Prosthetics and Orthotics International, 2004, 28,132-140

Characterisation of prosthetic feet used in

low-income countries
M. SAM*, A. H. HANSEN** and D. S. CHILDRESS***

*UC Berkeley-UC San Francisco Joint Medical Programme, Berkeley-San Francisco, California, USA
**Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg
School of Medicine, Chicago, IL, USA
***Department of Physical Medicine and Rehabilitation and Department of Biomedical Engineering,
Northwestern University; Department of Veteran Affairs; Engineering Research Program and Prosthetics
Research Laboratory, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

Abstract
Eleven kinds of prosthetic feet that were
designed for use in low-income countries were
mechanically characterised in this study.
Masses of the different kinds of prosthetic feet
varied substantially. Dynamic properties,
including damping ratios and resonant
frequencies, were obtained from step unloading
tests of the feet while interacting with masses
comparable to the human body. Data showed
that for walking, the feet can be appropriately
modeled using their quasistatic properties since
natural frequencies were high compared to
walking frequencies and since damping ratios
were small. Roll-over shapes, the effective
rocker (cam) geometries that the feet deform to
under walking loads, were determined using a
quasistatic loading technique and a spatial
transformation of the ground reaction force's
centre of pressure. The roll-over shapes for most
of the prosthetic feet studied were similar to the
roll-over shape of the SACH (solid-ankle
cushioned heel) prosthetic foot. All roll-over
shapes showed a lack of forefoot support, which
may cause a "drop-off experience at the end of
single limb stance and shorter step lengths of the
contralateral limb. The roll-over shapes of
prosthetic feet appear useful in characterization
of foot function.
All correspondence to be addressed to Andrew Hansen,
345 East Superior Street, Room 1441, Chicago, IL,
USA 60611.
132
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Introduction
The design and construction of the prosthetic
foot is important in low-income countries,
particularly for rural amputees. In many
instances, the durability of the prosthetic foot
determines the durability of the whole prosthesis
(Day, 1996). The prosthetic feet designed and
manufactured in industrialised countries often
do not adapt well to use in low-income countries
(Sethi, 1989), and it is often necessary to design
locally a prosthetic foot that will cater to the
needs of the local amputee population (Sethi et
al, 1978; Vossberg, 1985; Wollstein, 1972;
Meanley, 1995; Day, 1996; Cummings, 1996).
To date, several prosthetic feet have been
designed to try to meet the demands of rural
amputees in low-income countries. Some of
these feet are made in industrialized nations and
then exported to low-income countries, such as
the Snelson foot and the feet made in Geneva by
the International Committee of the Red Cross,
but most are made locally in the country of
targeted use. Many reports describe the
advantages of certain fabrication methods and
technology deemed appropriate (Kijkusol, 1986;
Oshin, 1981; Wollstein, 1972; Mathews et al,
1993; Mohan et al., 1992; Sethi et al, 1978;
Girling and Commings, 1972; Meanley and
Reed, 1998). However, fewer studies attempt to
describe the performance and biomechanical
properties of trans-tibial prostheses and
prosthetic feet used in low-income countries
(Arya et al, 1995; Kabra and Narajanan 1991;
Jensen and Heim, 1999; Verhoeff et al, 1999).
 Characterisation of low-cost prosthetic feet
The methods of these studies differ widely from
each other, rendering the comparison of one
prosthetic foot to another practically impossible.
In this study, the authors have tested a
selection of prosthetic feet that are
representative of those used in low-income
countries. The purpose was to characterize the
mechanical properties of prosthetic feet from
low-income countries according to a
predetermined common protocol. The primary
objectives were to obtain the roll-over shapes of
these prosthetic feet, their masses, their damping
ratios, and the resonant frequencies that arise
when oscillated with mass comparable to that of
the human body. Also, the feet were
photographed and radiographed. With this
information insight can be gained about the
design of prosthetic feet from low-income
countries and ways sought to improve them.
Description of the prosthetic feet
For normalisation purposes, all prosthetic feet
used in the study were solicited from the
manufacturer to fit a hypothetical amputee with
the following profile:
• 30 yr. old male;
• weight = 600 Newtons (mass = 61 kg);
• moderately active;
• size 9 (26 cm) left foot.
Unfortunately, not all of the prosthetic feet
tested were available in size 26 cm. When size
26 cm was not available, the closest available
size was tested instead.
Eleven different types of feet were included in
this study. They were:
• A solid ankle cushion heel (SACH) foot with
a wooden keel - fabricated by the Telethon
Foundation Pro-Rehabilitation (FUNTER),
San Salvador, El Salvador;
• A foot with a polypropylene keel (having a
C-shaped polypropylene keel covered with
foam) - fabricated by the Telethon
Foundation Pro-Rehabilitation (FUNTER),
San Salvador, El Salvador;
• A polypropylene leaf spring foot (leaf spring
keel encased in foam) from the International
Committee of the Red Cross (ICRC)
Cambodia Components Factory, Phnom
Penh, Cambodia;
• A polypropylene keel foot from the ICRC in
Mozambique;
• An EB-1 Foot, also known as the Ba Vi Foot
(rubber, wood, and aluminum keel) —
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133
designed by the Prosthetic Outreach
Foundation and fabricated in Ba Vi,
Vietnam;
• A modified SACH foot with a wooden keel
- fabricated by CADEG, Guatemala;
• A SACH foot with a wooden keel,
distributed by Roy Snelson - this foot was
designed by Roy Snelson and is now
manufactured by United States
Manufacturing Company (USMC);
• A Jaipur foot (comprised of a wooden ankle
block and layered sponge rubber covered
with nylon cord that is encased in vulcanized
rubber) from Bhagwan Mahaveer Viklang
Sahayata Samiti, Swai Mansingh Hospital in
Jaipur, India;
• A Polypropylene keel foot from Handicap
International in Maputo, Mozambique;
• A Polypropylene keel foot (leaf spring keel
encased in foam) from the International
Committee of the Red Cross in Ethiopia;
• A Polypropylene keel foot (modified
polypropylene keel encased in foam) from
International Committee of the Red Cross in
Geneva, Switzerland.
The above selection does not include all of the
prosthetic feet used in low-income countries.
However, it is believed to be a large enough
selection to represent the range of prosthetic feet
that are characteristic of the developing world.
In some of the feet, the traditional polyurethane
foam typically used in SACH feet was replaced
with natural rubber to prolong the life of the
prosthetic feet, since it has been reported that
rubber is much more durable than polyurethane
foam in tropical settings (Sethi et al., 1978;
Muller, 1957; Wollstein, 1972).
Methods
Physical measurements and dynamic
characterization
All feet were weighed, photographed, and
radiographed. The sizes of the feet were
recorded along with whether they were
manufactured for use on the right or left side.
Dynamic characterization of the prosthetic
feet was accomplished using the methods of
Sam et al. (2000) and Knox (1996). A prosthetic
foot loading apparatus (previously shown in
Hansen et al. (2000)) was used to apply a step
unloading force to each prosthetic foot-mass
system. A neutrally aligned pylon connected to
the foot was fixed in the apparatus at an angle of
134 M. Sam, A. H. Hansen and D. S. Childress

Data and model for a dynamic trial of a SACH Foot with a wooden keel
0.005

0.004

0.003

0.002

Q)
E
cu 0.001 •-•Data
u
CO — Model
Q.

-0.001

-0.002

-0.003
0.5 2.5 3.5

Fig. 1. Data from a dynamic trial (line with dots) and corresponding model (smooth line) for a typical SACH foot. The
successive minima of the response (xO, xl, x2 xn) were used to find the damping ratio (see text for details). The model
matches the data appropriately, especially during the first few oscillations of the system. The natural frequencies of
oscillation found in these step unloading trials were much higher than walking frequencies, indicating that quasistatic
roll-over shape measurements could be used to model the function of the feet during walking.

60° from the loading beam and such that loading The damping ratio was calculated using
was on the forefoot of the prosthetic foot. The logarithmic decrement of successive minima of
loading apparatus is a lever system that applies a the oscillations (Fig. 1) and using the following
force to the foot that is approximately twice the equation (adapted from Thomson, 1967):
load applied at the end of the lever. At the end of
the lever are 2 trays that hold weights, a top and
a bottom tray. The bottom tray can be rapidly Equation 2
removed (using a hammer release system),
leaving an effective mass (mass of the beam and
remaining weights on the top tray) representing
body mass. The displacement of the beam at the The natural frequency of the system (con= 2n fn)
approximate location of the foot's contact is was then found using Equation 3:
measured using a calibrated linear
potentiometer. Resonant frequencies (fn) and Equation 3
damping ratios (£) were measured for an
effective mass of 61 kg, and using a step unload After the data were obtained and processed,
force of 300 N. The damped natural frequency values for fn and t, were verified using
(GSd) was calculated directly from the period of Equation 4:
the oscillations (t) of the dynamic response:
X(t) = Ae "?mnt cos(05dt) Equation 4
05(i = Equation 1
This equation describes the free response of a
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 Characterisation of low-cost prosthetic feet 135

V fc)
Fig. 2. Quaisistatic roll-over shape measurement method: force is continuously applied to the prosthetic foot for angles
approximating heel contact to opposite heel contact of a typical gait cycle while marker trajectories and kinetic data are
recorded by a motion analysis system. Three instants during a typical trial are shown: (a) heel contact, (b) midstance,
and (c) end of single limb stance (opposite heel contact).

simple harmonic damped oscillator to a step
input, where x(t) is the displacement from the
steady-state value as a function of time, con = 2jt
fn is the natural frequency of the system
expressed in radians per second, and cod is the
damped frequency of the system expressed in
radians per second.
Roll-over shape measurement
Roll-over shapes were obtained using a
modified version of the quasistatic roll-over
method of Hansen et al. (2000). In this method,
the roll-over shape was measured using a device
that consists of a prosthetic foot and pylon
connected to a weight (Fig. 2). Two (2) reflective
markers (one at the foot's ankle level and another
on top of the weight) were placed on the device
such that a line through their sagittal plane
projections would be perpendicular to the
attachment surface of the foot. The same
alignment was used for all feet tested: neutrally
aligned with the pylon orthogonal to the
attachment surface of the foot. The heel of the
prosthetic foot was loaded by pressing the
apparatus against a force platform (Advanced
Mechanical Technologies Incorporated,
Watertown, MA, USA). Visual feedback of the
applied force was observed via computer display.
The foot was then slowly rolled over from heel to
toe while maintaining the specified force level
(e.g. 600N). During the period between the
orientation of 105° with the floor (corresponding
to heel contact) to the orientation of 60° with the
floor (corresponding to toe-off), forces and
moments applied to the force platform were
recorded as well as the trajectories of the 2
markers using an 8-camera motion analysis
system (Motion Analysis Corporation, Santa
Rosa, CA, USA). The centre of pressure (COP)
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of the vertical ground reaction force was
calculated in post-processing. The projections of
the COP and the 2 markers were found on a
stationary laboratory plane corresponding to the
sagittal plane of the foot. These projections were
then transformed from an inertial laboratory
coordinate system in the stationary frame to a
shank-based coordinate system in the same plane
(Hansen et al, 2000). The lower marker's
projection served as the origin of the new shank
coordinate system and the COP in this new
coordinate system was the roll-over shape of the
foot. The roll-over shapes were then vertically
adjusted by the offset distance between the lower
marker and the attachment surface of the foot so
that the new origin of the roll-over shapes would
be the intersection of the centre of the attachment
bolt and the attachment surface. The testing
procedure was repeated 3 times for each foot.
The data were averaged by obtaining the x- and y-
coordinates of the COP at every degree for a
pylon angle of 60° to 105°. For each degree, the
COPs from the 3 different trials were averaged in
both the x- and y-direction of the shank-based
coordinate system.
Results
Physical and dynamic characteristics
The sizes, sides (left or right), and masses of
all feet tested are shown in Table 1. There is a
wide variation in mass of the feet, from 193.0g
for the lightest to 854.6g for the heaviest, with
an average of 526.5+219.3g (all means are given
as average ± standard deviation). Data from the
dynamic trials fitted the corresponding simple
damped harmonic oscillator model well, with
discrepancies likely due to non-linear behaviour
of the materials used in the prosthetic feet, such
as creep, stress relaxation, Coulombic friction,
136 M. Sam, A. H. Hansen and D. S. Childress

Table 1 . Physical properties of prosthetic feet tested.

Foot name Size (cm) Side Mass (g)
EB-1 25 Left 809.8
Funter-PPP 26 Right 475.8
Funter-Wood 26 Left 455.7
Cadeg 25 Left 349.4
ICRC-Podes 24 Right 193.0
ICRC-Mozambique 26 Left 333.0
Snelson 28 Right 532.1
Jaipur 23 Right 822.0
ICRC-Geneva 25 Left 567.6
ICRC-Ethiopia 25 Right 398.0
Handicap International 26 R&L 854.6
Average 526.5
S.D. 219.3

and others. A typical dynamic trial with the
fitted model is shown in Figure 1. The average
resonant frequency of all feet was 5.35+1.5Hz,
which is well above normal walking frequencies
of approximately 2Hz. The average damping
ratio was 0.098±0.100 which is a low value and
indicates an "underdamped system" in
engineering terms.
Roll-over shape measurements
All feet tested in this study had roll-over
shapes similar to that of a SACH foot (Figs. 3
and 4), except for the Jaipur foot (Fig. 4H). The
roll-over shape of a typical SACH foot (i.e. one
that is used in Western Europe or North
America) is characterized by a flat region from
the heel until the metatarsal area where it
suddenly stops and/or curves upwards (Knox,
1996; Hansen et al., 2000; Sam et al., 2000).
This upward curve results from a lack of toe
support during the latter part of stance phase.
The Jaipur foot had a circular roll-over shape
which curved gradually along a small radius
from heel strike until toe off (Fig. 4H). Although
the roll-over shape progressed more gradually
and smoothly in the Jaipur foot than the others,
it also displayed a lack of toe support. The lack
of toe support, common to all feet tested in this
study, was indicated by the lack of extension of
the roll-over shape into the distal regions of the
feet.
The '+' signs that are surrounded by circles in
Figure 4 indicate for each foot the point at which
the hole for the attachment bolt intersects the
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attachment surface. The distance from the '+' to
the roll-over shape can be used to compare the
heights of the feet during walking. By
examining this distance one can see that the
ICRC Cambodia foot (Figure 4C) has a much
lower profile than the Jaipur foot (Fig. 4H). The
high profile of Jaipur may prevent its usage on
prostheses for unilateral trans-tibial amputees
with long stumps.
Discussion
The masses of the feet varied widely from one
another with the rubber feet being heavier than
the foam feet. As examples, the EB-1 and Jaipur
feet use rubber and were heavier than the ICRC
feet that use foam materials. The variation in
weight might also have been influenced by the
variation in sizes and heights of the feet.
The simple harmonic damped oscillator model
fit the data appropriately, with a small amount of
discrepancy between the data and model that
varied from one foot to another (Fig. 1). All
resonant frequencies (from a minimum of 3.54
to a maximum of 9.41 Hz) were higher than
normal walking frequencies (~2Hz, Winter,
1990) and the damping ratios were all low. Thus
these prosthetic feet are expected to behave in a
quasistatic manner and dynamic factors will not
come into effect under normal walking loads,
which is in agreement with previous reports
(Knox, 1996; Hansen et al, 2000).
The roll-over shapes of most of the feet tested
were similar to the roll-over shape of a typical
SACH foot, characterized by a flat region
 Characterisation of low-cost prosthetic feet 137

Funter Foot. Wooden Ksel

50 100 150
Shape X (mm)

Fig. 3. Roll-over shape of a SACH-like foot overlaid on its radiograph. All three trials and their average are shown,
standard deviations are omitted for clarity. The origin of the coordinate system (shown using a star inside a circle)
corresponds to the bolthole on the attachment surface of the foot. Note how the roll-over shape follows the wooden keel
in a flat section from the heel until it reaches the end of the keel and suddenly curves upwards when the foam and
belting material can no longer support the force imposed on the foot.

followed by a lack of toe support (Figs. 3 and
4A-G and J). This is predictable since the
structure of most of these feet is a variation of a
SACH foot. The roll-over shape of a SACH foot
approximates the shape of the wooden keel,
which is to be expected since the foam and
rubber will deflect under normal body loads, but
the solid wooden keel will not (see Fig. 3).
Replacing the polyurethane foam of a SACH
foot with natural rubber adds weight but may
improve the foot's durability. The replacement
of foam with rubber does not appear to affect its
roll-over shape, since the rubber used is also not
rigid enough to support body weight. This was
seen in the EB-1 and the HI feet from Maputo
(Figs. 4E and K). Replacing the wooden keel by
a polypropylene keel does not appear to affect
the roll-over shape either, as was seen in the HI
feet from Maputo (Fig. 4K). Other attempts have
been made to change the shape and material of
the keel of the foot, which can be seen in the
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FUNTER polypropylene keel foot, the ICRC
Mozambique foot, and the ICRC Geneva foot
(Figs. 4B, D, and J). In these cases, the roll-over
shape also followed the shape of the keel and
still yielded a roll-over shape similar to that of a
SACH foot, although the transition from the flat
region to the upward break seemed slightly
smoother than with wooden keels.
The structure of a Jaipur Foot is
fundamentally different from that of a SACH
foot. The Jaipur foot is made of a wooden ankle
block and several layers of sponge rubber.
There is no sudden change in the structure of the
foot itself, hence it follows that its roll-over
shape progresses smoothly from the heel into the
metatarsal area. This roll-over shape follows a
radius smaller than desired for walking (Gard
and Childress, 2001; Hansen, 2002; Hansen et
ah, 2004a). However at the same time, this small
radius allows for a great amount of apparent
"dorsiflexion", which may be beneficial for
138 M. Sam, A. H. Hansen and D. S. Childress

Fig. 4. Individual roll-over shapes of all feet tested: (A) FUNTER wood keel, (B) FUNTER polypropylene keel, (C) ICRC
Cambodia, (D) ICRC Mozambique, (E) EB-1, (F) CADEG, (G) Snelson, (H) Jaipur, (I) ICRC Ethiopia, (J) ICRC Geneva,
(K) HI Maputo. The roll-over shapes (squares connected by lines) are shown on top of cross-sectional outlines of each
prosthetic foot (solid lines). The '+' (surrounded by a circle) on each prosthetic foot outline indicates the attachment point,
where the bolt attaches the foot to the rest of the prosthesis. All feet display a lack of toe support, indicated by roll-over
shapes that do not extend into the toe region of the foot.
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 Characterisation of low-cost prosthetic feet
activities such as squatting and tree climbing.
All feet tested in this study displayed an
absence of toe support, exhibited by the lack of
extension of the roll-over shape into the toe
region (Figs. 4A-K). The absence of toe support
may shorten the step length of the contralateral
limb of the prosthetic foot's user and cause the
"drop-off experience felt during the end of
single limb stance (Hansen et al., 2000; Sam et
al., 2000; Hansen et al, 2004b).
For good walking performance, prosthetic feet
should be designed such that their roll-over
shape matches, as closely as possible, the roll-
over shape of the non-disabled ankle-foot
system during walking (Hansen et al., 2004a;
Hansen et al., 2004b). The combined ankle-foot
system should be used as a design goal as
opposed to the foot alone because a prosthetic
foot is replacing both the ankle and foot of a
person with a lower limb amputation that is at
ankle disarticulation level or above. The roll-
over shape of the non-disabled ankle-foot
system is also believed to be useful as a design
goal because it has been found to be generally
invariant to factors such as walking speed and
carrying added weights on the torso (Hansen,
2002; Hansen et al., 2004a).
One of the weaknesses of this study is the fact
that only one foot of each kind was tested. It
should also be noted that the properties
measured in these experiments are properties of
new and undamaged feet. A fatigued or
damaged prosthetic foot might show different
roll-over shapes and dynamic properties.
Additionally, prosthetic feet have other
characteristics that are not reflected in the
measurements done in this study but need to be
taken into account when designing them. Some
of these properties are durability, cosmesis,
medial-lateral motion, and shock absorption at
heel strike. Although the authors did not
evaluate these factors, they have shown in
previous studies that the roll-over shapes of
prosthetic feet are critical to their function. The
effects of a prosthetic foot on gait can be
predicted from its roll-over shape, which in turn
is dictated by its mechanical structure. This
insight can be used to save great amounts of time
and resources when designing or improving
prosthetic feet.
Conclusions
Prosthetic feet used in low-income countries
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139
vary widely in mass. Increased mass is likely
coupled with increased durability. Most of the
feet tested in this study portrayed functional roll-
over shapes that were similar to that of a typical
SACH foot. The exception to this finding was
the Jaipur foot, which had a roll-over shape with
a small radius. Because the radius is small, the
lack of toe support is also expected when
walking on the Jaipur foot. Roll-over shape
seems useful as a design tool for low-cost
prosthetic feet. However, other factors not
related to walking function may be more
important to prosthesis selection for each
prosthesis user including cosmesis, durability,
and the ability to assume a squatting position.
Acknowledgements
This work was funded by the National
Institute on Disability and Rehabilitation
Research (NIDRR) of the U.S. Department of
Education under subcontract grant No.
H133E980031, RERC (Physicians Against Land
Mines) and in collaboration with RERC
(Northwestern University Rehabilitation
Engineering Research Center in Prosthetics and
Orthotics) NIDRR grant No. H133E980023.
The opinions contained in this publication are
those of the grantee and do not reflect those of
the Department of Education.
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