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Prosthetics for Transtibial Amputees: A Literature Survey

Conference Paper · January 2011

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 Proceedings of the ASME 2011 International Design Engineering Technical Conferences &
Computers and Information in Engineering Conference
PROSTHETICS FOR TRANSTIBIAL AMPUTEES-A LITERATURE SURVEY
Thomas Powelson
Human-Centric Design Research Laboratory
Department of Mechanical Engineering
Texas Tech University, Lubbock, Texas, 79409
Email: thomas.powelson@ttu.edu
ABSTRACT
Approximately 82 percent of all amputations performed in
the United States are transtibial amputations, in which the leg
is removed below the knee. Because the knee joint is left intact
the use of prosthetics is one of the most preferred methods for
returning mobility to amputees. The improvement of prosthetics
for transtibial amputees is currently an area of intense
research. This paper summarizes the state of the art of
prosthetics for transtibial amputees by focusing on the four
major components associated with standard transtibial
prosthetic. The socket transfers the forces between the residual
limb and the prosthetic. A suspension system ensures that solid
contact is maintained between the leg and the artificial limb.
The prosthetic foot is attached to the socket by a pylon, which
also accounts for length of limb lost during amputation.
Prosthetic feet come in many forms ranging from little more
than wooden blocks to carbon fiber sprinting feet. Two recent
advances in transtibial prosthetics include the procedures of
direct skeletal attachment, and distal tibiofibular bone bridging
which increases the weight bearing capability of the residual
limb.
INTRODUCTION
The vast majority of amputations occur as a result of poor
blood circulation in the affected limb, often related to diabetes.
As of 2008, 82 percent of all amputations performed in the
United States were associated with dysvascular disease.
Besides complications linked to diabetes and dysvascular
diseases, the other main cause for amputations is trauma[2].
There has been a recent increase in amputations due to trauma
as a result of the recent military operations in Iraq and
IDETC/CIE 2011
August 29-31, 2011, Washington, DC, USA
DETC2011-47024
Jingzhou (James) Yang
Human-Centric Design Research Laboratory
Department of Mechanical Engineering
Texas Tech University, Lubbock, Texas, 79409
Email: james.yang@ttu.edu
Afghanistan. As of July 2009, there had been 1,224
amputations during Operation Iraqi Freedom and Operation
Enduring Freedom[3].
Of all amputations, lower limb amputations are the most
common, with 97 percent of all dysvascular related amputations
occurring somewhere on the leg[2]. Possible amputations of the
leg can be seen in Figure 1, and range from the loss of one or
more toes in a toe amputation to the loss of the entire leg in hip
disarticulation. The most common of these amputations is the
transtibial or below knee amputation. As the name suggests, the
amputation occurs proximal of the ankle and distal of the knee
joint. While there is no official definition, a transtibial
amputation is generally considered short if it is performed in
the proximal third of the tibia.
The fact that the knee joint is kept intact in transtibial
amputations makes it preferred over more proximal
amputations, such as the transfemoral amputation. The presence
of the knee joint also makes prosthetic use far more convenient,
practical, and economical for transtibial amputees. The standard
below knee prosthetic is generally comprised of four major
components: (1) the socket, which transmits forces between the
residual limb, also known as the residuum, and the prosthetic;
(2) the suspension system, which is designed to support the
prosthetic during the swing phase of the gait cycle and
whenever there is no weight being placed on the prosthetic; (3)
the pylon, which is the median that transmits forces between
the socket and the prosthetic foot, and which also compensates
for the lost limb length due to the amputation; and (4) the
prosthetic foot is attached to the distal end of the prosthetic
which can take the form of many different designs, ranging
from little more than a block of wood to a highly sophisticated
carbon fiber sprinting foot.
1 Copyright © 2011 by ASME

Figure 1. DEPICTION OF THE LOCATIONS OF
STANDARD LOWER LIMB AMPUTATIONS [1].
Over the last 50 years there have been a number of
significant advances in all of these components ranging from
the introduction of energy storage and return prosthetic feet to
the vacuum assisted suspension system. Over the last two
decades there has been a steady increase in the number of
amputations due to vascular diseases, as well as to trauma[2].
This rise has been accompanied by a similar increase in the
amount of research and development targeted at the design of
new prosthetic components, as well as the improvement of
current systems.
This review will attempt to summarize the purpose of the
components and procedures most commonly used in
contemporary transtibial prosthetics, as well as related research.
The first section will describe the patellar tendon-bearing and
total surface-bearing socket designs as well as some of relevant
studies pertaining to them. Numerous books and journal
reviews such as: [4-6] provide general overviews and
comparisons of these designs. Other journal articles such as
those by Narita [7] and Mak [8], attempt to formulate more
technical and quantitative comparisons between the two types
of sockets. In conjunction with the socket, the different types of
liners will be examined, as will Covey’s [9] research into the
mechanical properties of various liner materials. The third part
this section briefly describes distal tibiofibular bone bridging
and why the increased distal weight bearing capability it affords
might prove very beneficial for transtibial prosthetic users.
Over the past six decades there have been a number of studies,
including: [10-13] which have examined both the methods of
forming this type of bone bridge as well as the quantifiable
benefits of doing so.
Section two reviews the benefits and disadvantages
inherent in the relatively new field of direct skeletal attachment
of prosthetics, and what research is currently being carried out
in an effort to make it a more viable option. Mark Pitkin at
Tufts University School of Medicine is one of the leading
researchers in this field, and has published numerous papers
regarding the use of porous titanium rods in direct skeletal
attachment procedures, some of which include: [14-17]. Several
other similar studies have been carried out, such as those by
Fujibayashi [18] and Hagberg [19].
The third section explores the many suspension options
available for transtibial amputees. This topic is split into two
main segments, the first of which reviews conventional
suspension options, while the second explores vacuum-assisted
socket suspension systems. Descriptions of conventional
suspension methods can be found in many books and online
articles including [4] and [20]. In addition to general overviews,
there have been a large number of studies carried out examining
the potential mechanical and medical benefits associated with
using vacuum suspension systems, including: [21-27].
Section four briefly describes the pylon, some of the
devices that can be attached to it, and the studies that have
examined the effectiveness of those additions. Segal [28]
explored the quantifiable benefits of torsion adapters, while
Gard [29] did the same for shock absorbing pylons. Buckley
[30] examined the effectiveness of tele-torsion adapters, which
combine the properties of both a torsion adapter and a shock
absorbing pylon.
Section five, the final section of the paper, focuses on the
many different prosthetic feet available to transtibial amputees.
The first segment is devoted to the biologic foot and its
capabilities in an effort to better explain what features different
prosthetic feet are attempting to mimic. The information in this
section is garnered from a number of different books and
journal articles, including: [31-34]. The following parts
describe the solid ankle cushion heel, flexible keel, single-axis,
and multi-axis prosthetic feet. Much of the general information
for these feet can be found in the book: Physical Medicine and
Rehabilitation: Principles and Practice [4]. Following these
sections energy storage and return feet and some of the studies
related to them are explored. One of the principle areas of
research regarding energy storage and return feet is whether or
not they provide a noticeable decrease in energy consumption
or improve gait in users. Some of the studies relating to this
matter include: [35-37]. The last segment of this paper
examines dedicated sprinting feet, how they evolved from
energy storage and return feet, and their efficiency compared to
biologic feet; with information gathered from a number of
sources, such as: [32, 38-41].
SOCKET
The socket is possibly the second most important
component of the standard transtibial prosthetic following the
foot. It is through the socket that the ground reaction forces are
transferred from the prosthetic to the residuum, and thereby to
the rest of the body. During the stance phase of the gait cycle it
transfers the entire weight of the user to the residuum. It is a
common misconception that this weight is borne by the distal
end of the residuum, but baring bone bridging which shall be
discussed later, this area is generally incapable of bearing
heavy loads. For this reason the prosthesis is typically
supported by distributing the interface stresses amongst the soft
tissues of the residuum. Of the many socket options available to
transtibial amputees, there are two general ways in which the
2 Copyright © 2011 by ASME
pressure is distributed around the residuum currently in
extensive use. The first is the patella tendon-bearing (PTB)
design, which has been the principally used socket since the
1960’s. The other option is the total surface-bearing (TSB)
socket, which had been introduced by the 1980’s [8].
Patella Tendon-Bearing (PTB) Design
The primary concept of the PTB lies in the fact that not all
of the soft tissue of the residuum is capable of bearing weight
safely. The socket, therefore, is designed such that the pressure
is concentrated in the areas that are capable and away from
those that are sensitive. This selective loading is achieved by
first taking a cast of the patient’s residuum and then modifying
it through the addition and subtraction of material inside the
socket at strategic locations [4]. The pressure tolerant areas
include the anterior compartment, the medial tibial flare, and
the patellar ligament (hence the name PTB). Areas that are not
pressure tolerant include the fibular head, the hamstring
tendons, and the tibial crest [4]. A diagram of these various
areas can be seen in Figure 2. This, however, is just a general
guide, as each patient’s requirements can vary widely due to
such things as sensitive skin, tissue scars, or other trauma to the
residuum.
Total Surface-Bearing (TSB) Design
The alternative to the PTB socket is the total surface-
bearing design which as its name implies attempts to distribute
the pressure evenly around the entire area of the residuum
covered by the socket. These sockets are manufactured by first
taking a cast of the residuum, and with few modifications use it
as a mold for the socket. A gel liner is commonly used in
conjunction with the socket which simultaneously transfers
pressure throughout the socket and cushions any bony
prominences. This cushioning effect makes the socket ideally
suited for those amputees with secondary clinical concerns such
as burn tissue, scaring, bony residual limbs, or skin grafts [5].
One study that objectively compared the effectiveness of
the total surface bearing and patellar tendon bearing sockets
was performed by Narita [7]. This study used x-ray and
cineradiography measurements to test which socket type
provided the least displacement of the residuum between the
weight bearing and suspension positions for ten subjects. The
results indicated that the distal end of the subjects’ tibia
translated an average of 1.07cm more in the PTB socket than in
the TSB socket [7].
There are, however, a number of drawbacks to the TSB
socket. One issue is the increased sweating by the residual limb
due to the fact that the residuum is fully encapsulated by the
gel, thus preventing cooling. Another potential problem is that
the TSB socket can allow the limb to rotate within the socket,
thus leading to skin degradation [6]. Additionally, the gel liners
Figure 2. PRESSURE TOLERANT AND INTOLERANT
AREA ON THE RESIDUUM [4].
that are usually prescribed with TSB sockets tend to cost more
than other liner options and their decreased durability requires
that they should be replaced on a regular basis, every 6 to 12
months [4].
Liner
To ensure the proper function of the socket there is a need
for an interface, called a liner, between it and the residuum.
One of the primary purposes of the liner is to maintain an even
pressure distribution on the limb, while lessening the impact
forces and shear stresses acting on the residuum. The other
important role it plays is to keep the residual limb comfortable
by maintaining the temperature, moisture, and other
environmental factors at a comfortable and healthy level.
Additionally prosthetic socks can be used by themselves or in
conjunction with gel, foam, or other types of liners to
compensate for short term changes in the user’s limb volume
through the addition of more layers. The liner used by each
amputee is different depending on his or her socket,
preferences, and medical needs.
Choosing an optimal liner can be difficult because of the
various, and sometimes conflicting, requirements placed upon
it. Ideally, a socket liner should be stiff enough to allow good
control of the prosthetic, but is should also afford adequate
protection by lessening the impact forces and shear stresses on
the residuum. A third important desired property of liners is that
they retain their thickness during ambulation and not compress
unduly, thereby preserving the area of contact and keeping the
stump secure in the socket. Covey [9] examined these very
properties in four liner materials, specifically: urethane, silicone
A, silicone B, and a thermoplastic elastomer. The results of the
study indicated that urethane provided an exceptional
combination of both high stiffness and high energy absorption,
as well as a stable thickness under loading and unloading.
3 Copyright © 2011 by ASME
Figure 3. X-RAY EXAMPLE OF A DISTAL TIBIOFIBULAR
BONE BRIDGE [12].
Distal Tbiofibular Bone Bridging
In 1949 in Germany, the Hungarian Surgeon Janos Ertl
described a technique called osteoperiosteoplasty in which he
used a periosteum cylinder extracted from the tibia to bridge
the distal ends of the tibia and fibula [11]. Recently, Pinto [10]
performed a similar bone bridging procedure on fifteen
patients, and rather than using a section of the tibia, a piece of
the fibula was used instead. The results were very promising
with stable bone bridge unions forming for all of the patients in
the absence of extenuating circumstances. This study indicates
that if there happens to be more of the fibula present than the
tibia during an operation it is still possible to create a bone
bridge without making the residuum any shorter than necessary.
The joining of the tibia and fibula increases the transversal
area significantly over conventional transtibial amputations as
can be seen in Figure 3 [10, 11]. This increase in area allows
the patient to carry more weight on the distal end of their stump
without considerable pain. It is for this reason that distal
tibiofibular bone bridging is an excellent option for those who
have residuums with weight bearing or stress toleration
compromised by factors such as trauma, scars, skin grafts, or
sensitive skin. Another benefit to bone bridging is that the
fibula is stabilized to the tibia, thus decreasing the possibility of
the terminal end of the fibula from dislocating towards the tibia
when compressed [10].
Bone bridging allows for a significantly increased amount
of weight to be borne on the distal end of the stump, thereby
reducing the shear stresses on the soft tissues of the residuum.
Even though this technique has been in use for over half a
century, it is still not the standard form of transtibial
amputation. One limitation of the Ertl procedure is that due to
the fact that the periosteum cylinder is gathered from the tibia,
the amputation cannot be performed if the damage to the limb
is located very proximally in the tibia [13]. Additionally, this
procedure is typically disrecommend for those that do not have
adequate blood circulation due to the significant alteration of
the bone and tissues required [10]. While it is true that an
increased amount of weight can be borne on the distal end, this
Figure 4. A TRANSFEMORAL AMPUTEE WITH AN
ABUTMENT ATTACHED DIRECTLY TO HIS SKELETON;
(a) TITANIUM PYLON, (b) SURROUNDING SKIN, (c)
LAYER OF PUS, INDICATING INFECTION [14].
does not mean that all of the weight should be directed there
because there is still a possibility of tissue damage at the
terminal end of the stump. The skin on the leg which is used to
cover the end of the residuum is not designed to sustain the
pressures like that of the skin on the bottom of the foot [42].
DIRECT SKELETAL ATTACHMENT (DSA)
While the use of the socket has been the standard method
for transferring the forces from the prosthetic to the residuum
since the development of the peg leg prosthesis, a new method
has begun to evolve. In the 1980’s Dr. Per-Ingvar Brånemark
used a technique similar to the one he developed for threaded
titanium dental implants to attempt to attach the prosthetic
directly to the bones of the residuum[14]. His procedure
consists of implanting a threaded titanium fixture into the
residual skeleton, and then connecting it to an abutment that
passes through the skin to which the prosthetic can be attached.
Brånemark called this bond created between the implant and
the bone “osseointegration”. This integration of the prosthetic
with the skeleton was intended to reduce or even eliminate all
of the negative aspects of the use of a socket, including skin
irritation and deterioration, pain, and an imperfect mating of
prosthetic and residuum [14, 15].
Benefits of the DSA Method
The direct skeletal attachment method shows potential as a
future primary method of prosthetic mounting due to the
number of advantages it has over the use of a socket. First,
there is better force transfer between the prosthetic and the
residuum, as it eliminates any play between a socket and the
residual limb. There is also an extended range of motion
associated with the DSA system, due to the fact that there is no
socket extending proximally on the posterior side of the
residuum. It is for this same reason that comfort while in a
sitting position is also generally improved. Additionally, the
abutment provides the patient with a method of attachment far
faster and easier than donning a socket and all of its required
4 Copyright © 2011 by ASME
support features. Lastly, the DSA method shows promise in the
emerging field of direct neural control of prostheses as a
conductor of the required signals[14].
Disadvantages of the DSA Method
Despite all of these advantages over the current system,
there are a number of crucial long term disadvantages that
hamper its adoption as a reliable technique. The primary
problem that arises with the DSA method is the high percentage
of patients that develop an infection at the implant-device
interface, an example of which can be seen in the layer of puss
in Figure 4. There needs to be a firm union between the
abutment and the surrounding skin, or the skin will move along
the pylon, which can cause pus to form at the interface [16].
The infection can lead to the loosening of the abutment through
the formation of abscesses, and even to death in some cases.
Due to these potential complications, the method is not
approved in the United States, and only conditionally approved
in the United Kingdom and Australia. The only countries in
which the DSA method is currently approved are Sweden,
Norway, and Spain [12].
Research Advances for DSA
In spite of all of its current failings, there is a substantial
amount of research being carried out in an attempt to make
DSA a viable method, particularly by Mark R. Pitkin at Tufts
University School of Medicine. One of the studies that have
produced the most promising results is the use of porous
titanium pylons. Pitkin and others theorized that a porous
titanium pylon would allow the skin to grow deeply into the
pylon [14, 18]. As of June 2008, 100 transfemoral amputees
had been treated with DSA in Sweden alone but most if not all
of the pylons used have been smooth titanium rods [19]. Pitkin
did, however, test rods made from porous titanium in 15 rats
and achieved very promising results compared to the control
group of 15 rats with solid rods. In addition to better integration
of the pylon with the bone and skin than in the control group,
there were also fewer indications of inflammation in the rats
with porous abutments. While this pilot study indicates that
porous titanium pylons may solve a number of the problems
associated with DSA, the test was limited to 15 rats and the
pylons were only left in the subjects for periods of 14, 28, or 42
days before they were removed for examination [16, 17]. A
larger test population and a longer test period would be
necessary before definitive conclusions can be drawn about the
effectiveness of the technique.
SUSPENSION
While in traditional prosthetics the socket is the part that
transfers the forces from the foot to the residuum, it is not the
primary component that maintains the coupling between the
artificial limb and the residuum. A secondary system is required
to support it and ensure that it maintains its continual
connection to the residual limb. In addition to suspending the
prosthetic, it should also act to reduce the pistoning effect of the
limb within the socket during ambulation [4]. There are a
(a) (b) (c)
Figure 5. EXAMPLES OF VARIOUS SUSPENSION
OPTIONS. (a) CUFF STRAP WITH AND WITHOUT WAIST
SUPPORT, (b) NEOPRENE SLEEVE, (c) JOINT & CORSET
SYSTEM[4].
number of different options for this component, ranging from
neoprene sleeves to waist belt suspension systems, to vacuum
methods. Each option has its own benefits and detractions, and
the choice of which one to use mostly depends on the
subjective comfort afforded to each wearer individually.
Conventional Methods
Perhaps the simplest option for suspension is a sleeve
made out of either rubber or neoprene. The tight sleeve is
pulled up over the socket and the residuum above it, and uses
friction over its large surface area to maintain the contact
between the prosthetic and the residuum. While it is
inexpensive and effective for amputees of most activity levels,
it can lead to unacceptable heat or sweat build up, especially in
warmer climates [4].
Another method of suspension commonly used in
conjunction with PTB sockets is the PTB cuff strap. This
system consists of straps attached to the side of the socket
which are supported by a cuff strap above the knee, and if
additional support is required this can be attached to a belt at
the waist to afford maximum suspension. The primary
advantage of a strap based suspension system is that it can be
adjusted by the wearer without a prosthetist’s assistance. This
makes it suitable for those expecting significant changes of
weight [4, 20].
A third option that, while not currently used to a great
extent, can be very useful for special cases is often called a
“joints and corset” system. This consists of metal hinges
connecting the socket to a corset laced to the thigh. While the
mere weight of this option has led to its decline in use over the
years, it is still useful in a number of specialized cases, such as
when the tissue of the residuum is damaged to such an extent
that it can no longer bear the user’s full weight. In this case the
metal hinges can transfer approximately half of the forces to the
thigh and away from the damaged residuum. It can also be
useful when there is a need to brace the knee and prevent
excessive motion [4, 20]. Representations of the joint corset
and other conventional methods of suspension can be seen
Figure 6.
5 Copyright © 2011 by ASME
 as 10% of the residual limb’s volume during normal daily
activity [22]. This decrease in limb volume can be the
beginning of a cycle in which the pressure on the residuum is
steadily increased throughout the day by the addition of more
prosthetic socks to maintain control of the prosthetic, while
simultaneously causing a further decrease in limb volume. In
addition to jeopardizing the coupling between the socket and
the residuum, the decrease in volume can also force bony
(a) (b) (c) prominences to bear an increased amount of the load during the
ambulation [23].
Figure(a) 6. (b) (c)
EXAMPLES OF(d) VARIOUS SUSPENSION Studies performed by W. J. Board and J Goswami at St.
OPTIONS. (a) CUFF STRAP WITH AND WITHOUT WAIST Cloud University Minnesota examined the effects of normal
Figure
SUPPORT,7. X-RAYS DISPLAYING
(b) NEOPRENE SLEEVE,THE DIFFERENCE
(c) JOINT IN
& CORSET and vacuum condition in the socket. Board found that in normal
DISTAL
SYSTEM [4]. TIBIA DISPLACEMENT IN LOADED AND
conditions there was a mean decrease in volume of 6.5%, but
UNLOADED CONDITIONS WITH RESPECT TO THE
when a -78kPa vacuum was created in the space between the
SOCKET IN A PTB SOCKET (a AND b) AND IN A
socket and the liner the volume of the stump increased by an
SUCTION SOCKET (c AND d) [27].
average of 3.7% of its initial size [22]. Goswami examined
whether the size of the socket with respect to the initial size of
Vacuum Method
the stump affects volume loss or gain under vacuum conditions.
One form of suspension that has grown in popularity over
In the study three different sockets were used, one which was
the years since its introduction in 1999 is the vacuum-assisted
undersized, another that was neutral, and a third that was
socket suspension (VASS) system [21]. This system uses a
oversized. While there was a decrease in stump volume for the
combination of an airtight sleeve, a vacuum pump, a liner, and
undersized socket by 2%, the other sockets caused increases of
a TSB socket. The sleeve is rolled over the proximal end of the
as much as 11% under vacuum conditions. The results indicate
socket and the residual limb, thus creating a sealed pocket of air
that the residual limbs of the subjects were able to reach
between the socket and the liner worn on the residuum. The
volumes greater than that available in the sockets. The authors
pump is used to evacuate the air in this sealed space and create
propose that this is made possible by the vacuum drawing fluid
an area of negative pressure relative to the atmospheric
into the soft tissues of the limb and essentially extending the
pressure. Some prosthetics incorporate a vacuum pump in the
length of the limb distally. Despite this significant increase in
pylon that mechanically evacuates the air on each step, thus
volume there were no visual sings of reddening or reports of
automatically maintaining the vacuum during ambulation.
pain by the patients, thereby indicating to the researchers that
Other prosthetics use small battery powered pumps to create
the volume was gained globally within the limb [24].
and maintain the vacuum [4].
While there are few available studies that examine the
The VASS system has demonstrated a number of benefits
objective clinical benefit of VASS systems, there have been
over the more traditional forms of suspension. One such
some pilot studies and anecdotal evidence that the increase of
advantage is that for an average sized residuum, a negative
fluid in the stump may also help maintain the health of the
pressure of -78kPa can generate a large suspension force of
residual limb. An example of one of these pilot studies is the
70kg. Considering that typical extraction forces rarely exceed 5
measurement of transcutaneous oxygen tension in the residual
to 10kg, this suspension system is more than adequate for most
limb of an amputee who began wearing a VASS system. Before
users [21]. One issue, however, is that that the vacuum is
he began using one, the readings were 40mmHG, but after a
dependent on the integrity of the airtight sleeve. If a small hole
month of using the VASS system, it increased to 50mmHG,
develops, due to either normal wear or interactions with the
thereby indicating a possibly healthier limb [25]. There have
surroundings, the vacuum can dissipate, thereby removing the
also been patient reports of skin conditions or sores that have
suspension forces. It is for this reason that sleeves must be
begun to heal after they started wearing a VASS.
replaced on a regular basis [20].
Another aspect of vacuum assisted suspension systems that
In addition to creating an exceptionally large suspension
is regularly examined relates to the theory that they reduce the
force, the vacuum also acts to reverse the decrease in volume
cyclic vertical movement of the residuum within the socket,
observed in the limb during normal daily activity when wearing
which is sometimes called pistoning. In a pilot study, Söderberg
a standard suspension system. When a TSB suction suspension
used Roetgen Stereophotogrammetric analysis to measure the
socket is prescribed it is generally undersized by between four
vertical motion of the distal end of the tibia in relation to the
and six percent, to ensure that the stump and socket maintain a
socket in one subject, for four different support options. The
secure fit. This, however, can be counterproductive. The
VASS resulted in the least amount of pistoning, at an average
application of shear and normal stress to the soft tissues of the
value of approximately 7mm [26]. Board and Street also
residual limb can cause ulceration of the skin, vascular
conducted a study comparing the pistoning effects in vacuum
occlusion, and volume loss. A tight fitting socket, which is
and normal conditions. Their results showed that the tibia, on
necessary for stability, can therefore cause the loss of as much
average, shifted 7mm less under vacuum conditions, compared

6 Copyright © 2011 by ASME

to standard suspension, and the liner displaced 4mm less as
well [22]. A study by Grevsten further supports the conclusions
drawn by the other researchers. The displacement of the tibia
within the socket was measured for both a suction and PTB
socket while loaded. The displacement in the PTB socket was
measured at 2.25cm while in the suction socket it was only
1.10cm under the same load conditions [27]. Figure 7 illustrates
how Grevsten used X-rays to measure the difference in limb
displacement for PTB and suction sockets.
The reduction of pistoning is very important for
maintaining the health of the tissue in the residuum. Pistoning
transforms the tangential shear stress in the limb into friction
which is shear stress with slipping occurring between the socket
and the surrounding tissue. Friction typically results heat
generation and the formation of blisters with fluid gathering
between the granular and the basal cell layer. It can also result
in epidermal abrasions if the skin is too thin [42]. The
formation of blisters or skin ulcers generally results in the
amputee being unable to wear the prosthesis until the limb has
healed, thus reducing their mobility [23]. If there is no slipping,
on the other hand, the tangential shear stress is more evenly
spread throughout the tissue, thereby decreasing the potential of
injury due to stress concentrations [42]. This lack of slipping
also has the added benefit of reducing heat generation in the
residual limb, which increases quality of life for the amputee,
and further decreases the likelihood of skin problems. The
reduction in heat generation is no small matter; a study by
Hagberg and Brånemark showed that of 97 amputees 72% felt
that heat and sweating were the most common causes of
reduced quality of life [43].
PYLON
The pylon is the component that connects the foot to the
socket and also acts to compensate for the length of limb lost in
the amputation. It is typically a tubular piece of aluminum,
stainless steel, or titanium. Shasmin developed and tested a
pylon made of bamboo, in an attempt to create a pylon that was
both lightweight, and inexpensive [44]. In the study, a
comparison was made of the kinetics and kinematics of ten
unilateral transtibial amputees’ gaits when using steel and
bamboo pylons. Despite the bamboo components being lighter,
no significant difference was found in either the stride length or
stride frequency of the subjects. Although there was no
observed significant increase or decrease in gait performance,
bamboo may yet prove to be a cost effective material for use in
developing nations. While the basic pylon design in and of
itself may not be very complicated, it can be modified to
include a number of different mechanisms, such as torsion
adapters, and or shock absorbers.
Torsion adapters allow for transverse plane rotation and
thereby reduce the potential for torques to be transmitted to the
residuum from the socket. A test was conducted by Segal [28]
as to whether the addition of a torsion adapter to the proximal
end of the pylon reduced the transverse moments and therefore
the shear stresses on the limb, when compared to a simple rigid
adapter. Their tests indicated that there may not be any
Figure 8. ENDOLITE TELESCOPIC-TORSION PYLON
USED TO PROVIDE SHOCK ABSORPTION AND
DAMPEN AXIAL TORQUES ON THE RESIDUUM [29].
significant benefits during straight line ambulation, but that
there may be a reduction in the moments at the knee and hip
during turning maneuvers.
Shock-absorbing pylons (SAP) are marketed by
manufactures as a means of reducing the impact forces
imparted on the residual limb during ambulation, thus
increasing comfort and decreasing the possibility of injury.
Gard [29] examined how the addition of shock absorbers
affected the gait of unilateral transtibial amputees. His results
indicated that there may be a significant benefit for users that
walk at speeds above 1.3m/s. At these speeds the subjects’
residual limbs experienced reductions in applied forces by as
much as 60% of the subjects’ body weight during ambulation.
This and similar other studies have been limited to relatively
short time frames of observation, so the long term effects of
using SAPs is not currently known. It is, however, theorized
that their use may also act to reduce the probability of trauma to
the joints and back compared to using a rigid pylon [29].
While there are a number of studies that examined the
effectiveness of the use of torsion adapters and shock absorbing
pylons independently, a study carried out by Buckley [30]
examined the oxygen consumption of amputees using
prostheses with and without the tele-torsion adapters seen in
Figure 8. Their results indicate that at normal walking speeds,
the addition of a torsion adapter does not produce a significant
difference in oxygen consumption. However, similar to the
results obtained by Gard [29], at 130% and 160% of normal
walking speed the oxygen consumption of the amputees during
ambulation dropped by 5.4% and 9.1% respectively. A
reduction of 9.1% in oxygen consumption is a significant
advantage, and if the results garnered by this study of 6 subjects
can be applied to the transtibial amputee population as a whole,
then it would appear that for active users the tele-torsion
adapter is a valuable addition to the general prosthetic system.
PROSTHETIC FEET
On the distal end of the pylon is perhaps the most
important component of the transtibial prosthetic, the foot.
These can range in complexity from the solid ankle cushion
heel (SACH) to the specialized sprinting foot. Each one tries to
approximate one or more of the capabilities and functions of
the biologic foot. In general, however, there are five basic foot
archetypes currently available: the SACH, flexible keel, single-
axis, multi-axis, and energy storage and return feet. The
categorization of some feet is made difficult by the fact that
many have begun to incorporate features of multiple designs.
7 Copyright © 2011 by ASME
 (a) (b) (c)
Figure 10. CROSS SECTION EXAMPLES OF PROSTHETIC
FEET. (a) SACH; (b) SINGLE-AXIS; AND (c) FLEXIBLE
KEEL PROSTHETIC FEET [15, 45].

inversion occurs around the sagital axis in the frontal plane, and
represents the foot’s rotation away from the center line of the
body. Pronation which is sometimes called eversion is the same
Figure 9. GRAPHICAL EXAMPLES OF FOOT MOTIONS as pronation, except the foot rotates towards the centerline.
AND PLANES OF ACTION AS WELL AS THEIR Abduction and adduction are rotations around the longitudinal
NOMENCLATURE [33]. axis in the transverse plane away from and toward the
centerline respectively [33]. Figure 9 provides some graphical
examples of these types of movements, as well as the cardinal
For example the Genesis II foot (MICA, Longview, WA)
plans of the human body. While there are many other joints in
incorporates features of both multi-axis and energy storage and
the foot that play an important role while walking, most
return prosthetic feet. In addition to complicating classification,
prosthetics are categorized by the range of motion of the ankle
this also makes it difficult to objectively analyze and accurately
as that is perhaps the most crucial joint utilized during
compare broad groups of prosthetics, because ultimately each
ambulation.
prosthetic is essentially unique. In order to understand the
The foot and ankle are a complex system that we are only
intent behind the many designs for these prosthetic feet, it is
now beginning to understand. Recently there has been an
necessary to first understand some of the biomechanics of the
increase in the study of the human foot and how it functions
natural foot.
during ambulation, particularly for the purpose of designing
better prosthetics. Hansen [34] examined the “quasi-stiffness“,
Brief Biomechanics of the Biologic Foot
or the slopes of the sagittal plane moment versus ankle angle
The foot and ankle is a very complicated system comprised
curves during loading, and found that at low to normal speed
of 26 bones, 33 joints, and over 100 muscles, tendons, and
the ankle can be modeled with a fairly simple rotational spring-
ligaments. This intricate arrangement enables the biologic foot
damper model, but as the ambulation speed increases the model
to not only rotate in all three planes but also to conform to
becomes more complicated[34]. This set of results clearly
uneven surfaces, thus allowing a person to adapt to and
illustrates how the ankle and foot system may sometimes be
navigate rough terrain. Further complicating the study of the
modeled, or in the case of amputees replaced, with simple
foot is the fact that the mechanical axes of motion are not in the
devices. These simple devices, such as the SACH, only mimic
cardinal planes, but rather pass through all three [31]. The foot
the functions of the real foot under specific limited ranges of
also takes an active role in the gait process by providing power
capabilities, thus requiring increasingly complex prosthetics if
in the toe off phase with a calculated energy efficiency of 241%
that functional range is to be expanded.
while running [32]. Learning all of the complex interactions
and functions of the foot can be made a career in and of itself. It
is therefore the intention of this paper to describe the SACH Feet
One of the simplest feet on the market today is the SACH
biomechanics of the foot in a simplified form that can be easily
foot, a diagram of which can be seen in Figure 10-a. It is light,
understood, but still model the functions of the foot and foot
inexpensive, and durable which makes it one of the most
prosthetics to an acceptable degree.
commonly prescribed prosthetic feet. There are no moving
Due to the fact that the mechanical axes of motion of the
parts and is therefore the foot with the least range of motion
joints in the foot are not perpendicular to the cardinal planes,
(ROM). It is this lack of ROM that makes it ill-suited for
their motions occur in planes passing through all three and are
walking on rough terrain as the prosthetic transfers torque to
therefore called triplanar motions [31]. For simplicity of
the residual limb rather than adapting to non-level surfaces.
communication and analysis, however, the motions of the foot
The heel and toes, however, are made of a rubber which
are commonly broken down and treated as if they occur only in
compresses under weight, thus mimicking to a small extent the
the three cardinal planes. Dorsiflextion is the rotation of the
heel and forefoot rocker mechanisms of the biologic foot[4].
foot toward the dorsal (top) surface of the foot around the
The spring off action of the forefoot is small compared to other
frontal axis in the sagital plane, while plantar flexion is the
feet and further decreases as the rubber ages and deteriorates. It
rotation of the foot along the same axis, but towards the plantar
is suitable for low levels of activity on generally flat terrain, for
(bottom) surface of the foot. Supination also known as
which the full range of motion of a biologic foot is not strictly

8 Copyright © 2011 by ASME

necessary. It is also a good option for young amputees as they
require frequent changes in prosthetics due to growth, and the
low cost of the SACH makes it an economical choice [4].
Flexible Keel Feet
Flexible keel feet such as the stationary-ankle-flexible-
endoskeletal (SAFE) II have a flexible keel instead of the rigid
keel of the SACH. This flexibility offers the user a limited
amount of inversion and eversion, as well as a smoother
rollover than rigid keel prosthetics. Good for users with low to
moderate ambulation activity levels. Active users may find it to
be too flexible, especially during walking at higher speeds than
normal [4]. Flexible keel feet typically use an elastic material in
a layered fashion, as can be seen in Figure 10-c, which both
allows for some spring off near the toe off phase of the gait
cycle and provides a more realistic rollover action in the foot.
The lack of moving parts reduces weight, and maintenance
requirements.
Single-Axis Feet
Single-axis feet introduce a joint at the ankle location that
allows for plantarflexion and dorsiflexion motion. This allows
for a reduction in the bending moments at the knee during
ambulation, thus providing increased stability[4]. It is for this
reason that the single-axis foot is one of the more preferred feet
for those requiring stabilization of the knee, such as the elderly,
transfemoral amputees, or those with short residual limbs. The
addition of this axis of rotation also enables the user to traverse
up and down slanted surfaces, such as ramps. It, however, is
still not ideal for traversing rough terrain, as the lack of
supination and pronation causes torques to be transmitted from
the prosthetic to the residual limb. The primary disadvantage of
this design is that the motion they allow is often achieved
through the use of mechanical joints and mechanisms. This
increases the weight, the cost, and the amount of maintenance
required to keep them functioning properly. Lately, however,
the use of flexible rubber and polymers has allowed designers
to achieve some of these motion capabilities while
simultaneously mechanically simplifying the prosthetic[4]. A
common single axis foot design with a mechanical joint can be
seen in Figure 10-b above.
Multi-Axis Feet
Multi-axis feet typically not only allow for motion in the
sagittal plane, but also in the frontal, and transverse planes. The
enabling of movement in the frontal plane is critical for
allowing an amputee to navigate uneven terrain. The supination
and pronation of the foot is what allows one to remain stable
while standing on a slope facing perpendicular to its rise. It also
allows the amputee to lean to his left or right without subjecting
his residual limb to undue stress. This improved range of
motion, therefore, makes the multi-axis prosthetic foot ideal for
active users who often have to navigate uneven terrain, adjust
their walking speed during ambulation, or require the ability to
quickly pivot. The disadvantages of this design are similar to
those of the single-axis foot in respect to the increase in weight
and required maintenance.
Energy Storage and Return Feet (ESAR)
Another option for active users is an energy storage and
return foot, which is also sometimes called energy storing,
dynamic response, or dynamic elastic response prosthetic feet.
These feet use flexible materials to store energy as the foot
flexes in the stance phase of ambulation, and then returns that
energy near toe-off as it returns to its normal shape, thereby
giving the user some of the active response of a biologic foot.
This energy return is often marketed by manufactures as a
means of reducing the energy cost of walking.
While it is often stated that the energy storage and return
feet reduce the energy consumption of users, the objective
comparisons of metabolic energy expenditure while using an
ESAR vs. a conventional foot do not necessarily support this
claim. Of nine studies only three found a decrease in energy
consumption when using an ESAR. The results of these three
studies, however, may have been compromised due to factors
such as small sample size, short sample time, or the use of
experimental feet not available to the general market [35, 36].
Another claim is the use of an ESAR can increase the gait
performance of the user. A number of studies have been carried
out to test this theory by comparing such gait parameters as
self-selected walking velocity (S-SWV), stride length, and
cadence. In general there was an observed increase in all there
parameters, but it is unknown whether these increases are in
fact clinically significant. Comparing nine studies Hafner [35]
tabulated a mean increase in S-SWV of 4.7%, but it is thought
that the variability of a person’s daily S-SWV may be as much
as 7.1% of the average, thereby making the increase statistically
insignificant. Similarly, for five studies of cadence there was an
average increase of 2.1% while the daily variability is 3.4%.
Stride length was the only parameter that an increase over the
daily variation was observed. For seven studies in stride length
the mean increase was 3.3% and the daily variation is 3.0%.
While these small increases over the conventional foot may be
dismissed by some as insignificant, amputees may find
substantial benefit in them. Hafner used the mean walking
velocity of 75.4m/min and mean stride length of 1.34m to
calculate that over 3hrs of walking a day an amputee using an
ESAR foot can travel an additional 0.63km with 456 less
strides in a day. As he points out, that is nearly 500 fewer
impacts on the residual limb each day. This increase in
traversable distance, and decrease in impacts will be even more
significant for the more active users [35-37].
While statistically the objective data may indicate that
there is little if any benefit to the use of an ESAR over a more
conventional prosthetic foot, the subjective opinions of users is
generally overwhelmingly in favor of the ESAR foot. Generally
amputees believed that the use of an ESAR improved their gait,
increased their range of motion, and caused less pain. The only
category that users found the ESAR to be detrimental was in
walking downstairs or downhill [35].
9 Copyright © 2011 by ASME

Figure 11. THE ENERGY STORAGE AND RETURN
PROSTHETIC FOOT, FLEXFOOT AND DEDICATED
SPRINTING FEET CHEETAH, AND C-SPRINT [15, 41].
Dedicated Sprinting Prosthetic Feet
Another design that differs radically from all of the above
prosthetics is the sprinting foot. This foot design is an
adaptation of the original carbon fiber foot introduced in the
1980’s named the flex foot, a diagram of which can be seen in
Figure 11. It was not only one of the first ESAR feet but also
one of the first prosthetics to be made out of carbon fiber. The
flex foot is comprised of two pieces of carbon fiber, a shank
and ankle section and a heel section. By 1992 the ankle section
was removed, producing the sprinting foot design, which has
changed very little since then [32].
These prosthetics are so specialized for the task of
sprinting that the current record set by an amputee using them
in the 100m dash is 10.91s This record was set by the bilateral
transfemoral amputee Oscar Pistorius in 2007, which is less
than one and a half seconds slower than the current world
record [38]. Despite this amazing achievement, the prosthetics
are still not nearly as efficient as the natural human foot.
Czerniecki [39] observed that while running at a speed of
2.8݉‫ି ݏ‬ଵ the flex foot absorbs 28.6 J and returns 24.1 J while
the natural human ankle absorbs 26.1 J and generates 62.9 J.
This is a relative energy efficiency of 84% and 241%
respectively [32, 39]. While the efficiency of carbon fiber
prosthetics in this study may be nearly 90% their inherently
passive designs indicate that for the foreseeable future they
simply will not approach the capabilities of the natural foot.
Another study compared the energy consumption during
running for both amputees and individuals with sound limbs,
and in spite of the difference in energy efficiency, it was
observed that at speeds of 2.2݉‫ି ݏ‬ଵ their heart rate and volume
of oxygen consumption (ܸܱଶ ) were remarkably similar. For one
bilateral and two unilateral amputees their mean heart rate and
peak ܸܱଶ were 186 b/min and 50.7 ml/kg/min respectively
while similar non-disabled runners displayed values of 182
b/min and 55.0 ml/kg/min. It is theorized that this similarity,
despite the energy efficiency discrepancy is the result of the
prosthetics being on average 3.5 kg lighter than the natural leg
and foot system, thus requiring less effort from the leg
muscles[32, 40].
CONCLUSION
Many important advances in prosthetic technology have
been made over the last 50 years. Some have helped the
transtibial amputee population in general, such as the vacuum
assisted suspension system, the single-axis foot, and total
surface-bearing sockets. Others have provided the more active
prosthetic user with capabilities of movement hitherto
unavailable to them, such as the dedicated sprinting foot, shock
absorbing pylons, and the multi-axis foot.
Despite all of these advances there is still significant room
for improvement and study. Some of the key aspects of current
and previous studies that could be improved upon are the long
term effects of the use of particular components, and the sample
size for some experiments. Much of the current literature
available concerns studies with sample sizes as low as five
people, which can often give rise to questions of whether the
conclusions garnered from such studies can be applied to the
amputee population as a whole. Also, many investigations
attempting to objectively analyze the effectiveness of particular
components tend to gather data over very short periods of
ambulation, sometimes as little as two or five minutes. While
the results from these studies may give an accurate view of the
short term benefits and disadvantages for particular systems, it
does little to examine the long term effects, which is often what
concerns users the most.
While there is a substantial amount of effort being
dedicated to the study and improvement of these and other
components, even more research is being directed at entirely
new designs and concepts. One of these fields of research is the
study of the biologic foot in the effort to more accurately mimic
it in prosthetics. Another is the attempt to directly attach the
prosthetic to the residual skeleton of the amputee. It is to be
hoped that in the near future the current issues associated with
osseointegration and other fields of research be overcome, thus
providing the transtibial amputee community with a plethora of
new options and opportunities [5, 8].
ACKNOWLEDGMENTS
This work was partly supported by the President
Fellowship, Texas Tech University.
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