Prosthetics and the Amputee Athlete

Overview

Many athletes with limb loss or limb deficiency compete across para sport, from running and jumping to cycling and field events, and a well-fitting prosthesis is central to both performance and health. For the sport and exercise medicine (SEM) clinician the day-to-day work is rarely the engineering of the limb, which is the prosthetist's domain, but the problems that arise where the body meets the prosthesis: the skin of the residual limb, the fit of the socket, pain, and the overuse injuries that follow altered loading. Limb loss may be acquired, through trauma or disease, while limb deficiency may be congenital, and the level and cause shape what the athlete can do and what goes wrong. Recognising these problems, treating them, and knowing when to involve the prosthetist or a limb-fitting centre is what keeps an athlete training and competing.

Anatomy and Pathophysiology

Amputations are described by level. In the lower limb the common levels are transtibial, below the knee, and transfemoral, above the knee, and the preserved knee of a transtibial amputation generally gives better function and a lower energy cost. Upper-limb levels are transradial and transhumeral. The residual limb, or stump, bears load through the prosthesis, and its soft tissues remodel over the first year, so its volume changes with time, activity and hydration. The prosthesis has a few parts the clinician should recognise. The socket is the custom interface with the residual limb, and fit is everything. A liner, usually silicone or gel, cushions the skin, and suspension, by suction, a pin lock, vacuum or a sleeve, holds the limb in the socket. A pylon connects to the terminal device. For the foot, energy-storing carbon-fibre designs return energy at push-off, and running-specific prostheses use a curved carbon blade in place of a foot. For transfemoral athletes a prosthetic knee, increasingly microprocessor-controlled, manages stability and swing. Sensation in the residual limb varies with the cause and any nerve injury, so it cannot be assumed to warn of skin damage.

A labelled concept diagram of a lower-limb transtibial prosthesis on a residual limb, showing the residual limb within a soft liner, the custom socket, the suspension holding the limb in the socket, a pylon connecting down to an energy-storing carbon-fibre foot, and, shown alongside, a curved carbon running blade as the running-specific alternative to a foot. — The main parts of a lower-limb prosthesis: the residual limb sits in a liner within the custom socket, held by the suspension, with a pylon connecting to an energy-storing foot or, for running, a curved carbon blade.

Clinical Presentation

Most problems present at the residual limb. Skin breakdown, blisters, pressure marks over the bone ends, folliculitis and contact dermatitis from the liner are common, driven by shear, heat and sweating inside the socket. A change in the fit is often the root cause: as residual limb volume falls the limb sinks and pistons in the socket, concentrating pressure and rubbing the skin. Pain takes several forms. Residual limb pain is usually mechanical or skin-related, while phantom limb pain, felt in the missing part, and phantom sensation are common and can be distressing. A neuroma, a tender nodule at a cut nerve end, gives sharp or electric pain reproduced by pressure or a tap. Over time, altered and asymmetric loading brings overuse problems, with the intact limb and the low back carrying more, and a raised risk of osteoarthritis on the intact side.

Red Flags

•Spreading redness, warmth, swelling or discharge at the residual limb suggests infection and needs prompt treatment.
•A sudden change in socket fit with new pain or skin breakdown should stop training until the prosthetist reviews it.
•New or rapidly worsening pain, a mass, or systemic symptoms warrant investigation rather than being blamed on the prosthesis.

Investigations

Assessment is mostly clinical: inspect the whole residual limb out of the socket, note the pattern and site of skin damage, and watch the athlete stand and move to judge fit and alignment, ideally alongside the prosthetist. Imaging is used selectively. Ultrasound is the first choice for a suspected neuroma, a bursa or a soft-tissue collection, and can guide injection. Plain radiographs show bony spurs or heterotopic ossification, the formation of bone in soft tissue that can follow traumatic amputation, and magnetic resonance imaging (MRI) is reserved for deeper or unclear problems. Swabs and blood tests are added when infection is suspected.

High-Yield

•Most residual limb problems trace back to socket fit and residual limb volume change.
•A neuroma gives sharp or electric pain reproduced by pressure and is best imaged with ultrasound.
•Phantom limb pain is neuropathic and is managed differently from mechanical residual limb pain.
•Lower-limb amputees are at raised risk of osteoarthritis and overuse on the intact side.

Management

Skin problems respond to good socket hygiene, liner care, managing sweat, and treating dermatitis or folliculitis, with a short break from the socket and offloading while the skin heals. Where the cause is fit, the answer is a prosthetist review for socket adjustment or a new socket, with residual limb volume managed day to day using socks of different ply or the liner system. Phantom limb pain is neuropathic. General neuropathic-pain guidance offers a first-line medicine such as amitriptyline, duloxetine, gabapentin or pregabalin, though phantom-limb-specific evidence is limited. Non-drug options with variable evidence include desensitisation, graded motor imagery, mirror therapy and transcutaneous electrical nerve stimulation (TENS). A symptomatic neuroma may settle with an ultrasound-guided injection of local anaesthetic and corticosteroid; if diagnostic blocks or steroid injections fail, specialist non-operative ablation such as cryoneurolysis, pulsed radiofrequency or chemical neurolysis may be tried before referral for surgical revision or targeted muscle reinnervation (TMR). Overuse and asymmetry are managed as elsewhere in sport, with load management, targeted strengthening and attention to the intact limb and spine, and intact-side osteoarthritis is managed on standard lines. Much of this is shared with a multidisciplinary team (MDT) of prosthetist, physiotherapist and rehabilitation medicine, and persistent or complex problems are referred to a limb-fitting or specialist rehabilitation centre.

A labelled concept diagram of a lower-limb residual limb showing the common problems the clinician looks for: pressure marks and skin breakdown over the bone ends, a blister and rubbing from pistoning in the socket, folliculitis and contact dermatitis of the skin, and a tender neuroma at a cut nerve end, with a small inset indicating phantom pain felt in the missing part. — Common residual limb problems: pressure and skin breakdown over the bone ends, blisters from pistoning, folliculitis and dermatitis, and a tender neuroma at a cut nerve end, alongside phantom pain felt in the missing part.

Rehabilitation

Return to sport is built on a comfortable, well-fitting socket and healthy skin, so skin tolerance is conditioned gradually and any breakdown is allowed to heal fully before loading resumes. Gait re-education and progressive strengthening address the asymmetry that drives overuse, and the intact limb is trained as deliberately as the residual side. Athletes moving into running may benefit from a running-specific prosthesis, selected individually, and the change in alignment, blade stiffness and technique is introduced progressively with the prosthetist and physiotherapist. Throughout, load is managed to respect both the residual limb and the intact side, and the athlete is taught to recognise early skin or fit problems and act on them before they cost training time. Classification, which groups athletes by the impact of their limb deficiency, is covered in the companion para-sport topic.

Key Evidence and Guidelines

UK amputee and prosthetic rehabilitation standards set out the multidisciplinary model of care, from the limb-fitting centre to community rehabilitation.
General NICE guidance on neuropathic pain offers amitriptyline, duloxetine, gabapentin or pregabalin as first-line options; phantom-limb-specific evidence is limited, and mirror therapy and nerve stimulation have variable evidence.
Socket fit and residual limb volume management are central to preventing skin breakdown and maintaining function.
Running-specific prostheses may help some athletes, but the effect on performance depends on amputation level, components, alignment and the athlete, so prescription is individualised.
Lower-limb amputation is associated with a raised risk of osteoarthritis and overuse on the intact side, supporting attention to loading and the whole kinetic chain.

Exam Tips

•Transtibial (below-knee) amputation preserves the knee and generally has a lower energy cost than transfemoral (above-knee).
•Most residual limb skin problems come back to socket fit and residual limb volume change.
•Phantom limb pain is neuropathic; first-line medicines are amitriptyline, duloxetine, gabapentin or pregabalin.
•A neuroma gives sharp or electric pain reproduced by pressure and is best imaged with ultrasound.
•Residual limb sensation varies with cause and nerve injury and should not be assumed to protect the skin.
•Lower-limb amputees are at raised risk of osteoarthritis and overuse on the intact side.

Useful Links

NICE guidance on neuropathic pain in adults: pharmacological management (relevant to phantom limb pain)

nice.org.uk

British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR) clinical guidelines for the physiotherapy management of adults with lower limb amputation

bacpar.org

British Society of Physical and Rehabilitation Medicine (BSPRM) guideline documents, including amputee and prosthetic rehabilitation standards

bsprm.org.uk

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