Prosthetics and Athletics
By: Brandon Burke
Have you ever seen those flashy sprinting blades worn by those in the Paralympics, like Blake Leeper, Richard Whitehead, and April Holmes? It seems like they are flying down the track, as fast as any other human could, able-bodied, or not. Most of those runners were once in a position like a lot of us, witnessing for the first time amputees sprinting down those tracks in front of 100,000 cheering fans and being inspired to be able to race against those awesome guys and girls, and to win.
When the conversation comes to prosthetics and athletics, everyone always talks about the “blades”. We are guilty of promoting this as well, with our name, Amputee Blade Runners. When a lower-limb amputee sees another with a “running blade”, most of the time this evokes envy and a belief that they could be the one running if they only had a “blade” themselves. This, however, is a backwards way of looking at prosthetics and athletics and why Amputee Blade Runners does not just give “blades” to amputees. An amputee needs to be strong mentally and physically, and have a good fitting socket before they could truly benefit from a “blade”. We will go through in order what is required to be active in athletics, not just running, but also other sports like volleyball, baseball, tennis, basketball, cycling, and even football. And, remember that having a diverse support team of family, friends, your prosthetist, a physical therapist, mentors, and coaches makes all the difference in your goal to becoming an active amputee.
First off, the individual must be ready mentally to fully commit to the process and have the dedication to be active on a continual basis. When somebody is willing to make the commitment, the first step to being athletic as a lower-limb amputee is the strengthening of one’s residual limb(s) and their core. This is because building a strong musculoskeletal core and a strong residual limb, both in its strength and its durability is essential to protecting your body from the high speeds and strong forces of athletics. Talk to your prosthetist about ways to toughen up your residual limb(s) and a physical therapist, or trainer for strengthening of the muscles in your residual limb(s) and core. General topics to ask about improving residual limb toughness are residual limb sensitivity, weight-bearing capabilities, and massaging areas of scar tissue. General residual limb strengthening exercises for below-the-knee amputees includes doing lunges with good form everyday in sets of 25 without stopping, as well as practicing balancing on your prosthetic till you are capable of balancing on your prosthetic foot without touching anything for 60 seconds, or more. For above-the-knee amputees, the residual limb strengthening focus should include hip extension range of motion, adduction, and abduction, which can generally be worked out using resistance bands. Additionally, workouts like riding a bike, stationary, or otherwise for all lower-limb amputees are great ways to build up strength, range of motion, and endurance without having the impacts of running, but the best of all these and most accessible to do is walking. Not walking just for day-to-day activities, we all do that, but walking as a workout. Start out trying to walk a mile in less than 15 minutes and have a goal of building up to 3-4 miles in under one hour.
Once an amputee has a tough residual limb and has strength in both their core and their residual limb, they require a great fitting socket that will work for them at high-activity levels. Hopefully the amputee already has a prosthetic socket that fits their residual limb(s) without causing them pain that inhibits them from doing their day-to-day activities, as it is important for an amputee to always retain the ability to go about their daily life as normal as possible. Often times, however, as an amputee becomes more and more active: stationary biking, exercising, and even walking the one to four miles as mentioned above, they begin to experience pains and sores within their socket, often due to loss of limb volume, pressure points, and movement in the socket. These issues can arise in any type of socket system it is suggested that you work closely with your prosthetist as you experience these sensations, as you begin to become more active. It can require deep thinking and a lot of trial and error to alleviate these issues for an active amputee. The process for getting the right fit for a socket for an active amputee includes multiple test sockets and sometimes having to go back and cast all over again, as you and your prosthetist take what you have learned from the mistakes along the way and try to find the solution that works for you. Some potential changes to be prepared to experience on a prosthetic socket as an active amputee include higher trim-lines for better containment and support, as well as a tighter, more anatomical fit. From our experiences, some of the best types of socket/ suspension setups when done properly for active amputees include (read the one that applies to you):
Ankle Disarticulation/ Symes/ Boyd: Pe-lite with anatomical suspension and an optional suspension sleeve (for added stability)
Below-the-Knee: Gel-liner, supracondular, with a suspension sleeve and either suction, or elevated vacuum
Knee Disarticulation: Sub-ischial skin-fit, or gel-liner socket with anatomical and suction suspension
Above-the-Knee: Ischial-containment skin-fit, or gel-liner sockets with large anatomical contours for suspension and torsion resistance
Hip Disarticulation: A case-by-case basis determined upon what works best for the patient
This is not a complete list of socket methods for active amputees, as there are many individuals that have become active with other methods. Having one of these suspension types also does not mean that it will work for you. It is important in this process of finding the socket and suspension type that works best for you, for you to be working with a prosthetist that you trust and has experience successfully helping other amputees with your same type of amputation become active. The result of this process should allow for you to walk the 3-4 miles in under an hour without significant pain.
Once you have built up the body and residual limb strength, and have a great fitting socket for high-activity levels, you can begin to try and do the athletics that you are interested in. Lower-limb amputees on normal walking feet and knees can do activities such as basketball, volleyball, and soccer and sometimes even run. Talk to your prosthetist about any limitations your prosthetic may have, i.e. no running (often the case with electronic components likes microprocessor knees), etc, before being too rough with it. With traditional walking feet, an amputee, particularly below-the-knee amputees should be able to build up the strength, endurance, and tolerance to run a distance, such as one lap around a standard track. As you begin to try, or to get more serious about athletics and these sports, or running, you may become limited by the components attached to your socket. This is where the “blades” come into play, or more specifically, where running feet, sport feet, and knees used for running come into play.
There is not one type of foot, or knee that is best for all use cases unfortunately. Activities such as sprinting require really responsive feet and knees, where as long-distance running requires dampening of forces and stability, and sports such as basketball and other sports with a ball require stability and the ability to make quick turns and move quickly laterally. Below is a breakdown of some available prosthetic components and their best usages for different amputee types (read the one that applies to you):
For ankle disarticulates and long residual limb below-the-knee amputees, due to clearance heights, the individual must use a rear-mounted foot for high activity levels. Amputees with these type of amputations are often told that they cannot use a running foot, as their residual limb is too long, this is not the case. With a sprinting foot that mounts to the back of the socket, it is possible to use a running foot. Options geared more to running include the Ossur Cheetah foot and the Ottobock Springlite, as they are feet that mount to the rear of your socket. Options geared more to sports involving a lot of planting and lateral movement include the Ossur Cheetah Xplore Junior for kids and the rear-mounted version of the wave-sport for adults.
For below-the-knee amputees, options geared more to sprinting include the Ossur Cheetah foot and the Ottobock Springlite foot, as they are feet with quick response and a lot of energy return. Options geared more towards long-distance running include the distal mounted Ossur Flex-Run. Options geared more to sports involving a lot of planting and lateral movement include the Ossur Cheetah Xplore Junior for kids and the distal mounted wave-sport for adults.
For above-the-knee amputees, the same prosthetic foot options exist as above for below-the-knee amputees. Above-the-knee amputees that participate in athletics, whether it be track and field, or basketball, or another sport differ in whether they use a prosthetic knee, or not, as there are two ways to run as an above-the-knee amputee. The one way is to run without a knee, swinging the leg in a semicircle motion when bringing it forward to allow for the toe to clear and the other way is to use a knee that is suited for running. There are pros and cons to both sides. Prosthetics knees are expensive and having to buy a separate knee for usage in sports can be a barrier to playing them. For children, the strength and skill-level, and consistency can be thought to be too much for them, at least for starting out, as well as the prosthetic knees best for running are heavy and could be too long for the child. Running in this manner does develop bad habits in gait and is not the natural way of doing so, but can be very effective for individuals, particularly bi-lateral above-the-knee amputees, as it provides the most stability of the two methods. For this, the sport foot you choose is attached to a long pylon and aligned properly by your prosthetist. For running by use of a knee, I recommend to separate knee for separate usages. For sprinting, the Ottobock 3s80 has the quickest response time, but it is a knee that requires great skill to control and it is very difficult to do planting, or lateral movements with the knee without it buckling on you (although it does have a manual lock if you wanted to play sports with a straight leg). For long-distance running and sports, I recommend the Medi OH5, as it provides a locking mechanism that locks upon extension, providing more stability for uneven terrain, or cutting and planting when playing sports. These knees both should be used with what is called a flexion bumper to prevent excessive heel-rise and allow the leg to keep up with you even when sprinting, and can be made out of foam and be attached to the socket to prevent the knee from flexing past 90 degrees. Other lighter and shorter options exist, if you wish to run with a knee, but cannot use one of the others. These include the Ossur Total Knee Junior, the Ossur Total Knee 2000/2100, and Medi OMFl.
For hip disarticulates, it is a case-by-case basis, but it is often best to begin learning how to run and play sports without a knee and with a light sprinting foot such as the Ossur Cheetah, or Ottobock Springlite, however, down the line with a lot of practice it can be possible to use running knees, as well as the sports feet with good success.
It can be daunting to look at all of the componentry and potential expenses for getting prosthetics more suited for high activity levels and athletics, but there are avenues for getting what you need to be able to get out there and run around, or play sports, without breaking the bank. There are instances where your own prosthetist and the company he works for has the ability to help you out providing both the prosthetic care in regards to the socket, but also in getting you what you need as far a sports foot and/ or knee. It really depends on a lot of circumstances, but when seeking to get active, those are the first people to ask for help. If your child is a patient of Shriner’s, there may be avenues for your child to receive a sport prosthetic through their care.
Secondly, there exist non-profits, such as Amputee Blade Runners and Challenged Athletes Foundation that can help in that process. Amputee Blade Runners is a non-profit that provides a complete running prosthetic to its recipients, which we call our ambassadors. These recipients travel into Nashville, TN, or Savannah, GA and are fitted with new sockets and the proper feet and componentry for them and what sports they want to do. They spend about a week, or so in one of these locations and are properly assessed of their condition/ residual limb health, fit with a socket for athletics, and fit with a sports foot and a knee, where applicable. We then work with the new ambassador to teach them how to use their new sport prosthetic, practice with them, and take their feedback to make any changes needed, before they return home with their new leg(s). You can see more about what we do and who we’ve helped here www.amputeebladerunners.com, as well as find the application up on the website. The other major non-profit is Challenged Athletes Foundation and one of their services is that they provide equipment grants to lower-limb amputees that can be used to receive a sport foot. Their website and application process can be found here http://www.challengedathletes.org.
Running on a prosthetic is not always as natural as running with two normal limbs and can often be difficult to learn at first, but rest assured it becomes more and more comfortable over time. The first thing in learning to run comes from the very definition of it, which requires both feet to be off the ground at the same time in between each stride. The best way to practice this is running in place and jump roping. For jump roping, use quick jumps off of your toes only if possible. Do it pushing off of both feet, as well as each foot individually, if you can get enough bounce with your prosthetic. Often times you can only jump high enough to jump rope with just your prosthetic when you have a sport foot, but you can still give that leg a workout by making sure to push off both feet evenly. Once you master running in place and jump roping, you can begin to move forward slightly when you run in place, gradually increasing your speed forward, while always trying to move your feet as quickly as possible, i.e both feet off the ground in between each tiny movement forward. As you increase your stride length, this eventually becomes running and is possible to be accomplished even without a blade. This is a very short overview of the process of learning how to run and it can be a long and difficult process, but as you dedicate yourself to practicing this, you will continue to improve. Future articles may focus in more detail on the steps and processes for learning how to run.
The biggest thing to remember throughout the whole process of trying to gain an active lifestyle and participate in athletics with a prosthetic is that it is a process and it is not always a linear progression. There will be tough points in the road, but there will be some awesome moments as well. If you dedicate yourself to it, you’ll be able to find the support you need to accomplish whatever you want, whether its racing Blake Leeper, or playing tag with all your friends at recess.