825

PROSTHE TICS, ORTHOTICS, DEWCES

Influence of Prosthetic Foot Design on Sound Limb Loading in

Adults With Unilateral Below-Knee Amputations
Christopher W. Powers MS, PT, Leslie Torburn, MS, PT, Jacquelin Perry, MD, Edmond Ayyappa, ‘V&V,CPO

ABSTRACT. Powers CM, Torburn L, Perry J, Ayyappa E. Influence of prosthetic foot design on sound limb
loading in adults with unilateral below-knee amputation. Arch Phys Med Rehabil 1994;75:825-9.
l Altered gait patterns resulting from amputation has been implicated as a possible mechanism for early degenera-
tive changes in the sound limb of unilateral amputees. The purpose of this study was to examine the ground
reaction force characteristics and joint motion in this population. Ground reaction forces, joint motion, and stride
characteristics of 10 traumatic below-knee amputees were analyzed while wearing five different prosthetic feet
(SACH, Flex-foot, Carbon Copy II, Seattle, and Quantum). Subjects used each foot for 1 month prior to testing.
Results indicated that the Flex-foot significantly reduced the initial peak of the vertical ground reaction force on
the sound limb compared to all other feet tested @ < .OOOl). The SACH foot consistently produced the greatest
ground reaction forces on the sound limb: however, this was not statistically significant. The effective factor of
the Flex-foot appears to be minimization of the center of gravity elevation, which was accomplished through a
significant increase in terminal stance dorsiflexion compared to the other feet tested @ < BOOI).
i-51993 hv the American Conaress
., of Rehabilitation Medicine and the American Academy of Physical Medicine and
I

Rehabilit&ion

Alteration of the normal walking pattern over many years of the Dynamic Elastic Response (DER) prosthetic foot has
may result in degrnerative changes to weight-bearing joints.’ attempted to provide better mobility and control in order to
This is of particular concern to the individual with unilateral more closely approximate the normal function of the foot/
lower extremity amputation because abnormal gait patterns ankle complex. Wagner and Sienko” found that the sound
and loading characteristics related to limb loss have been limb struck the floor with greater force during trials using
identitied by several investigators.‘.’ Two large studies of the SACH foot component compared to the Flex foot trials.
persons with below-knee amputations have found significant These authors. however did not report any quantitated data
increases in the incidence of osteoarthritis in the knee of the or statistical analysis. Apparently, variability in prosthetic
sound limb compared to the amputated limb.‘,’ In addition. foot design such as range of motion capabilities. stiffness.
this population has demonstrated a higher incidence of pa- and heel cushion components may play a key role in repro-
tellofemoral osteoarthritis in the sound limb compared to ducing normal gait dynamics and ground reaction force pat-
nc)rmal4 (41 G to Z.% ).’ Both studies suggest that altered terns.
hiomechanic\ resulting from amputation as a lihely cause. The purpose of this investigation was to examine the joint
Eberhart” ha., shown that the sound limb carries more of a motion and ground reaction force characteristics in a group
load than the limb with the prosthesis in adults with below- of adults with below-knee amputations using five different
knee amputations. thus providing a possible mechanism for prosthetic foot components. We hypothesized that a foot that
these degenerative changes. allows a smoother forward progression of body weight
Despite these clinical tindings. several studies report that would allow for more normal stride characteristics and a
the forces acting across the joints of the sound limb in adults decrease in the vertical ground reaction force during loading
with below-knee amputations are no different from that of of the sound limb, thus potentially reducing the deleterious
normals. suggesting that there is no predisposition for degen- effects of increased joint forces during loading.
erative arthritis in Ithis population.‘.x This discrepancy be-
METHODS
tween results may be related to the prosthetic foot designs
u\ed in these laboratory studies. The SACH foot. which Subjects
has long been considered the industry standard. provides Ten men with below-knee amputations participated in this
minimal foot mobility. In contrast. the recent development study (table I). All had amputations secondary to trauma
.-__ and were independent community ambulators. None used
assistive devices. Each subject had displayed volume stabil-
ity of the residual stump for at least 30 months. Following
completion of the study. each subject was able to choose
one of the five feet tested for permanent use. Subjects con-
senting to participate in this study signed the informed con-
sent form (as approved by the Institute Review Board) and
the Rights of Human Subjects form.

Foot Selection/Fitting
Five different prosthetic feet were tested in random order
Flex-foot.” Carbon Copy II,h Seattle.’ Quantum.’ and SACH.’

Arch Phys Msd Rehabil Vol75, July 1994

826 SOUND LIMB LOADING IN BK AMPUTEES, Powers

Table 1: Subject Information the amputated and sound limbs. The final, successful force
Height Weight Years Post- Stump Length plate run was the source of free walking speed data.
Age
Subject No. (years) (cm) (kg) Amputation (cm)
1 46 I75 61.3 I9 17.6 Data Management
2 71 163 68.1 38 13.8
The progressive and vertical ground reaction forces were
3 4; 175 78.6 27 7.6
1 46 I71 98.1 19 17.6 analyzed for the five feet for each subject. The magnitude
5 22 I75 80.4 5 21.4 and timing of the first peak, valley, and second peak of the
6 70 I84 90.9 3 13.9 vertical, and the first and second peaks of the progressive
7 60 179 94.0 24 8.8 force were compared between feet. This comparison was
8 43 175 76.3 I4 15.1
9 44 I75 70.9 4 Il.3 facilitated by reporting all forces as a percentage of body
IO 5s 179 88.1 25 30.1 weight (BW).
Joint motion data were analyzed to identify the maximum
Mean 49.9 I75 80.7 18.3 15.8
and minimum degree of motion in each subphase of gait and
the point (percentage of the gait cycle) at which it occurred.
To ensure the fitting of appropriate foot components and Footswitch data were used to determine the subphases of
keel. each manufacturer was provided with the subject’s gait and to calculate stride characteristics.
age. weight, height, contralateral shoe size. activity level, All gait data were normalized to a 62% stance phase in
amputation level, and length of stump. The selection of the order to average data from multiple strides and different
SACH foot heel wedge was based on the subject’s weight subjects.
according to the developer’s guidelines. The appropriateness
of each foot component/keel selection was then confirmed Data Analysis
or modified at the time of prosthetic fitting. Statistical analyses were performed using BMDP’ statisti-
The fit of each prosthesis was clinically optimized and cal software. All data were analyzed for normality of distri-
reviewed by a team of three certified prosthetists. Alignment bution using the Shapiro and Wilk’s W statistic. Differences
of the first foot followed established prosthetic principles. between the five prosthetic feet were determined by repeated
The Vertical Fabrication Jigd was used for subsequent align- measures analysis of variance (ANOVA). A significance
ments when more than the interchange of a foot-bolt was level of p < .05 was used. A post-hoc Tukey test was used
required. to find the significantly different comparisons.
Procedures
RESULTS
Each subject was given an accommodation period of 1
month to adjust to each prosthetic foot. After this period,
the prosthesis and alignment were rechecked and the subject Stride Characteristics
was then sent to the Pathokinesiology Laboratory at Ranch0 Of the stride characteristics recorded, only stride length
Los Amigos Medical Center for instrumented gait analysis. showed a statistical difference. During normal free walking,
Each subject was tested once a month over a 5-month period. stride length was greater for the Flex-foot ( 1Slm) com-
The testing procedure was identical during each session. pared to the Sach and Quantum (1.44m) (p < .05). There
Prior to data collection, each subject was weighed with were no significant differences in velocity between the five
and without the prosthesis. Compression closing foot- feet (table 2).
switches were taped to the soles of the subjects’ shoes to
calculate stride characteristics and foot-floor contact patterns
(Stride Analyzer System’). Reflective markers were placed
Joint Motion
at specific anatomical landmarks so that sagittal plane motion During free gait, the significant difference detected in joint
of the pelvis. thigh, knee, and ankle could be measured motion was the maximum ankle dorsiflexion achieved in
using the VICON motion system.g The markers placed on terminal stance. The Flex-foot achieved greater dorsiflexion
the prosthesis were estimated from bony landmarks of the (23.2”) compared to all the other feet tested @ < .OOOl) (fig
intact side.
Medial-lateral. progressive, and vertical ground reaction
Table 2: Stride Characteristics, Free Walking
forces were recorded from a Kistler” piezoelectric force plate
(41 x 61cm) concealed in the middle of the walkway. The Mean (standard deviation)
varigated pattern of the tile flooring camouflaged the force
Velocity Stride Length Cadence
plate. Force plate position was not revealed to the subjects
fmlmin) (meters) (step/min)
in order to eliminate targeting.
SACH 78.7 (11.1) I.44 (.15) 108.5 (8.0)
Subjects were instructed to walk at a self-selected speed
Flex 83.2 (8.3) 1.50 (.13)* 110.6 (8.8)
along a 10m walkway with forceplate and motion data being cc11 80.6 (7.7) 1.46 (.14) I IO.1 (7.1)
collected simultaneously. A successful trial was one in which Seattle 81.4 (8.4) 1.47 (.13) 110.7 (7.7)
the foot of interest landed fully on the force plate. Typically, Quantum 79.2 (6.1) 1.44 (.14) 110.0 (5.7)
three to five trials were required to record the data success- Normal” 8 I .6 (9.4) 1.51 (.14) 108.2 (9.1)
fully. Repeated trials were necessary to obtain data on both * Flex > SACH, Quantum (p -c .05).

Arch Phys Med Rehabil Vol75, July 1994

 SOUND LIMB LOADING IN BK AMPUTEES, Powers 827

1.4

_ _ .._ _ _._ 1.0

G
R
F 0.8

; 0.6
0 20 40 60
w
0.4
96 GAIT CYCLE
Fig l-Ankle motion during the stance phase of free-paced . SEATTLE
walking. Abbreviations: DF, dorsiflexion; PF, plantarflexion. 0.2

I ). In addition, the Quantum showed a statistically significant

difference in maximum dorsiflexion (19.5”) when compared
0.0 ____._
+__-
___..
+
40 60
to the Carbon Copy II (12.l”), Seattle (15.1”) and SACH
Fig 2-Vertical ground reaction force (normalized by body-
t 12.0”) (/7 ( .OOOl). weight) during the stance phase of free-paced walking.

Force Plate Data

vertical Jhe. On the amputated limb. only the initial peak) ( 15.4% GC) compared to the Flex-foot ( 10.3% GC)
peak of the vertical ground reaction force registered a sig- and the Quantum ( 10.2% GC) (table 5 ). A significant differ-
nificant difference among the five feet. This occurred be- ence was also seen in the timing of the posterior shear force.
tween the SACH ( ‘I 18.8% BW) and the Quantum ( 106. I % The peak for the Flex-foot occurred later in the gait cycle
BW) (p < .05). There was no significant difference in the compared to all other feet (p <: .OOOl I (table 6). In addition,
timing of this peak (table 3). the Seattle demonstrated a signiticant delay in the second
The sound limb demonstrated a significantly lower verti- peak when compared to the Quantum Ind SACH feet (11
cal force at the beginning of stance (first peak) when the < .OOOl) (table 6).
amputee was titted with the Flex-foot than with any of the On the sound limb. there were no signiticant differences
other feet tested (p = < .OOOl) (fig 2). Although not statisti- in the magnitude or timing of the peaks of the progressive
cally significant. the SACH tended to result in the greatest ground reaction force.
vertical ground reaction force on the sound limb compared
to the Seattle. Quantum and Carbon Copy II (table 4). There
was no signiticant difference in the timing of this first peak DISCUSSION
between feet
The Flex-foot demonstrated significantly lower peak verti-
cal ground reaction forces during loading of the sound limb
Progressive Force
when compared to the other feet tested. This is in agreement
During stance phase of the amputated limb, there were
with Wagner and Sienko’ who found decreased sound limb
no significant differences in the magnitude of the progressive
ground reaction forces with the Flex-foot compared to the
forces. The SACH however, demonstrated a significant delay
in the forward horizontal shear force (initial progressive
Table 4: Peak Initial Vertical Ground Reaction Force:
Sound Limb
Table 3: Peak Initial Vertical Ground Reaction Force:
Amputated Limb Mean (standard deviation)
~-~ -__. -.--
Mean (standard deviation) Timing of Peak ( %GC)
Foot Type Magnitude Peak 1 (%BW)

Foot Type Magnitude Peak 1 (%BW) Timing of Peak (%GC) SACH 135.1 (12.6) I? I (I.51
Flex 109.5 t 14.7)” 12 9 (3.9)
SACH Il8.4 (10.2) 16.3 (3.5)
CC11 129.0 I I-1.7 ) 13 3- (1.7)
Flex 115.5 (I’.?) 14.Y (I.91
Seattle 137.9 (13.9) 131 (I.61
(‘Cl1 Ill.h(ll.2) 15.Y (3.3)
Quantum 129.2 (9.9) 130(1.7)
Seattle 111.0~11.71 16.6 (3.5)
Normal I I I.0 (7.0) N/A
Quantum 106.1 (I 1.7)* 15.1 (3.3)
Normal’ I I I.0 (7.0) N/A * Flex < SACH. CCII. Seattle, Quantum (p .(KHIl)
___.
See reference I I.
c Quantum 6 SACH (17 < .05).

Arch Phys Med Rehabil Vol75, July 1994

 SOUND LIMB LOADING IN BK AMPUTEES, Powers

Table 5: Peak Anterior Horizontal Shear Force: Flex-foot was within normal limits. This is in sharp contrast
Amputated Limb to the other prosthetic feet tested because the vertical forces
Mean (standard deviation) on the sound limb exceeded normal values whereas the gait
velocities were near normal. It appears that an additional
Foot Type Anterior Shear Peak (%BW) Timing of Peak ( % CC) factor other than gait velocity may be contributing to this
SACH 13.6 (6.0) IS.3 (4.4)* phenomena.
Flex 12.6 (4.7) 10.3 (1.0) SimonI has described the normal function of the calf
cc11 14.3 (3.5, 12.8 (4.1) muscles as acting to control the forward momentum of the
Seattle 14.6 (5.7) 14.0 (5.3)
tibia and, consequently, to restrain forward motion of the
Quantum 12.7 (5. I J IO.:! (3.1)
body. In the presence of a fixed ankle as exists in the SACH
* SACH > Flex, Quantum (p < ,005). component, tibia1 advancement depends on an excessive heel
rise as a substitute for the lack of ankle dorsiflexion. The
SACH component. The mean initial vertical force for the resulting rise in the center of gravity would introduce a
Flex-foot in our study was found to be slightly lower than the greater fall onto the sound limb and its recorded increase in
values established by Chao” for normal individuals (table 4). the vertical force of weight acceptance. The SACH compo-
The vertical forces of the sound limb with the Flex-foot were nent consistently produced the greatest vertical forces on the
also found to be lower than the sound limb values of previous sound limb although this was not statistically signiticant.
data collected on adults with below-knee amputations.x The magnitude of the vertical forces on the sound limb with
These results with the Flex-foot support the conclusion of the SACH foot is not consistent with the velocity of ambula-
Lewallan’ and Hurley7 that the intact limb does not develop tion if one considers the relationship proposed by Skinner.”
increased joint forces. In contrast, the remaining four pros- One would expect that because the SACH had the slowest
thetic feet (SACH, CCII, Seattle, Quantum) showed in- walking velocity of the five foot components tested, there
creased vertical forces on the sound side compared to the would be an associated decrease in ground reaction force.
amputee data of LewallanX and the normative data of Chao.” This was not the case, leading us to believe that the degree
On the average, these values were approximately 17% of heel rise and the subsequent rise in the body center of
greater than normal, implying that these prosthetic foot de- gravity played a greater role in the magnitude of the loading
signs increase the joint forces acting on the sound limb. forces of the sound limb.
Loading forces have been shown by Skinner” to be pro- The Flex-foot has consistently shown increased dorsiflex-
portional to gait velocity in a nonlinear relationship. In gen- ion in terminal stance compared to other prosthetic feet.“.”
eral, as velocity increases so does the vertical component of Our data confirm these results because the peak dorsiflexion
the ground reaction force. Adults with amputations have of the Flex-foot was significantly greater than the other feet
been shown to use slower walking velocities, which keep tested. This increased dorsiflexion may be responsible for
ground reaction forces on the sound limb at acceptable lev- the delay in the posterior shear force, because dorsiflexion
els.7.8 In his study of six subjects with below-knee amputa- increases the ankle rocker motion providing greater tibia1
tions wearing the SACH foot component, LewellanX con- progression. This mechanism probably was also responsible
cluded that the amputee uses a slower walking speed, for the significantly greater stride length with the Flex-foot.
decreased step length, and increased double limb support to In addition, the yielding into increased dorsiflexion mini-
reduce forces acting across the joints of the contralateral mized the heel rise stimulus and correspondingly reduced
limb. This is in agreement with Hurley7 who also found the rise of the center of gravity and its subsequent effect on
normal forces in the sound limb of seven below-knee ampu- weight transfer to the sound limb.
tees (five Seattle components, two Flex-foot components). Because the excessive dorsiflexion was not accompanied
These findings also were attributed to a slower walking ve- by an increase in knee flexion, the rate of tibia1 mobility
locity in the amputee group despite a lack of statistical com- must have been appropriately restrained by the Flex-foot
parison. shank. This is further supported by Gitter et al’” who demon-
The adults with below-knee amputations in the present strated that the power generated by the Flex-foot in stance
study walked at velocities very close to normal, deviating had minimal effect on the power curves at the knee and hip.
on the average only 1.5% from the normal values established The Quantum, Carbon Copy II, and Seattle feet all had
by Waters and colleagues’” (table 2). The mean Flex-foot
velocity for free walking was actually greater than these
Table 6: Peak Progressive Posterior Shear Force:
normal data. Stride characteristic data from this group of Amputated Limb
amputees showed that velocity was maintained despite con-
sistent decreases in stride length. This was achieved through Mean (standard deviation)
an increase in cadence that was evident in all five feet tested. Foot Type Posterior Shear Peak (%BW) Timing of Peak ( %GC)
The increased velocity seen with the Flex-foot was primarily
the result of an increase in cadence because stride length SACH 13.1 (4.6) 50.6 ( 1.3)
Flex IS.5 (6.0) 54.3 ( I. I )*
was normal. cc11 13.5 (4. I ) 51.4 (1.6)
When walking velocity was related to the initial peak of Seattle 15.3 (5.2) 52.6 ( I .2)+
the vertical ground reaction force for the sound limb, an Quantum 12.5 (5.7, 50.5 (1.1)
interesting observation was seen. Despite a greater than nor- * Flex > Seattle, CCII. SACH, Quantum (p < .OOOlI.
mal gait velocity, the peak ground reaction force for the ’ Seattle > Quantum, SACH (p < .OOOI).

Arch Phys Med Rehabil Vol75, July 1994

 SOUND LIMB LOADING IN BK AMPUTEES, Powers 829

vertical ground reaction forces higher than normal and these References
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Orthot Int 1981;5:11~8.
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spring leaf mechanism of the Quantum and CCII. which 7. Hurley GRB. McKenney R. Robinson M. Zadravec M. Piertynowski
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The greater vertical loading force recorded by the sound
12. Skinner SR. The correlation between gait velocity and rate of lower
limb in this study indicates an increased demand compared extremity loading and unloading. Bull Prosthet Res 19X 1; I X:303-4.
to that experienced by the amputated limb. The Flex-foot, 13. Simon SR. Mann RA, Hagy JL. Larsen LJ. Role of the posterior calf
by its large arc of controlled ankle dorsiflexion reduced the muscles in normal gait. J Bone Joint Surg 1978;60:465-72.
14. Torbum L. Perry J, Ayyappa E. Shanfield SL. Below knee amputee
need to use a heel rise for tibia1 progression and also pre- gait with dynamic elastic response prostheti<: feet: a pilot study. J
served knee stability. This resulted in a lower vertical loading Rehabil Res Dev 1990;27:369-84.
force on the sound limb than was imposed by any of the 15 Gitter A. Czemiecki JM. DeGroot DM. Biomzchanical analysis of the
four other prosthetic feet. The effective factor appears to influence of prosthetic feet on below-knee amputee walking. Am J Phys
Med Rehabil 1991:70: 142-8.
be minimization of the center of gravity elevation. Other
prosthetic feet that allow dorsiflexion mobility comparable Suppliers
a. 3ex Foot Incornorated. 27071Cahot Road. flltlh. Lacuna
. Hills. CA
to that of the Flex-foot may demonstrate similar results.
226S3.
These conclusions were based on the subject population h. rhe Ohio Willow Wood Company. PO Box l,J7 Mount Sterling, OH
of adults with traumatic below-knee amputations who were 13143.
c. Model and Instrument Development. X61 Poplar Placr. Seattle. WA
able to ambulate at a nearly normal velocity. Extrapolation
)8 144.
to other populations with slower gait velocities must be made d. -losmer Dorrancr Corporation, 561 Division Street. Campbell. CA
with caution. Further research is necessary to determine if )5008.
similar results are common to a variety of walking speeds, Kingsley Manufacturing Company. PO Box (‘SY 5010. Costa Mesa.
IA 92928.
such as those of the slower ambulating adult with below- B & L Engineering, 8807 Pioneer Boulevard I.nii C’. Santa Fe Springs.
knee amputation secondary to dysvascular disease. or the :A 90670.
high-speed mobility common in running and athletics. 3xford Metrics LTD. Unit 14. 7 West Wa) HotIcy. Oxtord OXZOJB.
Kistler Instruments Corporation. 2475 Grand Island Boulevard. Grand
island. NY 14072.
Acknowledgment: The authors extend their gratitude to the manufactur- BMDP Statistical Software Incorporated. 1440 Sepulvcda Boulevard.
ers for their generosity in donating the prosthetic feet used in this study. Suite 316. Los Angeles CA 9002.5.

Arch Phys Med Rehabil Vol75, July 1994