles, rotational movements

etc.

• Assess knee stability during stance.

Look for varus/valgus, knee hyperextension or drop off (excessive

flexion).

• Check abduction/adduction of the socket.

Check for good, even, flat contact with the ground.

• Assess knee movement during swing (lateral view).

Check there is no limitations or restrictions in movement.

Check trimlines and suspension is not impinging on knee movement

(especially knee flexion).

Make sure there are no medial or lateral whips.

• Assure full hip movement.

Note whether any restrictions are prosthetically related (i.e., influence

of trimlines or suspension).

• Assess adequate trunk movement.

• Analyse degree of hip internal/external rotation.

Check prosthesis tracks/follows through straight during swing.

Check for whips (particularly in above knee athletes).

• Assess the movement of the foot in transfemoral and through knee athletes.

Check for whips and terminal swing impact.

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COACH

Initially, the coach takes a holistic approach to analysing the running gait of

the athlete. The coach will then analyse the athlete in parts (upper limb and lower

limb) and then review the athlete as a whole.

• Check the athlete’s balance and posture.

Ensure the athlete demonstrates core stability.

Check for a good posture – reasonably upright, symmetry between the

stomach and back muscles (i.e., not leaning back, not leaning forward).

• Look at the iliopsoas.

Check it provides the initial drive during take off.

• Look at the gluteals.

Ensure gluteals provide the drive.

• Watch the leg movement during recovery.

Ideally the foot should follow through the knee while maintaining hip

flexion and a horizontal thigh.

Ensure quadriceps are utilised during recovery and not the gluteals.

• Check the pelvic position.

Ensure pelvis and hips are forward and up (to an extent) with no

rotation.

Review core strength and stability.

• Assess trunk movement.

Look for adequate trunk movement - excessive trunk movement

indicates possible balance problems and core instability.

• Check arm movement is symmetrical and controlled.

Arm action should be controlled in action and drive.

• Assess symmetry.

Check stride speed is even between limbs.

Check arm and leg movements are similar on both sides (i.e., no

balancing compensations etc).

• Review the athlete as a whole. Check the arm and leg movements are

coordinated and symmetrical.

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GAIT DEVIATIONS

GENERAL DEVIATIONS

• Lateral Trunk Bending

Presentation - athlete leans towards their amputated side during prosthetic stance. The

athlete has difficulty stabilising on the prosthetic side.

CAUSE MANAGEMENT

MUSCULAR Difficulty in stabilising on

prosthetic side

Strengthen extensors and adductors

on prosthetic side

Prosthesis length Assess and adjust height. Prosthetic

side should be approximately ¾”

longer than the intact limb (BK). PROSTHETIC

Foot too outset Inset foot under the athlete to

enable good ground contact

Introduce proprioception and

balance enhancing exercises

Compromised balance

Strengthen core

Introduce co-ordination exercises

Strengthen shoulders and trunk

Strengthen core

Uncontrolled trunk and arm

movement

Postural maintenance

TECHNICAL

Fatigue Increase recovery within and

between sessions

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• Excessive Anterior Trunk Flexion

Presentation – some anterior trunk flexion is necessary for forward progression in

running. It is necessary for the foot to contact the ground behind the centre of gravity

and moving at the same or slower velocity. However, if the athlete excessively leans

forward during running it limits the hip range of movement and as a result the stride

length is reduced.

CAUSE MANAGEMENT

Tight hip flexors/anterior

capsule

Decreased flexor range

Stretch and strengthen flexors

MUSCULAR

Poor core stability Core stability and strengthening

exercises

Foot too anterior, athlete has

to lift to get over the toe

Move foot back under athlete

PROSTHETIC

Socket too flexed Modify alignment

Teach to strengthen and utilise

trunk and arms

Co-ordinated arm movement

exercises

Unbalanced style

Posture and core stability exercises

Overcompensating Teach to run more upright

TECHNICAL

Fatigue Increase recovery within and

between sessions

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• Pelvic Shift

Presentation – pelvic shift occurs in each plane. Pelvic shift occurs naturally during

running however can become excessive. Excessive pelvic movement is a result of the

athlete’s inability to stabilise the core. Pelvic movement causes a displacement of the

centre of gravity and increases energy expenditure. Excessive pelvic movement does

not allow the athlete to fully utilise the characteristics of the prosthesis as the foot is

ineffectively loaded and unloaded.

CAUSE MANAGEMENT

Pelvis tilts anterior to

ground

Strengthen abdominals and core

Poor stability of hip on

prosthetic side

Strengthen abdominals, core and

hip extensors MUSCULAR

Unable to stabilise the core Include more core stability work in

program

Excessive foot compression

(category too soft)

Use a stiffer category – refer to

selection form.

Prosthesis too short Prosthesis should be approx ¾”

longer than intact side during static

alignment PROSTHETIC

Inversion/eversion of foot at

push off

Reposition foot to allow as much of

the foot is in contact with the

ground as possible

Teach athlete to run with as much

ground contact as possible

Don’t allow athlete to favour

prosthetic side

Poor prosthetic contact with

ground

Encourage loading of the prosthesis

Stretch and strengthen hip flexors

TECHNICAL

Lumbar spine rotation

(partial core instability) Core stability exercises

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• Prosthetic Pull-Off

The athlete lifts the leg into swing rather than pushing off with the prosthesis.

Occurs in both below knee and above knee athletes. The hip muscles and the

proportion of the prosthetic foot in contact with the ground influences the amount of

push-off. Prosthetic pull-off does not use the power generated by the hip extensors

efficiently.

CAUSE MANAGEMENT

MUSCULAR Tight hip flexors/anterior

hip capsule

Stretch and strengthen hip flexors

PROSTHETIC

Ineffective use of prosthesis

In suffice ground contact ∴

ineffective push off

Position socket and align prosthesis

allowing good ground contact and

enabling an effective push-off

TECHNICAL

Ineffective use of hip

extensors and their energy

to assist push-off

Drills focusing on hip extensor

recruitment

• Uneven Stride Length

Presentation – the prosthetic or intact leg has an increased stride length compared to

the contralateral side.

CAUSE MANAGEMENT

MUSCULAR Limitations in the hip or

knee ROM

Stretch out tight structures

Prosthetic alignment Realign to allow full hip and knee

movement

Impinging suspension Assess suspension PROSTHETIC

Trimlines too high Lower trimlines

Poor gait Walking gait re-education

TECHNICAL Fatigue causes athlete to

overstride

Enhance cardiovascular fitness

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• Toe Drag

Presentation – during swing the toe drags as a result of inadequate toe clearance.

CAUSE MANAGEMENT

MUSCULAR Weak knee flexors Strengthen knee flexors

Prosthetic length Shorten prosthesis (pros should be

approx ¾” longer) PROSTHETIC

Ineffective suspension Modify suspension

PROSTHETIC

(transfemoral)

Knee flexion restricted Decrease knee resistance

Increase recovery times during and

between training sessions

Fatigue

Enhance cardiovascular fitness TECHNICAL

Unsuitable gait Modify walking gait pattern

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• Increased Knee Flexion (Drop Off)

Presentation – throughout the gait cycle, excessive knee flexion can present in a

number of ways. At initial contact the knee is excessively flexed and the athlete tends

to ‘drop off’, coming off their prosthetic toe and falling quickly to the sound side.

CAUSE MANAGEMENT

MUSCULAR Weak knee extensors Strengthen knee extensors

Toe lever too short / foot too

posterior

Reposition foot more anterior

Inability to control energy

storing characteristics of the

prosthetic foot

Align prosthesis with more stability

(ground reaction force anterior to

knee)

PROSTHETIC

Socket to flexed Assess and modify alignment

PROSTHETIC

(transfemoral)

Inadequate knee flexion

resistance in knee unit

Increase flexion resistance

TECHNICAL

Inability to use musculature

to stabilise and control

prosthesis.

Implement knee stability and

control exercises and drills

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• Knee Hyperextension

Presentation – the knee is fully extended throughout stance phase. Forces are not

absorbed through the eccentric quadriceps and as a result can cause a number of

injuries. Continuous joint loading can eventually lead to degenerative changes in the

lower limb joints.

CAUSE MANAGEMENT

MUSCULAR

Poor muscle control

(particularly vastus

medialis)

Strengthen knee musculature

(esp. eccentric quadriceps)

Insufficient socket flexion Assess and modify alignment

PROSTHETIC Foot too anterior / toe lever

too long

Reposition foot more posterior and

under the athlete

Increase foot category PROSTHETIC

(transfemoral)

Excessive vertical

compression in foot Use a Flex-Sprint I or II

Strengthen and utilise trunk and

arms TECHNICAL

Unbalanced running style Postural maintenance, core strength

and stability work

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• Lumbar Lordosis

Presentation – the lumbar lordosis of the athlete is accentuated during running and the

trunk leans posteriorly. It is a compensatory measure adopted to overcome poor pelvic

stability and inadequate abdominal strength and control. It limits the stride length of

the athlete as there is a decreased range of hip extension and is difficult to achieve a

good range of hip flexion. This deviation occurs in both below knee and above knee

athletes.

CAUSE MANAGEMENT

Tight iliopsoas Stretch out iliopsoas

Hip extensor weakness Strengthen extensors

Core weakness and

instability

Strengthen core especially

abdominals MUSCULAR

Restricted hip movement Stretch hip musculature to improve

flexibility

Loss of socket fit Assess socket fit and alignment

PROSTHETIC

(transfemoral)

Insufficient socket flexion Modify alignment

Walking gait re-education

introducing upper body rotation TECHNICAL

Limited arm movement and

upper body rotation

Core strength and stability work

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• Excessive Heel Rise

Presentation – the prosthetic foot rises higher than the sound side’s foot. The

prosthetic foot can even hit the posterior aspect of the socket. There is forceful hip

flexion and as a result the foot flicks up behind the athlete, increasing prosthetic swing

duration and producing interlimb asymmetry.

CAUSE MANAGEMENT

MUSCULAR Decreased hip extensor

movement

Stretch and increase hip extensor

flexibility and mobility

Insufficient knee unit

flexion resistance

Increase knee unit flexion

resistance

Prosthetic knee axis higher

than anatomical knee

Reposition and align knee unit PROSTHETIC

Flexion bumper on the posterior

distal aspect of the socket

TECHNICAL

Inability to push off with

prosthesis

Introduce a prosthetic push off

technique to limit the use of the hip

flexors

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• Medial/Lateral Whip

Presentation – the heel twists at toe off and follows a medial or lateral direction

throughout swing.

CAUSE MANAGEMENT

MUSCULAR

(transfemoral)

Flabby musculature causes

socket and musculature to

internally/externally rotate

around bony reminant

Strengthen and tone musculature

Internal or external socket

rotation in relation to line of

progression

Socket fit too tight or does

not accommodate contour of

muscles

Modify socket fit and suspension

Toe break not in line of

progression

PROSTHETIC

Insufficient foot contact

with ground

Assess and modify alignment

PROSTHETIC

(transfemoral)

Knee not horizontal with

ground (AK)

Assess and modify assessment

Insufficient contact with

ground causes foot to twist

during stance

Teach athlete to control and utilise

energy characteristics of the foot

TECHNICAL

Not fully weightbearing

through prosthesis

Determine why not fully

weightbearing (i.e., pain, insecure)

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• Abducted Gait

Presentation – the athlete has a wide running base where the legs do not follow a

single line underneath the athlete. It also involves excessive pelvic and trunk

displacement and is often associated with lateral trunk bending.

CAUSE MANAGEMENT

Weak hip extensors Strengthen extensors

MUSCULAR Hip muscular imbalances

(abductors and adductors)

Strengthen hip adductors

PROSTHETIC

(transtibial) Prosthesis too long

Pros approx ¾” longer

than intact

Stump not in socket

Medial wall to high

Socket does not support

femur in adduction

Assess and modify socket

fit PROSTHETIC

(transfemoral)

Prosthesis too long Prosthetic side approx

same height as intact

Running weave drills

(works adductors) TECHNICAL

Inability to control trunk

and maintain good posture

Core stability work

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• Circumduction

Presentation – the entire prosthesis tracks laterally in swing and returns to the correct

position for heel strike. This deviation can occur in both below knee and above knee

athletes, usually above knee unless otherwise stated).

CAUSE MANAGEMENT

MUSCULAR Weak hip extensors Strengthen hip extensors

PROSTHETIC Prosthesis too long Pros approx ¾” longer

than intact

Knee unit position / knee

too stable

Modify and adjust socket

and knee position

Excessive knee flexion

resistance

Decrease knee flexion

resistance

Medial socket wall too

high

Assess and modify socket

fit

PROSTHETIC

(transfemoral)

Prosthesis too long Pros approx same height

as intact (level knees)

Athlete lacks confidence

loading knee, does not use

knee effectively (AK)

Teach to trust knee unit

during loading

Knee lifts

TECHNICAL

Foot does not follow

through knee arc Increase hip flexibility

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• Vaulting

Presentation – rising up on the toe of the intact leg to accommodate for prosthetic

swing. Vaulting occurs in both below knee and above knee running gait. Management

is generally the same unless otherwise specified.

CAUSE MANAGEMENT

MUSCULAR Weak hip flexors Strengthen hip flexors

Prosthesis too long Shorten leg

PROSTHETIC Excessive knee flexion

resistance making it

difficult to break the knee

(AK)

Decrease knee flexion

resistance

Athlete not confident to

load knee (AK)

Teach athlete to trust knee

unit during stance (explain

exercises) TECHNICAL

Athlete does not utilise

prosthesis’ characteristics

Educate athlete on ways to

utilise foot and knee unit

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BELOW KNEE SPECIFIC DEVIATIONS

• Knee Mediolateral Instability

Presentation – knee adopts a varus or valgus position during stance. Prosthetically,

mediolateral knee movement relates to the amount of toe on the ground.

CAUSE MANAGEMENT

MUSCULAR Muscular weakness and

instability

Strengthen knee musculature

Foot too inset or outset Reposition foot

Socket position in frontal

plane

Adjust alignment PROSTHETIC

M/L diameter of socket too

wide

Assess and modify socket fit

Enhance endurance capacity of the

athlete TECHNICAL Fatigue

Increased recovery periods within

and between training sessions

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ABOVE KNEE SPECIFIC DEVIATIONS

• Terminal Impact

Presentation – at the end of swing the prosthetic shank hits full extension and bounces

back. This reduces the stride length because when the foot bounces back off the knee,

it is positioned back under the athlete when the foot is loaded.

CAUSE MANAGEMENT

MUSCULAR Lack of proprioception Proprioceptive development

exercises

Friction and extension bias

unbalanced

Modify friction and assistance of

knee unit PROSTHETIC

Absent knee extension

bumper

Replace bumper or entire knee unit

Teach athlete smooth technique

TECHNICAL Over-striding Teach athlete to increase stride

speed and frequency to run faster,

rather than over striding

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REFERENCES

• Bowker, J.H. and Michael, J. W. (1992) ‘Atlas of Limb Prosthetics: Surgical,

Prosthetic and Rehabilitation Principles, 2nd edn.’ American Academy of

Orthopaedic Surgeons.

• Brouwer, B.J., Allard, P. and Labelle, H. (1989) ‘Running Patterns of Juveniles

Wearing SACH and Single-Axis Foot Components’, Archives of Physical

Medicine and Rehabilitation; 70: 128-134.

• Czerniecki, J. M. (1996) ‘Rehabilitation in Limb Deficiency’, Archives of

Physical Medicine and Rehabilitation; 77: S3-S37.

• Czerniecki, J. M. and Gitter, A. (1992) ‘Insights into Amputee Running: A

Muscle Work Analysis’, American Journal of Physical Medicine and

Rehabilitation; 21: 209-218.

• Czerniecki, J. M. and Gitter, A. J. (1996) ‘Gait Analysis in the Amputee: Has it

Helped the Amputee or Contributed to the Development of Improved Prosthetic

Gait Components?’ Gait and Posture; 4: 258-268.

• Czerniecki, J. M., Gitter, A. J. and Beck, J. C. (1996) ‘Energy Transfer

Mechanisms as a Compensatory Strategy in Below Knee Amputee Runners’,

Journal of Biomechanics; 29(6): 717-722.

• Czerniecki, J. M., Gitter, A. and Munro, C. (1991) ‘Joint Moment and Muscle

Power Output Characteristics of Below Knee Amputees During Running; The

Influence of Energy Storing Prosthetic Feet’, Journal of Biomechanics; 24 (1): 63-

75.

• De Castella R. and Clews, W. (1996) ‘Smart Sport: The Ultimate Manual for

Sports People’, RWM Publishing Pty Ltd.

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• Enoka, R. M., Miller, D. I. and Burgess, E. M. (1982) ‘Below-Knee Amputee

Running Gait’, American Journal of Physical Medicine; 61(2):66-84.

• Fergason, J. and Smith, D. G. (1999) ‘Socket Considerations for the Patient With

a Transtibial Amputation’, Clinical Orthopaedics and Related Research; (361):76-

84.

• Gitter, A., Czerniecki, J. and Meinders, M. (1997) ‘Effect of Prosthetic Mass on

Swing Phase Work During Above-Knee Amputee Ambulation’, American Journal

of Physical Medicine and Rehabilitation; 74(2):114-121.

• Lees, A. (1999) ‘Running’ in Durward, B. R., Baer, G. D. and Rowe, P. J.

(editors) Functional Human Movement, Butterworth Heinemann.

• Macfarlane, P. A., Nielsen, D. H. and Shurr, D. G. (1997) ‘Mechanical Gait

Analysis of Transfemoral Amputees: SACH Foot Versus the Flex-Foot’, Journal

of Prosthetics and Orthotics; 9(4):144-151.

• Mensch, G. and Ellis, P.E. (1986) ‘Running Patterns of Transfemoral Amputees:

A Clinical Analysis’, Prosthetics and Orthotics International; 10:129-134.

• Miller, D. I. (1987) ‘Resultant Lower Extremity Joint Moments in Below Knee

Amputees During Running Stance’ Journal of Biomechanics; 20(5): 529-541.

• New York University: Postgraduate Medical School Prosthetics and Orthotics

(1982) ‘Lower Limb Prosthetics: including Prosthetists Supplement’.

• Nunn, C.J. (1992) ‘Coaching Amputee Athletes’, Goanna Print.

• Nunn, C. J. (1995) ‘Walk This Way’, Sport Health; 13(4) 6-7.

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• Prince, F., Allard, P., Therrien, R.G. and McFadyen, B.J. (1992) ‘Running Gait

Impulse Asymmetries in Below Knee Amputees’, Prosthetics and Orthotics

International; 16: 19-24.

• Sabolich, J. (1985) ‘Contoured Adducted Trochanteric-Controlled Alignment

Method (CAT-CAM): Introduction and Basic Principles’, Clinical Prosthetics

and Orthotics; 9(4): 15-26.

• Sabolich, J. (1987) ‘The O.K.C. Above-Knee Running System’, Clinical

Prosthetics and Orthotics; 11(3): 169-172.

• Sanderson, D. J. and Martin, P. E. (1996) ‘Joint Kinetics in Unilateral Below Knee

Amputee Patients During Running’, Archives or Physical Medicine and

Rehabilitation; 77: 1279-1285.

• Seroussi, R. E., Gitter, A. Czerniecki, J. M. and Weaver, K. (1996) ‘Mechanical

Work Adaptions of Above-Knee Amputee Ambulation’, Archives of Physical

Medicine and Rehabilaition; 77: 1209-1214.

• Smith, A. W. (1990) ‘A Biomechanical Analysis of Amputee Athlete Gait’,

International Journal of Sport Biomechanics; 6: 262-282.

• Thordarson, D. B. (1997) ‘Running Biomechnaics’, Clinics in Sports Medicine;

16(2) 239-247.

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SECTION 4

APPENDICIES

AMPUTEE CLASSIFICATIONS

IMPAIRMENT SPECIFIC SCREENING FORM

IMPAIRMENT SPECIFIC SCREENING EXPLANATORY NOTES

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APPENDIX I – AMPUTEE CLASSIFICATIONS

CURRENT

CATEGORY

PREVIOUS

CATEGORIES DESCRIPTION

F42 A2 & A9 single AK & combination

F43 A3 & A9 double BK & combination

F44 A4 & A9 single BK & combination

F45 A5 & A7 double AE & double BE

F46 A6 & A8 single AE & single BE

T42 A2 & A9 single AK & combination

T43 A3 & A9 double BK & combination

T44 A4 & A9 single BK & combination

T45 A5 & A7 double AE & double BE

T46 A6 & A8 single AE & single BE

LEGEND

Abbreviations AK – above or through the knee joint

BK – below the knee, but through or above the talo-crural joint

AE – above or through the elbow joint

BE – below the elbow, but through or above the wrist joint

Previous classifications A1 – double AK – both legs amputated above the knee

A2 – single AK – one leg amputated above the knee

A3 – double BK – both legs amputated below the knee

A4 – single BK – one leg amputated below the knee

A5 – double AE – both arms amputated above the elbow

A6 – single AE – one arm amputated above

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A7 – double BE – both arms amputated below the elbow

A8 – single BE – one arm amputated below the elbow

A9 – combination - upper and lower extremity amputations

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APPENDIX IIa – IMPAIRMENT SPECIFIC

SCREENING FORM

Name :

Sport :

Events :

Level of amputation

Walking prosthesis

Sporting prosthesis

Training prosthesis / aids / orthotics

• Residual Limb Diagram:

Length

Verrucose hyperplasia

Sensitivity / Pain

Redundant tissue

Sensation

Phantom pain

Scarring

Abrasions

• Posture

HEAD & CERVICAL SPINE

Normal

Lordosis

Pokeneck

Flat C/S

Side tilt Left Right

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Rotation Left Right

• THORACIC SPINE

Normal

Kyphosis

Flattened

Scoliosis

Shoulders level

Sloping

Rounded

• LUMBAR SPINE

Normal

Flattened

Lordotic

Scoliosis

Muscle bulk

Atrophied

Hypertrophied

• PELVIS

Normal

Shift Left Right

Anteriorly rotated

Posteriorly rotated

Check leg length – PSIS level

• FEMUR

Normal

Gluteal wasting Left Right

Internal rotation Left Right

External rotation Left Right

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• KNEE

Normal

Genu Recurvatum Left Right

Genu Varum Left Right

Genu Valgum Left Right

Quad wasting Left Right

Knee joint swelling Left Right

• PATALLAE

Normal

Lateral Left Right

Squinting Left Right

• FOOT POSITION

Normal Left Right

Hallux Valgus Left Right

High arch Left Right

Low arch Left Right

Evert Calcaneus Left Right

Invert Calcaneus Left Right

Foot turned in Left Right

Foot turned out Left Right

• Stability/Muscle Activation

7 stage abdominals

Activated abdominals Single leg Double leg

Resisted hip rotation Internal External

Hip capsule Left Right

Isolation of abdominal & gluteal activity

Unilateral hip extension Left Right

Unilateral knee flexion (activation sequence)

Eccentric quads

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Single leg stance

Step down

Single leg squats

Hops

Comments

• Gait analysis

Lateral trunk bending

Pelvic shift

Upper body rotation

Lumbar spine hyperextension

Knee hyperextension

Increased knee flexion (drop-off)

Uneven step length

Knee deviation

Whip medial/lateral

Terminal impact

Abducted gait

Circumduction

Vaulting

• Problems

• Recommendations

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APPENDIX IIb – IMPAIRMENT SPECIFIC

SCREENING EXPLANTORY NOTES

• Prosthesis type: documentation for both walking and sporting prostheses note:

- Socket type

- Suspension

- Liner

- Knee/elbow joint

- Foot/ankle complex or terminal device

• Residual limb: skin arising from suboptimal socket fit or prosthetic alignment

obviously will require prosthetic review.

Verrucous hyperplasia appears distally on the residual limb. The skin appears

roughtened and warty and this is due to loss of distal contact with the prosthetic

sockets.

Redundant tissues is an excessive amount of soft tissue tht extends beyone the bony

remanent. It may cause problems with socket fit and comfort which may respond to

different types of prosthetic liner.

Note whether the sporting activity has an impact on residual limb pain or phantom

pain.

Measurement of residual limb length:

- Transtibial – tibial tuberosity to distal tibia

- Tranfemoral – greater trochanter to distal femur

- Transradial – acromion process to distal humerus

- Transradial – olecranon to distal radius

• Posture: assess with the walking prosthesis donned. The sports specific

alignment of the sporting prosthesis usually does not allow the athlete to adopt a

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comfortable standing posture. The sporting prosthesis is designed and aligned

depending on the demands of the sport.

Ensure the feet are level and the weight is evenly distributed on both feet. The athlete

should look straigh ahead. If weight is taken unevenly on the prosthetic foot, an

alignment fault maybe indicated. The athlete should not have to exert effort to

maintain a comfortalble and symmetrical standing alignment.

• Stability and Activation:

1. Seven stage abdominals: in supine with the knees flexed to 90o. Walking

prosthesis is on.

2. Activated abdominals: measure the distance to the surface when abdominal

control is lost for single and double leg tests.

3. Resisted hip rotation: the athlete lies supine with the knees bent to 90o. Observe

deviation of the naval as they resist applied hip rotation force. Note any abdominal

muscle imbalances.

4. Hip capsule: determine any tightness in the hip capsule and iliopsoas muscle

independantly. The athlete is prone with the legs in a figure 4 position. Measure

the distance from the supporting surface to the raised ASIS.

5. Isolation of abdominal and gluteal activity: test in the above position. Also note

the ability to co-contract these muscles and any compensations evident.

6. Unilateral hip extension: in prone, time to fatigue bilaterally.

7. Unilateral knee flexion: note the activation sequence, i.e., activation of stabilisers

v’s hamstrings.

8. Eccentric quadriceps: test strength and control in standing. Pop onto prosthetic

toe. Note control of flexion/extension and where in range control is lost.

9. Single leg stance: Observe lateral pelvic tilt, rotation, lumbar spine lateral flexion.

Balance. Co-activation of abdominals and erector spinae.

10. Step down and single leg squat (trantibial athletes only - prosthetic side as able).

Note knee angle and deviation at fail, note any pelvic deviation at fail.

• Gait Analysis: if any of the mentioned gait deviations are present and considered

to be excessive then a prosthetic clinic review may be necessary to determine the

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cause and rectify the problem. A gait fault in walking will be magnified in running

or any other higher activity, which may predispose to injury. (Refer to gait

deviations in Chapter 8 – Gait deviations and management).

1. Lateral trunk bending – inadequate shift of the pelvis to the stance side with

compensatory trunk lateral flexion to the stance side. Upper body rotation is

lacking. Could indicate a problem with prosthesis and/or athlete.

2. Pelvic shift – excessive or inadequate?

3. Upper body rotation – is it equal on both sides?

4. Lumbar spine hyperextension – this is usually a compensation related to poor

pelvic stability and inadequate abdominal strength and control. Note hip range of

movement.

5. Knee hyperextension – in stance phase. This may indicate poor muscle control.

6. Increased knee flexion – is there drop-off before prosthetic toe-off?

7. Uneven step length – this will indicate a need for physiotherapeautic review and

gait training.

8. Knee deviation during stance phase – a varus or valgus deviation will indicate

either a malalignment or knee instability, requiring intervention.

9. Whip – medial or lateral. Is present when the foot has an altered course throughout

prosthetic swing phase. Indicates malalignment of knee axis and foot.

10. Terminal impact – occurs in a prosthetic knee joint when friction and extension

bias are not balanced. Requires knee adjustments.

11. Abducted gait – base is too wide. Could indicate prosthetic problems (e.g.,

discomfort in groin) or muscle imbalance.

12. Circumduction – the prosthesis tracks laterally in swing and is placed in the

correct heel strike position.

13. Vaulting – rising up on the toe of the intact eg to accommodate prosthetic swing.

Could indicate the prosthesis is too long.