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High level rehabilitation of amputees

Original Editor - Grace Hughes and Suzanne Ferreira as part of the World Physiotherapy Network for Amputee Rehabilitation Project

Top Contributors - Jess Bell, Sheik Abdul Khadir, Ewa Jaraczewska, Kim Jackson, Admin, Tarina van der Stockt and Simisola Ajeyalemi  

Introduction

Ambulation is an early focus of rehabilitation for people with lower-limb amputation. Once a person is walking efficiently, they can progress to higher-level activities, such as fast walking, jogging or running. Beyond this, some will go on to participate in recreational or competitive sport, potentially extending to elite competition, such as the Paralympic Games. Increasing physical activity and sport participation has real health benefits, helping to mitigate the cardiovascular, metabolic and bone density risks associated with lower-limb amputation.[1][2]

Physical Fitness and General Health

The American College of Sports Medicine (ACSM) Guidelines for Exercise Testing and Prescription outline physical activity recommendations for healthy adults.[3] For cardiovascular fitness, adults are advised to accumulate at least 150–300 minutes of moderate-intensity aerobic activity per week, or 75–150 minutes of vigorous-intensity activity. To build strength, the ACSM recommends training all major muscle groups at least twice a week. Current guidance sets intensity by training with sufficient effort rather than a single fixed load, with heavier loads (around 80% or more of 1-repetition maximum, for 2–3 sets) used specifically to maximise strength.[4] Flexibility training and neuromotor exercise, such as yoga or balance training, are also recommended on at least 2–3 days per week.[5]

People with lower-limb amputation are, however, less likely to meet the ACSM targets and are more likely to be sedentary than the general population.[6] Cardiorespiratory fitness is typically below age-referenced norms. Van Schaik et al.[2] reported a mean peak VO₂ more than 50% lower than reference values in a cohort of people with lower-limb amputation. They also expend more energy during walking and other activities and have a higher oxygen consumption.[6]

Exercise training can improve aerobic and strength outcomes in this population. Combining muscle endurance training with functional exercise improves cardiorespiratory health, strength, and functional performance,[7] targeted exercise prescription improves physical performance and quality of life,[8] and targeted hip strengthening programmes have enabled people with prostheses to progress from walking to running.[9]

Specific Considerations for Athletes with Lower-limb Amputations

Amputation drives a chain of physiological changes and adaptations that affect muscle, bone, and load distribution. Understanding this sequence is important when designing training programmes for people with lower-limb amputation.

Muscle Loss and Weakness

People with lower limb amputations tend to have reduced thigh cross-sectional area, quadriceps thinning, and muscle fibre atrophy in the residual limb. Increased fat mass in the thigh is also common, which complicates prosthetic socket fit and control. By contrast, the intact limb may show some compensatory hypertrophy.[10] These changes have direct performance consequences: reduced power and strength in the residual limb can lead to inter-limb asymmetries and altered force production.[11] The specific location of these impairments varies by amputation level: athletes with transtibial amputations typically experience the greatest weakness in the knee extensors and flexors of their residual limb, while transfemoral amputation is associated with greater deficits at the hip. Notably, the gap in strength between the residual and intact limb may be smaller in athletes than in non-sporting populations.[9]

Reduced Bone Mineral Density

People with lower-limb amputation frequently experience a reduction in bone mineral density (BMD) in their residual limb compared to their intact limb or compared with people without amputation. This is associated with a higher prevalence of osteopenia and osteoporosis, and means that people with amputation have an elevated risk of femoral neck fractures.[10] Encouragingly, weight-bearing through the residual limb (particularly in the first six months post-surgery) and participation in sport appears to benefit bone health in people with unilateral lower-limb amputation.[12][10][13] However, it may not be enough on its own to maintain sufficient bone mineralisation at the residual hip following above-knee amputation.[12]

Overload Risk

Physiological overload reflects the increased energy cost of activity and the reduced muscle mass available for force generation. People with limb loss may therefore need longer recovery periods. Mechanical overload arises from compensatory movement patterns and suboptimal alignment.[14] High-level training adds further load, so programmes should include strategies to manage load.

The Rehabilitation Team

Ideally, a dedicated rehabilitation team will work with these individuals to achieve their fitness and sporting goals. They must understand the above considerations to train athletes safely and effectively, adjusting for the altered bone, muscle and loading. This team will often include a physiotherapist, prosthetist, coach, and, for elite athletes, a strength and conditioning specialist.

The physiotherapist assesses the athlete, designs and progresses the programme, and monitors for the compensatory patterns and injury risks described above. The prosthetist considers the athlete's requirements and the condition of both limbs, selecting and designing a prosthesis that supports the athlete's functional goals while managing biomechanical deficits. The coach needs knowledge of muscle function, imbalances, gait and population-specific injury risks, and builds individualised programmes. The fundamentals of training (overload, progression, recovery, specificity, periodisation and ongoing evaluation) are the same as in any population. The strength and conditioning specialist develops conditioning that reflects the demands of the sport, spanning strength, power, stability, balance and endurance.[15][16]

Physiotherapy Assessment

Before a person with lower-limb amputation participates in higher-level training, they should have a comprehensive physiotherapy evaluation. This assessment should cover the person's medical history, medications, current functional level, home circumstances, emotional state, and expectations of the programme, along with the condition of the residual limb (including skin integrity, shape, volume, and pain). The sport-readiness assessment should examine joint integrity, range of motion, strength and endurance in both the residual and intact limbs. The functional mobility assessment should include gait (walking and running), cardiovascular fitness, core strength, balance, proprioception, and compensatory mechanisms. Prior injury history should always be documented, as previous injury is a recognised risk factor for re-injury. Findings from the assessment are used to build a personalised problem list and goal-oriented treatment plan.

General Training Principles

Improving cardiorespiratory fitness is a central goal, given that this population starts from a lower aerobic baseline. The first physical activity guidelines developed specifically for people with lower-limb amputation identify the minimum dose needed to achieve measurable health benefits, particularly improvements in balance and mobility: at least 60 minutes per week of moderate-to-vigorous aerobic exercise, combined with strengthening exercise (at least three sets of ten repetitions, twice a week) and balance exercise (20 minutes, three times a week).[17] This is a minimum for health benefit rather than a target for sport,[17] but it provides a foundation on which higher-level training can be built. For building capacity beyond this baseline, interval training with short recovery periods may be more effective than continuous, long-duration exercise, both for aerobic gains and for maintaining movement quality.[18]

Strength Training

Rehabilitation should target all major muscle groups, including the upper limbs, before shifting focus to sport-specific conditioning as strength improves. Athletes with lower-limb amputation follow the same core strength development principles as athletes without amputation.[19] Training should focus on the movements essential to the specific sport. Because the body readily compensates and adapts, movements should be evaluated carefully for compensatory patterns, and the type of prosthesis taken into account. Load should be increased only once a movement is performed with good biomechanical efficiency. Some movements may be performed without a prosthesis, especially after transfemoral amputation (e.g. plyometric jumping). Training load can then be progressed by increasing movement complexity, resistance, speed, or time to fatigue.[14]

Core and Hip Stability

Establishing robust core and hip stability is particularly important, as poor proximal control can compromise balance and limit the base from which force is produced.[20] Rehabilitation should advance from static control to dynamic exercises, eventually integrating these stabilisation patterns into functional, sport-specific movements. Advanced stability and control must be built on a solid endurance base. Clinicians should also watch for upper-body compensations that can arise as adaptations to postural change.

Flexibility Training

Flexibility training is important for both the residual and intact limbs to support movement efficiency. Maintaining range of movement is essential, but it is particularly important at the joint immediately above the amputation, which is prone to contracture and carries added functional demand. Preserving this range helps maintain gait symmetry and reduce musculoskeletal strain.[8] Better flexibility also supports prosthetic alignment and control, which in turn reduces compensatory movements that could otherwise lead to overuse injuries in the intact limb.

Example Exercises

This video demonstrates high intensity seated exercises for athletes with lower limb amputation:

[21]

These videos show examples of functional training for athletes with lower limb amputation:

[22]
[23]
[24]
[25]

Additional Resources

References

  1. ↑ Grecco MV, Brech GC, Soares-Junior JM, Baracat EC, Greve JMD, Silva PRS. Effect of concurrent training in unilateral transtibial amputees using Paralympic athletes as a control group. Clinics (Sao Paulo). 2023 Apr 8;78:100165.
  2. ↑ 2.0 2.1 van Schaik L, Blokland IJ, van Kammen K, Houdijk H, Geertzen JHB, Dekker R. Cardiorespiratory fitness in persons with lower limb amputation. Int J Rehabil Res. 2024 Jun 1;47(2):116-121.
  3. ↑ ACSM, Cemal O. ACSM’s Guidelines for Exercise Testing and Prescription, 12th edition. Lippincott Williams & Wilkins 2025
  4. ↑ Currier BS, D'Souza AC, Singh MAF, Lowisz CV, Rawson ES, Schoenfeld BJ, et al. American College of Sports Medicine position stand. Resistance training prescription for muscle function, hypertrophy, and physical performance in healthy adults: an overview of reviews. Med Sci Sports Exerc. 2026 Apr 1;58(4):851-872.
  5. ↑ ACSM Unveils Landmark 2026 Resistance Training Guidelines — First Update in 17 Years. Available from https://acsm.org/resistance-training-guidelines-update-2026/ [last accessed 19.06.2026]
  6. ↑ 6.0 6.1 Delbello F, Zullo L, Giacomini A, Bizzarini E. Enhancing Performance and Quality of Life in Lower Limb Amputees: Physical Activity, a Valuable Tool-A Scoping Review. Healthcare (Basel). 2026 Jan 20;14(2):253.
  7. ↑ Bouzas S, Molina AJ, Fernández-Villa T, Miller K, Sanchez-Lastra MA, Ayán C. Effects of exercise on the physical fitness and functionality of people with amputations: Systematic review and meta-analysis. Disabil Health J. 2021 Jan;14(1):100976.
  8. ↑ 8.0 8.1 Chang S, Yan JX, Mu L. Effects of exercise on physical performance and quality of life in individuals with limb amputation: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2025 Oct 15;26(1):965.
  9. ↑ 9.0 9.1 Nolan L. A training programme to improve hip strength in persons with lower limb amputation. J Rehabil Med. 2012 Mar;44(3):241-8.
  10. ↑ 10.0 10.1 10.2 Finco MG, Kim S, Ngo W, Menegaz RA. A review of musculoskeletal adaptations in individuals following major lower-limb amputation. J Musculoskelet Neuronal Interact. 2022 Jun 1;22(2):269-283
  11. ↑ Cavaggioni L, Trecroci A, Scurati R, Tosin M, Casalini L, Castiglioni P, Merati G, Formenti D. Neuromuscular and Balance Performance Across the Fundamental Preparation Period in Elite Athletes with Lower Limb Deficiencies: A Retrospective Case Series. Sports. 2026 Apr 7;14(4):144
  12. ↑ 12.0 12.1 Cavedon V, Sandri M, Peluso I, Zancanaro C, Milanese C. Sporting activity does not fully prevent bone demineralization at the impaired hip in athletes with amputation. Front Physiol. 2022 Oct 19;13:934622.
  13. ↑ Behan FP, Bull AM, Beck BR, Brooke-Wavell K, Müller R, Vico L, Isaksson H, Harvey NC, Buis A, Sherman K, Jefferson G. Developing an exercise intervention to minimise hip bone mineral density loss following traumatic lower limb amputation: a Delphi study. British journal of sports medicine. 2024 Nov 1;58(21):1251-7.
  14. ↑ 14.0 14.1 Hadj-Moussa F, Ngan CC, Andrysek J. Biomechanical factors affecting individuals with lower limb amputations running using running-specific prostheses: A systematic review. Gait & Posture. 2022 Feb 1;92:83-95.
  15. ↑ Nutter DL. Considerations for coaching athletes with prosthetic limbs for transtibial and transfemoral amputations. Strength & Conditioning Journal. 2019 Oct 1;41(5):1-8
  16. ↑ De Luigi AJ, Cooper RA. Adaptive sports technology and biomechanics: prosthetics. Pm&r. 2014 Aug;6:S40-57.
  17. ↑ 17.0 17.1 Dupuis F, Martin Ginis KA, MacKay C, Best KL, Blanchette V, Robert MT, et al. Development of physical activity recommendations for adults living with lower limb amputation. Disabil Rehabil. 2026 Mar;48(5):1424-1435.
  18. ↑ Atakan MM, Li Y, Koşar ŞN, Turnagöl HH, Yan X. Evidence-Based Effects of High-Intensity Interval Training on Exercise Capacity and Health: A Review with Historical Perspective. Int J Environ Res Public Health. 2021 Jul 5;18(13):7201.
  19. ↑ Huxel Bliven KC, Anderson BE. Core stability training for injury prevention. Sports Health. 2013 Nov;5(6):514-22.
  20. ↑ Willson JD, Dougherty CP, Ireland ML, Davis IM. Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg. 2005 Sep;13(5):316-25.
  21. ↑ National Center on Health, Physical Activity and Disability (NCHPAD). Exercises for Amputees. Available from: https://youtu.be/pGubJvanSf8
  22. ↑ Bodyweight Muscle. Amputee Functional Workout-Plan (Beginner to Advanced). Available from: https://youtu.be/Mk1IzZ4ZQpo
  23. ↑ David Clonts. Functional Training for an Amputee Part 1 - Single Leg Deadlift. Feb 2015. Available from: https://youtu.be/XqFxtH5D77I
  24. ↑ David Clonts. Functional Training for an Amputee Part 2 - Pistol Squats. Available from: https://youtu.be/WCYvjcIGMKQ
  25. ↑ David Clonts. Functional Training for an Amputee Part 3 - Balance Check Exercises. March 2015. Available from: https://youtu.be/XV7gerb2kEE


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