40 Ways to Celebrate Limb Loss & Limb Difference Awareness

The O&P PT joins the Amputee Coalition’s Show Us Your 40 Challenge in celebrating National Limb Loss and Limb Difference Month.^1,2

40 things I’ve learned as a physical therapist dedicated to orthotic and prosthetic rehabilitation:

1. Never stop learning.

Technology is constantly evolving and evidence-based care is becoming more robust every day. O&P users are becoming even more savvy as availability to resources are more readily available. Whether you are a professional, someone with LLLD or a family member, stay curious and increase your knowledge of O&P rehabilitation.

2. The Limb Loss Limb Difference Community is unbelievable.

This is a united, collaborative, generous community of people. From those with LLLD to their families, O&P professionals, researchers, innovators, educators and clinicians to volunteers and peer visitors; the list is endless. Each person contributes in their own way to a greater goal. I have never felt just like a PT in this community; I have always felt like a valued member.

3. Lay prone.³

Individuals following limb loss should lay on their stomachs for at least 20 minutes per day to help stretch their hip flexor muscles. Remaining flexible allows us to engage our strong extensor muscles of our core for stability with walking.

4. Strengthen hip abductor muscles.⁴

If there was one message I have clearly conveyed to my students and clients over the years it is this: Strengthen the hip abductor muscles! These muscles are key contributors to the stance phase of gait, stabilizing the pelvis and helping provide stability of the residual limb within the prosthetic socket.

5. Know your Nomenclature.

Be an informed consumer and/or provider of healthcare. Understand and use the proper terms to streamline care. To describe an intervention: use the nouns orthosis or prosthesis. Unless you’re describing the field of orthotics or prosthetics, save those words as adjectives. If you’re a professional, keep “brace” as a layman’s term.

6. All about alignment.³

Skeletal alignment allows our muscles to function at their full potential. We achieve this by proper posture and staying flexible. These are necessary actions for O&P users to perform an efficient gait pattern. Together your healthcare team can help guide you in reaching this goal. Certified Prosthetist Orthotists can optimize the trochanter knee ankle line through prosthetic adjustments. Physical Therapists can promote engagement of muscle activation through customized stretching and strengthening exercise prescription.

7. Advocate.²

The shift in our healthcare system has necessitated consumers to become self-advocates. Informed decision making and knowledge of the multi-facets of health delivery including diagnostic tests and insurance authorization are just a few areas required. To ensure best care, we must work together to advocate for access, quality and availability of free resources. The O&P PT is one avenue where users can find current advocacy information.

8. Proper Fit = Proper Function.⁵

Another phrase I drive home with students and patients: proper fit equals proper function. Each orthosis and prosthesis is engineered with strategically placed forces to load pressure tolerant areas, offload pressure sensitive areas and support a specific O&P goal. The CPO has evaluated and fitted the O&P device specifically to reach the user’s needs. Ensuring the proper fit each time the intervention is donned is vital to protect one’s skin and allow for optimal use. If you as a user or clinician are unsure of how to properly don the O&P device, check with the CPO.

9. Volunteer!^6-8

If you wish to learn more about yourself and prosthetic & orthotic care, volunteer with a LLLD group. In my humble opinion, nothing compares to experiential learning. Being a member of a family, sorority & profession that values philanthropy and undergoing cooperative educational learning to become a physical therapist have all strengthened this view. You gain when you give. There are numerous opportunities for laypersons and clinicians to participate (e.g., mobility clinics, adaptive sports, camps for kids). Sign up today.

10. Documentation is key.^9,10

Specific physician documentation of medical necessity is instrumental to insurance authorization of the prescribed O&P device. Requirements of Medicare Local Coverage Determinations (LCD codes) set the standard of criteria for which devices are deemed “reasonable and necessary”.

11. The energy cost of prosthetic gait can be 100-200% more than typical gait.¹¹

In general, there is a higher energy cost ambulating with a prosthesis, but additional factors can raise that need. The shorter the residual limb, the greater the demand of the remaining muscles which are at a mechanical disadvantage given a shorter lever arm. In other words, less muscle mass to move more prosthesis. The presence of certain comorbidities (e.g., peripheral vascular disease) will lead to a higher energy cost with prosthetic gait as well.

12. Healing process following limb loss is both physical and mental.^12-14

An individual faces many levels of adjustment following limb loss. These could include physical, emotional, personal, vocational, financial factors and more. Many will progress through the 5 stages of grief and some may experience anxiety, depression and posttraumatic stress. Maladaptive coping skills can lead to overcompensation, avoidance, increased pain, self-isolation and refusal of services. It is important that individuals with LLLD and their families have access to peer support, open lines of communication, promotion of adaptive coping mechanisms and sound resources. Fortunately, there are a bounty of legitimate resources available. One I readily share with my patients and their families is the Amputee Coalition website which holds robust sources in both English and Spanish.

13. Check your skin.⁵

Our skin is our largest organ and first line of protection. We must respect it and build tolerance when wearing new shoes, orthoses or prostheses. Slowly increasing wearing time and checking skin regularly are paramount. Areas of compromised skin integrity (e.g., scars, blisters, grafts) and those with reduced healing (e.g., diabetes, medications) require extra attention. Protect your skin.

14. Wear an interface with your orthosis.

It is best practice to wear a sock or stockinette when wearing an orthosis. An interface acts as protection between your skin and the materials that make up your orthosis (e.g., thermoplastic, carbon graphite). This will also help wick away moisture.

15. Daily cleansing is instrumental to prosthetic use.

In general, follow these instructions. Residual Limb: wash with gentle soap, dry thoroughly and inspect skin daily. Gel Liner/Shrinker/Prosthetic Socks: hand wash with mild soap and air dry regularly. Prosthetic Socket: spray with alcohol based cleaner and air dry regularly. Check with your prosthetist for specific products recommended for your prescribed prosthesis.

16. Lower density = lower energy cost.

The lighter the materials of the orthosis or prosthesis leads to less weight borne by the O&P user and ultimately lower energy expenditure. Energy efficient gait is beneficial to anyone but particularly those with compromised musculature (e.g., loss of muscle mass with limb loss; hemiparesis following stroke). Lower energy cost can lend to greater distance of ambulation, improved endurance and less compensatory strategies & potential resultant pain from overuse.

17. Prosthetic users should carry varied sock ply with them at all times.

Volume changes are likely to occur in one’s residual limb throughout the day. The amount of activity and perspiration and the type of suspension & socket will influence the extent of these changes. Having sock ply readily available will help the user ensure proper fit & function to promote optimal participation in the day’s activities.

18. There’s a reason your AFO is as tall as it is.

Many times orthotic users ask if their AFO can be made shorter. While this may seem like a strategy to make an AFO less cumbersome, it would inevitably create unnecessary pain. The length of the AFO is relative to the length of the lever arm needed to safely lift your foot up for walking and support your knee and ankle.  A longer lever arm reduces forces required to provide torque on a joint which leads to greater comfort for the person wearing the orthosis.  

19. Goal is to have the mechanical axis aligned with the anatomical axis.

The bending moment is the location of max orthotic control or correction. The design of the orthosis aims to have the central force and bending moment congruent with the actual joint axis. This allows for effective outcomes and greater comfort for the user.

20. Don’t automatically blame the orthosis.⁵

More times than I can count, I have heard clients and colleagues report there was something wrong with the prescribed AFO. More times than I can count, the cause was either the shoe and/or loss of ankle range of motion. Shoes with crowded toe boxes, seams at the forefoot or improper fit can lead to pressure or friction. The shoe and the AFO work together as a system to keep the ankle-foot complex properly positioned for weightbearing and gait. Tight ankle muscles which do not allow for neutral positioning prevent the heel from being properly seated within the AFO. This can lead to pain at the forefoot and pistoning within the AFO. If you have questions regarding the fit of your AFO, check with your PT or CPO.

21. Stability of one’s knee can be influenced by ankle position.

A CPO can promote knee flexion or extension lending to the O&P user’s knee stability by placing the orthotic or prosthetic ankle in more dorsiflexion or plantarflexion respectively. Additionally, placing a wedge under the heel of a static ankle foot orthosis will promote a knee flexor moment. This is a helpful modification for individuals who go into knee hyperextension (a.k.a. genu recurvatum) even with the use of an AFO while walking.

22. There is inherent pistoning in a pin-lock suspension prosthesis.

Due to the design of a pin lock suspension, a certain degree of pistoning of the residual limb is going to occur within the prosthetic socket. This motion causes a milking of the soft tissues and ultimately volume fluctuations. Individuals may report pain at the distal end of their residual limb and require increased sock ply throughout the day to ensure a proper fit.

23. Targeted Muscle Reinnervation does not have to take place during the initial amputation.¹⁵

Individuals may develop neuromas in their residual limbs from severed nerves which become inflamed and sprout new axons creating a bulbous shape. These can be quite painful and interrupt one’s ability to tolerate donning their prosthesis. Undergoing resection of the neuroma followed by Targeted Muscle Reinnervation (TMR) helps give purpose to these nerves. TMR involves transferring the peripheral nerves which are cut during an amputation to small adjacent motor nerves in areas of muscle which are newly denervated. This provides a guided target promoting coordinated nerve regeneration rather than formation of a neuroma. Additionally, TMR helps foster more intuitive use of myoelectric prostheses often seen in the upper extremity.

24. GivMohr Sling was created by a PT and an OT.¹⁶

A commonly used upper extremity sling used to support an arm with hemiparesis during gait was developed by Occupational Therapist Victoria Givler and Physical Therapist Paul Mohr. The goal is to reduce risk of subluxation at the shoulder while allowing potential for arm swing with gait.

25. Appearance of gapping in a transfemoral prosthetic socket may be from lack of gluteal muscle contractions.

We’ve noted the necessity of proper skeletal and prosthetic alignment and maximizing one’s strength and range of motion. A prosthetist will set a transfemoral prosthetic socket in 5 degrees of flexion to allow firing of the hip extensor muscles. If a person has a hip flexion contracture, the prosthetist can set the socket in 5 more degrees of hip flexion to support this contraction. Unfortunately, the further flexed one’s hip is positioned, the greater the mechanical disadvantage of the hip extensors thereby reducing their ability to generate force.

26. Residual Limb Protectors are a key component of post-operative healing and pre-prosthetic care.^17-18

Residual limb protectors are a device provided by a Prosthetist following transtibial amputation surgery. These protect the limb from having contact at the distal end, promote knee extension and provide compression in conjunction with soft dressings. This protection is key given the high risk of post-operative falls. Additionally, evidence indicates faster maturation of the limb with a rigid removable dressing compared to a soft dressing alone. This equates to less time from limb loss to prosthetic fitting. Preservation of knee extension helps with prosthetic alignment and knee stability in stance. Compression is helpful with edema reduction, desensitization and building one’s tolerance in preparation for donning a prosthetic socket.

27. Phantom limb pain management requires a customized, multimodal approach.¹⁹

Phantom limb pain (PLP) occurs when an individual experiences a painful sensation in the missing limb following an amputation. PLP arises due to severed peripheral nerves and interrupted feedback between brain & body followed by resultant remapping of the brain’s sensorimotor cortex. Pain symptoms may match neuropathic pain descriptors (e.g., burning, stabbing, pricking) or mimic nociceptive pain (e.g., squeezing, crushing, sharp). Unfortunately, there is no one best method in addressing PLP. There is no strong evidence towards a particular pharmacological intervention, however, individuals have shown results treating neuropathic pain with anticonvulsants (e.g., gabapentin, pregabalin) and antidepressants (e.g., amitriptyline). Non-invasive therapies like physical therapy, psychosocial approaches, mirror therapy, virtual reality and myoelectric prostheses can help restore activation of cortical representation of the amputated limb/body scheme and promote neuroplasticity in the affected sensorimotor cortex.

28. K levels indicate ability and potential.⁹

K levels are a term used to describe Medicare Functional Classification Levels defined by Centers for Medicare and Medicaid Services. These classifications are based on a 0-4 rating system and are administered by a clinician. K0=does not have ability to transfer or ambulate safely and is not a prosthetic candidate. K1=household level ambulator with fixed cadence. K2=limited community level ambulator negotiating low level environmental barriers. K3=community level ambulator with varied cadence; vocational and other needs beyond simple locomotion. K4=high impact, stress or energy levels (e.g., child, athlete or active adult). Prosthetic components are assigned a corresponding K level and a person’s prosthetic prescription is determined by their functional ability and potential. For example, a person’s potential for varied cadence of a K3 ambulator is intrinsic as well as extrinsic. These individuals require the prosthetic componentry to support their functional mobility.

29. Amputee Mobility Predictor outcome measure is a helpful assessment tool to differentiate K levels for prosthetic prescription.²⁰

Outcome measures are often utilized in calculating mobility and functional capacity. The Amputee Mobility Predictor (AMP) is a 21 item outcome measure which incorporates the International Classification of Functioning, Disability and Health (ICF) Model and is validated for individuals with lower limb amputation. This measure correlates with gait speed, Timed Up and Go test and self-report measures of prosthetic mobility. The AMP can be completed with or without a prosthesis. It is important when administering the AMP to consider a patient’s ability and potential for functional mobility as this will determine K levels and ultimately prosthetic prescription. A lower functional level equates to a lower profile prosthesis which could limit their ability to develop functionally.

30. Individuals with transtibial amputations must stretch their hamstrings and strengthen their quadriceps to promote effective prosthetic gait.^21-22

We keep looking at the need for proper skeletal and prosthetic alignment for optimal mobility. This theme keeps coming up because alignment is instrumental to human biomechanics regardless of health condition. For individuals status post transtibial amputation, full knee extension range of motion is a key component to optimal prosthetic gait. Decreased knee extension can lead to decreased stance phase stability, ineffective swing and shortened step length. Individuals may report pain at their tibial crest due to altered weight distribution within the socket causing contact at the anterior wall. Prolonged gait with knee extension can lead to knee osteoarthritis and low back pain due to overuse.

31. Pay attention to Medicare 2-day rule during inpatient rehabilitation and delivery.^23-24

For Medicare & Medicaid, prostheses fall under DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics, Supplies. Physician prescriptions and DMEPOS orders must be submitted for pre-authorization which entails a SWO: Standard Written Order to the CPO. Prosthesis and components require WOPD: Written Order Prior to Delivery for authorization. There is a 2-day window from discharge from facility to home to deliver a prosthesis (or orthosis) to allow for fitting and gait training. Proof of delivery must be obtained and made available to Medicare. If your patient’s discharge disposition changes from acute rehab to short term rehab, the O&P device cannot be delivered until 2 days prior to heading home.

32. Ankle Foot Orthoses and Night Splints will not be covered together under Medicare coverage.

Under the Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination codes, an ankle foot orthosis (AFO) for gait and a night splint for positioning and stretching are considered “same or similar”. Many managed Medicare programs and private health insurance providers follow the same specifications. Coverage for both devices during the same time of service is denied under CMS guidelines, despite their proven medical necessity during the individual’s orthotic rehabilitation. This requires either the individual or the facility to purchase an off-the-shelf night splint while the CPO obtains preauthorization of the DMEPOS order and physician prescription for the AFO. The night splint promotes the necessary amount of ankle range of motion to properly utilize an AFO for safe, effective gait.

33. Hooray, Microprocessor Knee Units are now covered for K2 ambulators!^25-26

A huge victory but most of all a well-substantiated approval of prosthetic componentry made available to all appropriate functional users. As of September 2024, the Centers for Medicare & Medicaid Services (CMS) extended coverage to allow K2-level lower limb prosthetic users access to microprocessor-controlled prosthetic knees (MPKs). Managed Medicare programs are slowly catching up with HCSC: Health Care Service Corporation (an independent licensee of the Blue Cross Blue Shield Association) joining suit as of January 1, 2026. The intuitive technology and capabilities of the MPKs allow better response to environmental factors. Availability to these components promotes greater activity and functional potential in K2 users thereby increasing their independence and participation in personal pursuits. As we know, greater activity and independence leads to greater health outcomes. Win, win!

34. Inside the Microprocessor Knee lies a hydraulic knee.^27-29

The technology of a microprocessor knee (MPK) allows for a customized and optimized gait specific to the prosthetic user. The intuitive technology helps the user respond to the environment supporting stance phase stability, swing phase control, recovery with tripping, and controlled resistance while negotiating descents and tight turns. This access to higher level activities requires an infrastructure that can meet the high demands. The hydraulic knee provides durability and resistance. The microprocessor serves as enhanced hydraulics by using sensors to adjust the hydraulic fluid for real-time responses to encountered terrain.

35. Running blades with prosthetic running advice are available to trial for free.^30-31

For those who wish to explore prosthetic running, access to running blades and guided prosthetic running trials are available. Free clinics like Össur & Challenged Athlete Foundation Running & Mobility Clinic and Ottobock’s Full Circle Movement offer trials with running blades fit to your existing prosthesis by a Certified Prosthetist. Instructors and volunteers will advise you on running techniques.

36. Common prosthetic gait deviation predisposes one to osteoarthritis, low back pain, osteopenia and cardiopulmonary compromise.²²

A commonly seen gait deviation among unilateral prosthetic users entails placing the sound limb closer the body’s midline and in slight external rotation. There is increased stance time on the sound side in comparison to the prosthetic side. This leads to increased force asymmetry through the joints with potential for osteoarthritis on the sound side and low back pain. There is a potential to decrease gait speed to minimize force on the body. This predisposes one for osteopenia on the prosthetic side due to decreased weightbearing/loading through the limb. Ultimately, lower activity leads to decreased endurance. Greater fatigue may lead to less ambulation which increases one’s cardiovascular risk.

37. O&P devices have limited use in the Paralympics.³²

The Paralympic Games are host to 22 different types of adaptive sports with the next set of games to take place in LA in 2028. In this arena, orthoses are optional for the athletes but cannot facilitate running. Prostheses however are allowed for running provided they restore an athletes function without boosting their performance abilities. Only body-powered, passive prostheses are allowed.

38. Financial assistance for prosthetic care is available.^33-34

Lifetime healthcare costs are on the rise for all individuals. Managing health conditions, comorbidities, and access to O&P care can be costly and potentially out of one’s means. Thankfully, there are financial assistance programs available. The Range of Motion Project (ROMP) US Assistance Program (USAP) is one example of a nonprofit organization dedicated to helping those in financial need access quality prosthetic care. The Amputee Coalition is a great resource for seeing what forms of assistance may be available to you.

39. A transfemoral prosthesis fit for a longer residual limb may appear as being shorter than the opposing sound limb in sitting.

A longer residual limb following a transfemoral amputation leads to an altered knee center. Adding a prosthetic knee under this type of socket adds length to the prosthesis. The knee center must be adjusted for in order to clear the prosthetic side with swing phase of gait. A four bar linkage knee will shorten the prosthetic leg in swing and lengthen in stance to allow for equal height bilaterally. A microprocessor knee unit however cannot change size throughout the gait cycle. The knee center of the prosthetic side will not match the anatomical knee of the sound side but is necessary to allow foot clearance during swing. This accommodation lends to the prosthetic side looking shorter than the sound side in sitting but is functionally appropriate for standing and gait.

40. Orthotic & Prosthetic Rehabilitation and teaching are my professional calling.

From my days as a Northeastern University physical therapy student I have been enthralled with O&P rehabilitation. The collaboration, challenges, evolution of technology and rewards of giving individuals tools to succeed are invaluable to me. My colleagues and students have become my O&P family. The exchange of knowledge is truly a gift. I am eternally grateful to all those who have helped shape me the past 3 decades and ecstatic to know there is more to come. My sincere gratitude to my professional mentors and my patients who have become my mentors. ~ In memory of L.D. & R.S. ~

Join the 40 Challenge and support LLLDAM in your own way. As a community, we are stronger!

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