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Sports and recreation for persons with limb deficiency

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S38
FOCUSED REVIEW
Sports and Recreation for Persons With Limb Deficiency
Joseph B. Webster, MD, Charles E. Levy, MD, Phillip R. Bryant, DO, Paul E. Prusakowski, CPO
ABSTRACT. Webster JB, Levy CE, Bryant PR, Prusa-
kowski PE. Sports and recreation for persons with limb defi-
ciency. Arch Phys Med Rehabil 2001;82 Suppl 1:S38-44.
Opportunities for persons with limb deficiency to participate
in sport and recreational activities have increased dramatically
over the past 20 years. Various factors have contributed to this
phenomenon, including an increased public interest in sports
and fitness as well as improvements in disability awareness. An
even more essential element has been a consumer-driven de-
mand for advances in prosthetic technology and design.
Whether the activity is a music performance, a friendly round
of golf, or a high-level track-and-field competition, the benefits
of participation in sports and recreation are numerous both at
the individual and at the societal level. This article provides an
overview of the development and scope of sport and recre-
ational opportunities available to persons with limb deficiency.
In addition, specific prosthetic considerations for several com-
mon sport and recreational activities are presented in a case-
discussion format.
Overall Article Objective: To review the development and
scope of sport and recreational opportunities available to per-
sons with limb deficiency.
Key Words: Prostheses and implants; Artificial limbs; Lei-
sure activities; Sports; Rehabilitation
© 2001 by the American Academy of Physical Medicine and
Rehabilitation
ARTICIPATION IN SPORTS and recreation has many
P physical, psychologic, and emotional benefits for the per-
son with limb deficiency. These factors make integration into
1-4
leisure, recreation, and sports activities a vital part of the
rehabilitation process. Opportunities for persons with limb
deficiency to participate in leisure and competitive sports have
improved immensely over the past 20 years. This improvement
has been realized in part through an increased public interest in
physical fitness, leisure, and sports, and also through greater
awareness that persons with limb deficiency and other disabil-
ities can compete at very high levels of athletic competition.4-6
Accompanying this has been the growth and development of
innumerable sports organizations for the disabled which pro-
vide information, resources, and support for almost all sports
and leisure activities. Advances in prosthetic design, compo-
From the Department of Physical Medicine and Rehabilitation, Brody School of
Medicine, East Carolina University, Greenville, NC (Webster, Bryant); Physical
Medicine and Rehabilitation Service and Brain Rehabilitation Research Center, North
Florida/South Georgia Veterans Health System, Department of Orthopaedics and Re-
habilitation, College of Medicine, University of Florida, Health System and Univer-
sity of Florida College of Medicine, Gainesville, FL (Levy); and Orthotics and
Prosthetics Clinical Technologies, Inc., Gainesville, FL (Prusakowski).
Accepted November 1, 2000.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the author(s) or upon any
organization with which the author(s) is/are associated.
Address correspondence to Joseph B. Webster, MD, Dept of Physical Medicine and
Rehabilitation East Carolina University, Brody School of Medicine, 600 Moye Blvd,
Greenville, NC 27858.
0003-9993/01/8203-6659$35.00/0
doi:10.1053/apmr.2001.22243
Arch Phys Med Rehabil Vol 82, Suppl 1, March 2001
nentry, and fabrication have also been an essential part of this
development. Many of these improvements have been driven
by persons with limb loss who have challenged the system and
demanded prosthetic componentry capable of facilitating,
rather than limiting, their athletic, artistic, and leisure ambi-
tions. The objective of this article is to review the development
and importance of sports and recreation for persons with limb
deficiency as well as the specific prosthetic considerations for
this group.
HISTORY AND IMPORTANCE
The social need for leisure has been identified as an impor-
tant component of the quality of life of persons, especially if a
person’s full involvement in society is limited by a physical
impairment.1-3,7 Several studies have noted that participation in
sports and recreation is a major concern for persons with limb
deficiency and that these activities are important for their
reintegration into the community.8-11 In addition to the physi-
ologic benefits—improved strength, cardiopulmonary endur-
ance, muscle coordination, and balance—involvement in ther-
apeutic recreation and physical fitness can also enhance coping
behavior, cognitive abilities, mood, psychologic well-being,
self-confidence, and self-esteem.1,12-15 Particularly for a child
with limb deficiency, involvement in sport and recreational
activities provides an important mechanism for development of
motor coordination, integration with peer groups, and adjust-
ment to physical limitations.1,16-18
The origin of organized sports for persons with disabilities
has been largely attributed to Sir Ludwig Guttmann, who
implemented athletics and sports as a part of comprehensive
rehabilitation at the Stoke Mandeville Hospital in England in
1944.4,6 Since then, there has been steady growth in the rec-
ognition and organization of both recreational and competitive
sports for persons with disabilities. Organized athletic compe-
titions and recreational sport opportunities for persons with
limb deficiency are currently widely available across the
globe.5,6,19,20 Many organizations are available to assist the
person with limb deficiency who desires to become more active
in recreational and sport activities.4,19-22 While the majority of
these organizations are impairment or disability specific, others
are more sports specific. One such organization, Disabled
Sports USA, provides opportunities for recreational rehabilita-
tion and competitive sports programs, along with training
camps to prepare amputee athletes for the summer and winter
paralympic games.
The International Paralympic Games were founded in
1960.4,6 As the number of participants has steadily grown, the
level and scope of competition have sharpened and public
interest has increased. Although competitions initially focused
on wheelchair athletes, since 1976 the Paralympics have in-
cluded ambulatory persons with limb deficiencies.6 The 1996
International Paralympic Games in Atlanta, GA, hosted a
record 3500 athletes from 120 nations, who participated in 17
full medal and 2 demonstration sports. Athletes with limb
deficiencies were involved with the majority of these sports.6
The growth of events such as the Paralympics has been valu-
able for increasing public awareness of the capabilities of both
amputee athletes and the disabled population in general.
 SPORTS AND RECREATION FOR PERSONS WITH LIMB DEFICIENCY, Webster S39

EVALUATION PROCESS
The evaluation of a person with limb deficiency who desires
to participate in recreational and sports activities is in many
respects similar to that for any amputee patient.23-25 In addition
to the more standard aspects of evaluation, the exact demands
of the desired activity and the environment in which the sport
is to be played need to be considered. For example, the pros-
thetic requirements for fishing from a pier or dock may vary
greatly from the requirements for surf fishing or fishing from a
boat. If the demands of the activity cannot be adequately
assessed or simulated in the clinic, an on-site evaluation or a
videotape review may provide additional insight. The fre-
quency and intensity of participation in the activity also need to
be assessed.
During the physical examination, the physician and the pros-
thetist must attempt to objectively and realistically assess
whether the individual and his/her residual limb(s) can tolerate
the added stress and demands of the desired recreational activ-
ity. This includes a complete musculoskeletal evaluation and a
cardiopulmonary assessment. A gradually progressive exercise
and training program may have to be prescribed to prevent
complications such as musculoskeletal injuries, residual limb
skin breakdown, cardiopulmonary complications, and/or frus-
tration with associated loss of self-esteem.26,27 Cardiac stress
testing may be indicated, depending on the desired activity and
the status of the patient.26,27 Another component of the evalu-
ation and the prosthetic prescription is clear communication
among all team members, including the therapist and/or the
coach or trainer, if possible, so that the goals, expectations, and
options for prosthetic fitting are clear. For persons wanting to
participate in competitive sports, a detailed evaluation of the
limb deficiency and other musculoskeletal impairments is also
necessary, as this typically serves as the basis for competition
classification.6
IMPAIRMENT CLASSIFICATION FOR SPORTS
The impact of limb deficiency on athletic performance varies
greatly, depending on the anatomic location, extent, and cause
of the limb deficiency. Classification systems for competitive
sports ensure that persons compete on as equal terms as pos-
sible.21 Classification must also take into account whether or
not the use of prostheses, wheelchairs, or other adaptive equip-
ment is allowed during competition. For most sports involving
persons with limb deficiency, the classification depends pri-
marily on the location and extent of the amputation(s).6,21 For
competitions involving track and field events, all classes in-
clude a letter T (for track) or F (for field), followed by a number
that designates the severity of the amputation (table 1). Com-
petitive swimming events for persons with amputations do not
allow use of prosthetic devices, and the swimming classifica-
tion divides athletes with different disabling conditions into 10
functional classes based on impairment level. Paralympic
sports such as tennis and basketball, which are played in
wheelchairs, are also open to persons with limb deficiency and
have separate classification schemes. Despite these structured
systems, each limb deficiency is different, and this difference
may impart a slight biomechanical or prosthetic advantage for
1 person compared with the next.
PROSTHETIC CONSIDERATIONS
General
There are several special prosthetic considerations for the
individual interested in using a prosthesis during recreational or
sports activities.1,20,22 One of the first is whether the prosthesis
will be used for both a specific recreational purpose and daily
activities or exclusively for a particular activity (eg, sprint
running). The demands and frequency of the sports activity
play a role in this decision-making process, as do financial
issues. In general, durability and strength of the prosthesis and
its ability to withstand increased biomechanical forces are
important, especially during running or jumping activities.
Failure of the prosthesis during either recreational use or com-
petition can result not only in psychologic repercussions but in
physical injury as well.
The significant biomechanical forces and repetitive nature of
recreational and sport activities also have a bearing on pros-
thetic suspension and the prosthetic interface with the residual
limb. Auxiliary suspension systems provide added stability and
security to the prosthetic suspension, especially with kicking
activities in the lower limb or throwing and catching activities
in the upper limb. The use of interface materials such as
silicone liners, gel liners, or hypobaric socks provides added
padding and helps to absorb and disperse potentially damaging
pressure and shear forces. Maintaining appropriate prosthetic
fit is particularly important in a child with limb deficiency, who
will need frequent socket revisions with growth changes.
For prosthetic devices that are to be used for recreation and
sports activities, cosmesis is typically less of a priority than
function, unless the prosthesis is to be used for everyday
activities as well. Weight of the prosthesis is also important.
Although some research28 has noted that metabolic costs dur-
ing walking are unchanged with the addition of up to 1.34kg to
a transfemoral prosthesis, little is known about the metabolic
effects of prosthetic weight on higher level activities such as
running. Despite the lack of supporting scientific evidence,
most prosthetists strive to keep the prosthesis as light as pos-
sible while simultaneously providing a structure that is both

Table 1: Track and Field Classification System for Persons With a Limb Deficiency

T42 Single above-the-knee; combined lower and upper limb amputations; minimum disability
T43 Double below-the-knee; combined lower and upper limb amputations; normal function in throwing arm
T44 Single below-the-knee; combined lower and upper limb amputations; moderate reduced function in 1 or both limbs
T45 Double above-the-elbow; double below-the-elbow
T46 Single above-the-elbow; single below-the-elbow; upper limb function in throwing arm
F40 Double above-the-knee; combined lower and upper limb amputations; severe problems when walking.
F41 Standing athletes with no more than 70 points in the lower limbs (based on function and strength of muscle groups)
F42 Single above-the-knee; combined lower and upper limb amputation; normal function in throwing arm
F43 Double below-the-knee; combined lower and upper limb amputations; normal function in throwing arm
F44 Single below-the-knee; combined lower and upper limb amputations; normal function in throwing arm
F45 Double above-the-elbow; double below-the-elbow
F46 Single above-the-elbow; single below-the-elbow; upper limb function in throwing arm

Arch Phys Med Rehabil Vol 82, Suppl 1, March 2001

S40 SPORTS AND RECREATION FOR PERSONS WITH LIMB DEFICIENCY, Webster

durable and able to function in the sports activity required. Advances in prosthetic pylon, ankle, and foot componentry,
Typically, persons using a prosthesis for sports require exten- especially the advent and development of high-profile dynamic
sive education regarding the maintenance, care, and adjustment elastic-response feet, have been a great benefit to both trans-
of the device. They need to be able to perform required pros- femoral and transtibial amputee runners. Although low-profile
thetic adjustments either before or during their athletic or dynamic elastic-response-type feet and multiaxial-type feet
recreational activity. They must also be able to inspect the designs can be used for occasional running,37-39 the advantages
prosthesis regularly and identify signs of impending compo- and benefits of high-profile dynamic elastic-response feet that
nent failure. incorporate the shank, ankle, and foot mechanism into a single
unit have been noted in several studies.40-46 This research,
combined with clinical experience, has made high-profile dy-
Sport-Specific Considerations namic elastic-response components such as the Flex-Foota and
Running Activities: case. Formulate a prosthetic prescrip- the Springliteb and their variations the preferred choice for
tion for a 25-year-old man with a traumatic left transfemoral many amputee runners, especially those involved in competi-
amputation due to a motorcycle accident 1 year ago who wants tive sports (fig 1). The Sprint-Flexa and Springlite Sprinterb are
to begin running for exercise and to resume playing basketball. components designed exclusively for competitive sprint run-
He is currently an active prosthetic user and ambulates without ning (fig 2). Through plantarflexion alignment and increased
assistive devices. keel stiffness, they allow a toe-running pattern. Although these
Discussion. Running is a part of many sports and recre- design features have advantages for sprint running, they are not
ational activities (eg, track, basketball, baseball, tennis). For suitable for everyday activities.
persons with limb deficiency, running can also be a method of Pylon-ankle-foot systems such as the Re-Flex-VSP®,a
exercise to help maintain or improve general fitness, weight Pathfinder™,c and Free-Flow,c which incorporate a dynamic
control, cardiopulmonary endurance, and psychologic well- elastic-response-type foot and a shock-absorbing pylon, are
being.1-3 For children with limb loss, running can be an integral well suited for the highly active person for training and also for
part of play and peer interaction. Even for the less active long-distance running47 (fig 3). The shock-absorbing pylon
amputee, the ability to run could be useful in an emergency.29 reduces forces on the residual limb with repetitive activities
As with many other activities, lower extremity amputee run-
ning has been revolutionized over the past 20 years by ad-
vances in prosthetic componentry. The use of materials such as
carbon fiber, titanium, and graphite has provided added
strength and energy-storage capabilities to prostheses while
decreasing the weight of prosthetic components. Significant
changes in prosthetic design have also occurred. Despite this,
the loss of normal biologic function and proprioceptive feed-
back of the distal extremity in persons with limb deficiency
leads to altered running biomechanics, including changes in
muscle work output and joint kinetics.30-33
With regard to prosthetic considerations for persons with
transfemoral amputations who desire to run, most will utilize a
narrow mediolateral socket design. They may also benefit from
the use of a flexible inner liner to decrease the weight of the
prosthesis and to accommodate the changing shape of the thigh
during muscular contraction and relaxation. Acrylic socket
laminations provide both the desired strength and low weight.
Because of its secure nature, suction is a commonly used
method of suspension in the transfemoral amputee patient,
although roll-on silicone or gel liners with pin-locking mech-
anisms are also viable options.34 The socket fit, suspension, and
interface are very important to the amputee runner because of
the much greater force and frequency of loading on the residual
limb. Swing- and stance-control hydraulic knee units, which
allow variable cadence, are preferred for most amputee run-
ners, especially now that units have become smaller and
lighter. Although recent studies and anecdotal reports have
found significant benefits with microprocessor-controlled knee
units for walking activities,35,36 they are not currently being
used for competitive running because of technical limitations.
For the transtibial runner, the posterior and lateral socket
trim lines are lowered to maximize range of motion at the knee.
Although these changes allow greater range of motion at the
knee, the compromise is a less secure suspension system.
Silicone sleeves, neoprene sleeves, or a waistbelt and fork-strap
are typical options for auxiliary transtibial suspension.34 Sili-
cone or gel liners are helpful in reducing shear forces and
preventing skin breakdown. Endoskeletal shank systems, Fig 1. Springlite Gold Medal.b A high-profile dynamic elastic-re-
which will be described below, provide the required strength sponse-type of pylon-ankle-foot system with removable heel plugs
and desired weight for a running prosthesis. for adjusting heel resistance to match activity level.

Arch Phys Med Rehabil Vol 82, Suppl 1, March 2001

 SPORTS AND RECREATION FOR PERSONS WITH LIMB DEFICIENCY, Webster S41

months after a left transtibial amputation with new skin break-

down on the residual limb after beginning a recreational bicy-
cling program.
Discussion. Cycling is regarded by many as an excellent
form of exercise and recreation for persons with limb defi-
ciency. Cycling has also become a major competitive sport for
amputee athletes.6 The choice whether to use a prosthesis
during cycling activities depends primarily on the level of the
amputation. Persons with unilateral deficiencies above the
midtransfemoral level typically do not have enough strength in
their residual limb to push a pedal and thus do not benefit from
using a prosthesis during cycling. For these persons, a toe clip
on the intact side allows power to be applied to the pedal during
both the downward and the upward strokes.48-51 Persons with
unilateral amputations below the midtransfemoral level usually
prefer to use their prosthesis for cycling. The prosthesis pro-
vides better balance and symmetry during riding. For the
person interested in recreational cycling, as in the case de-
scribed, relatively few prosthetic accommodations are required.
Trim lines on the transtibial prosthetic socket may need to be
adjusted to prevent skin breakdown because of the need for
additional knee flexion with cycling, as compared with walk-
ing.50,51 For the transfemoral amputee, a knee unit that allows
adequate range of motion with variable resistance is helpful.
Ankle and foot components that allow some degree of ankle
motion are also desirable. Seating difficulties and proximal

Fig 2. Sprint-Flex.a A high-profile dynamic elastic-response foot

used for competitive sprint running.

such as distance running. These systems are also excellent

choices for sports requiring frequent jumping such as basket-
ball and high jumping. In the case described above, the indi-
vidual patients would likely benefit from this type of compo-
nentry in combination with a narrow mediolateral socket, a
suction or silicone suspension system, and a hydraulic knee
unit.
Historically, component failure, skin breakdown, and resid-
ual limb trauma, as well as the need for modified training
regimens, have been major concerns for amputee runners.
Technologic and design advances have made componentry
failure much less of a problem. Adequate suspension systems
remain a problem for some transtibial amputee runners because
systems that provide the most secure suspension have the
disadvantage of restricting range of motion at the knee. With
the use of gel liners and silicone interfaces, residual limb skin
problems have also been minimized. Although amputee ath-
letes must appreciate that new socket and interface systems
often require a break-in period during which training regimens
need to be modified, many competitive amputee runners are
now capable of training along with nonamputee runners.
Cycling: case. Provide prosthetic recommendations to a Fig 3. Re-Flex-VSP.a A dynamic elastic-response-type foot and an-
62-year-old man with peripheral arterial disease who returns 6 kle componentry with a shock-absorbing pylon.

Arch Phys Med Rehabil Vol 82, Suppl 1, March 2001

S42 SPORTS AND RECREATION FOR PERSONS WITH LIMB DEFICIENCY, Webster
skin irritation are common problems for transfemoral amputee
cyclists. A narrow-design seat allows more room for the prox-
imal brim of the prosthesis, and proximal socket adjustments
can also be helpful.48 One of the most frequent problems
encountered with using a prosthesis for cycling is trouble
keeping the prosthetic foot on the pedal. Using pedals with
serrated edges or toe clips can help prevent foot slippage, but
it may also increase the risk of injury during a fall or when
stopping.48-50 For optimal power while pedaling on the pros-
thetic side, the mid-foot of the prosthesis should be placed
directly over the pedal.48-51 For persons who do a large amount
of riding, the prosthetic alignment may need to be adjusted to
a more straight-ahead position as opposed to the slightly toe-
out position used for walking. Persons with bilateral transfemo-
ral or higher level amputations can also enjoy the benefits of
cycling through the use of hand-powered, hand-controlled tri-
cycles or bicycles or specially designed tandem bicycles.9,50
Swimming and water-based activities: case. Discuss the
advantages and disadvantages of prosthetic use for swimming
with a 17-year-old female patient who presents after having
undergone a right transfemoral amputation because of osteo-
sarcoma.
Discussion. Although prosthetic use is not allowed in of-
ficially sanctioned competitive swimming events, specialized
prosthetic componentry and fitting are very important for other
water-based activities. Whether a person is swimming in a pool
or in an open-water environment, using a prosthesis can assist
with entry into and exit from the water. Use of the prosthesis in
the water, either with or without a fin attachment, also facili-
tates exercise and strengthening of the residual limb. The
buoyancy of the prosthesis can be problematic, although many
prostheses can accommodate for this by allowing water to
partially fill the internal space during swimming.9,48 For per-
sons who do not need a swim prosthesis but who may occa-
sionally be around water with their standard prosthesis, covers
are available to provide protection from water damage. A
beach or utility prosthesis can also be used for this purpose as
well as for showering.48
Specialized components for swim prostheses include ankle
systems such as the Activankle,d which can be locked at a
neutral position for walking and at a plantarflexion position for
swimming. These systems are waterproof and salt resistant.9,52
Several waterproof knee units are also available for the trans-
femoral amputee, and they can be used with either endoskeletal
or exoskeletal systems. A fin added to the prosthesis improves
propulsion through the water and can allow the person with
limb loss to swim greater distances with less fatigue.53,54
For scuba diving and snorkeling, use of prostheses with
swim fin attachments are typically beneficial for the person
with a unilateral or a bilateral transtibial amputation. Those
with transfemoral or higher level amputations often prefer to
scuba dive or snorkel without a prosthesis.52 Persons with limb
deficiencies involving both the upper and the lower limbs can
also benefit from water-based activities, either with or without
custom-designed prosthetic devices. Aquatic activities can also
be a beneficial means of exercise and cardiopulmonary condi-
tioning for a person with multiple limb amputations.
Golf: case. Anticipate the prosthetic needs for a 42-year-
old man with a recent transradial amputation who is interested
in playing golf.
Discussion. For the person with an upper extremity defi-
ciency, various prosthetic components are available to allow
participation in sports and recreational activities.21,55-57 Al-
though some may choose not to use a prosthesis during sport or
recreational pursuits, they may still benefit from modifications
of the equipment to be used in their particular activity. In other
Arch Phys Med Rehabil Vol 82, Suppl 1, March 2001
cases, depending on the level of the extremity involvement and
the particular interests of the patient, a highly specialized
prosthetic prescription may be required.55,56 The important
characteristics of the upper limb recreational prosthesis are
secure suspension, durability, and optimal weight. Just as with
the lower limb amputee, a secure suspension system is impor-
tant for the upper limb amputee, especially for throwing,
swinging, or catching. Auxiliary suspension systems such as a
chest strap or a shoulder harness may be useful for the trans-
humeral amputee to maintain adequate contact with the resid-
ual limb and to provide added support for the prosthesis. A
supracondylar suspension system or a silicone sleeve is a
reasonable option for a person with a transradial amputation, as
in the case described above.57,58 The interface between the
residual limb and the prosthetic socket is also critical to prevent
skin breakdown with repetitive motion activities, and a roll-on
liner should be considered in these instances. The prosthetic
componentry in general should be as lightweight as possible
and relatively simple in design so that mechanical failures are
minimized.
The decision to use a body-powered system or a myoelectric
system depends primarily on the sport and the person’s prior
experience with 1 system or another. Body-powered systems
are commonly preferred for outdoor activities because they are
versatile, durable, relatively lightweight, and able to function in
various environments. The use of a quick-release wrist unit
allows relatively simple exchange of terminal devices for dif-
ferent activities. Terminal devices for most common sports and
recreational activities are now commercially available,e includ-
ing devices for holding hockey sticks, rackets, golf clubs,
bowling balls, fishing poles, baseball bats, and ski poles.56,57,59
For musicians, devices are available for holding a drumstick,
violin bow, or flat pick.55-57 A terminal device useful for
golfing consists of a flexible cable attached between the golf
club and the prosthesis (fig 4). With it, the prosthesis provides
added stability and power to the golf swing. It is approved by
the US Golf Association and can be changed from 1 club to
another. Flexible and durable hand devices are effective in
assisting a person with a unilateral upper limb deficiency to
catch a football or basketball or to throw a soccer ball (fig 5).
Padded or webbed devices are also available for swimming,
and these can be used either with or without other specialized
prosthetic components (fig 6). If a specific device is not com-
mercially available for a particular activity, the prosthetist and
physician may have to be creative and develop a custom system
that will meet the needs of the person.21
Fig 4. Amputee Golf Grip.e Terminal device used for golfing.
 SPORTS AND RECREATION FOR PERSONS WITH LIMB DEFICIENCY, Webster
Fig 5. Re-Bound Probasketball hand device.e Terminal device used
for basketball and other ball sports.
Persons with lower limb amputations who are interested in
playing golf also require several special prosthetic consider-
ations.51 The socket, interface, and suspension considerations
are similar to those previously described for any person who is
involved with recreational or sport activities. Secure suspen-
sion and a shear-reducing interface are especially important. A
torque absorber placed distal to the socket can help to accom-
modate the added rotation needed during a golf swing. A
multiaxial or low-profile dynamic elastic-response-type foot is
advantageous for amputee golfers because it can accommodate
to uneven terrain. A shock-absorbing pylon may also be a
consideration in this population to help decrease pressure and
shear on the residual limb.
CONCLUSION AND FUTURE DIRECTIONS
Advances in prosthetic technology and design have laid the
foundation for the growth and development of recreational and
sports activities for persons with limb deficiency. These rapid
Fig 6. Freestyle Swimming Td device.e Terminal device used for
swimming.
S43
advances are expected to continue, offering all amputees
greater opportunity to pursue their leisure interests or to com-
pete with other athletes at the highest levels of competition.
The popularity of sports competitions for the disabled is also
expected to grow. Although currently perceived as highly ex-
perimental and controversial, the areas of direct skeletal attach-
ment of prosthetic devices and human bionics are likely to
challenge the current thinking in prosthetic componentry and
lead to advances for all persons with limb deficiency, including
those who participate in sports and recreational pursuits.
Acknowledgments: The authors thank Brian Frasure (Hanger
Prosthetics, Raleigh, NC) for his expertise and contributions to this
article. The authors also recognize and thank the following corpora-
tions for their assistance and willingness to supply images utilized in
the article: Flex-Foot, Springlite, and TRS.
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