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Pre-Fitting Management of the Patient with a Lower Limb Amputation

Original Editor - Liezel Wegner as part of the World Physiotherapy Network for Amputee Rehabilitation Project

Top Contributors - Sheik Abdul Khadir, Admin, Leslie Angama, Tarina van der Stockt, Stacy Schiurring, Lucy Aird, Kim Jackson, Tony Lowe, Ewa Jaraczewska, Simisola Ajeyalemi, Jess Bell and Amrita Patro  

Introduction

Pre-prosthetic management refers to the phase of lower limb amputation rehabilitation that occurs after acute post-surgical recovery and before prosthetic prescription and fitting. Its purpose is to prepare both the residual limb and the patient for a prosthesis: shaping and desensitising the residuum, building strength and balance, restoring the patient's sense of independence, and coordinating timely referrals to the wider multidisciplinary team. Done well, this phase shapes how smoothly the later stages of prosthetic fitting and gait training go.

Where This Fits in the Rehabilitation Pathway

The overall rehabilitation process has nine phases.[1]

Phase Hallmark
Pre-operative Assess body condition, patient education, surgical level discussion, and post-operative prosthetic plans
Amputation surgery/reconstruction Length, myoplastic closure, soft tissue coverage, nerve, handling, rigid dressing
Acute post-surgical Wound healing, pain control, proximal body motion, emotional support
Pre-prosthetic Shaping, shrinking, increasing muscle strength, restoring patient locus of control
Prosthetic prescription Team consensus on prosthetic prescription and fabrication
Prosthetic training Increase prosthetic wearing and functional utilisation
Community integration Resumption of roles in family and community activities. Emotional equilibrium and healthy coping strategies. Recreational activities
Vocational rehabilitation Assess and plan future vocational activities. May need further education, training or job modification
Follow-up Lifelong prosthetic, functional and medical assessment and emotional support

Physiotherapist Roles and Responsibilities: The Evidence Base

Physiotherapy input during the pre-prosthetic phase should be informed by evidence-graded clinical guidance rather than individual judgement alone. The ten role areas below are drawn from the 3rd edition (2025) of the BACPAR clinical guideline, a set of graded recommendations produced by the British Association of Chartered Physiotherapists in Limb Absence Rehabilitation (BACPAR).

1. Working within the Multidisciplinary Team (MDT)

Pre-prosthetic rehabilitation is a multidisciplinary task. A physiotherapist experienced in this area of rehabilitation should be responsible for coordinating physiotherapy care and contributing to the choice of MDT outcome measures. They should also be involved in the decision to refer for prosthetic assessment.[2]

Some of the professionals and resources that should form part of the MDT are shown in the following table.

Professional Role
Physiotherapist Coordinates physiotherapy care across the pathway; leads gait and functional rehabilitation
Prosthetist Casting, fabrication, and ongoing management of the prosthesis
Occupational therapist Home/work environment assessment and adaptation, ADL retraining
Nurse Specialist wound care
Psychologist/counsellor Psychological adjustment support
Dietitian Nutrition education, particularly with poorly controlled diabetes
Physician Medical management, including phantom pain
Social worker Financial/disability support, discharge planning
Podiatrist/foot care specialist Contralateral limb risk management
Amputation support group Peer support
Patient and carer(s) Central members of the team; goal-setting, decision-making, and day-to-day self-management
2. Assessment

Assessment should document the level of amputation, pre-existing medical conditions, and social environment, all of which affect rehabilitation potential.[2]

Known predictors of outcome, supported by cohort evidence, include:

  • Vascular status: patients without a patent popliteal artery had four times less chance of successful prosthetic use after transtibial amputation.[3]
  • Cardiovascular fitness: people with transfemoral amputation reaching 30 watts or more on arm ergometer testing were more likely to walk indoors with a prosthesis.[4]
  • Cognitive status: impaired memory and executive function negatively affect independence.[5]
  • Falls history and psychological status: should be documented as part of every assessment.[2]

A validated prediction tool such as the BLARt score (Blatchford Leicester Allman Russell tool) can help guide goal setting and manage expectations from an early stage.[2]

3. Patient and Carer Education

Education in this phase starts with helping the patient understand what the rehabilitation programme actually involves: the stages it moves through, roughly how long each takes, and where it will happen. Two other threads run through this education: teaching care of both limbs, not just the residual one, to reduce the risk of complications and re-amputation; and being upfront about the potential pain the patient is likely to feel post-surgically, since knowing what to expect tends to improve cooperation and outcomes. Education should be tailored to their individual situation rather than delivered as a generic script. With the patient's consent, bring carers into these conversations early too, since they will be supporting the patient well beyond the therapy room.[2]

Backing verbal explanations up with written material helps information stick, but it needs to actually be accessible: font size, plain language, and the patient's health literacy all matter here.[2]

Where appropriate, offer to connect the patient with someone else who's living with limb loss; peer contact is genuinely valuable during adjustment, not just a nice extra.[2]

4. Residual Limb and Oedema Management

Glossary: the residuum (or residual limb) is the remaining portion of the limb after amputation.

Desensitisation, scar massage, and skin care. Once the wound is adequately healed, begin desensitisation to prepare the residuum for weight-bearing, and scar massage to prevent adhesion to bony prominences. If possible, teach the patient to do both themselves.

[6]
[7]
[8]
Coning of the residual limb, before and after

Shaping ("coning") the residuum. A bulbous residuum (one that is wider at the distal end than higher up the limb) prevents or greatly complicates prosthetic fitting until it is shaped through bandaging appropriate to the amputation level. Dog ear(s) is surgical slang for the small puckers or cones of redundant tissue left at the ends of an incision line where wound edges of unequal length have been closed together (also called a standing cutaneous cone). Note that this term has been criticised in the surgical literature as imprecise and, in some cultures, disrespectful when used in front of patients. "Standing cone" or "conical deformity" are the more formal alternatives for documentation or conversations with the patient.

Oedema management. Uncontrolled post-operative oedema delays healing, increases pain, delays mobility, extends time to the prosthetic phase, lengthens hospital stay, and results in poor residual limb shaping.[9] A 2023 systematic review and meta-analysis found that, compared with soft dressings, rigid dressings significantly reduced time to wound healing, time to prosthetic fitting, residual limb volume, and post-operative pain, and lowered rates of revision surgery and joint contracture.[10] This is broadly consistent with earlier reviews,[11][12][13] though the authors of the 2023 review do note that caution is required when interpreting results due to the high risk of bias in included studies. Current evidence is against the use of plain elastic bandages for oedema management, due to unreliable and potentially unsafe pressure distribution.[2][9]

Compression therapy should ideally start within 10 days post-operatively, agreed jointly with the MDT.[2]

In practice, several methods are available for managing residual limb oedema, each with a different balance of evidence strength, cost, and practicality. The following table summarises the main options.

Method Notes
Rigid or semi-rigid dressing (removable/non-removable)
  • Strongest evidence base
  • Reduces contractures, trauma, healing time
Pneumatic post-amputation mobility (PPAM) aid
  • Early walking aid
  • Enclosed pneumatic sleeve
Compression sock/silicone liner
  • Conical, graduated compression garment for the residuum
  • Preferred over elastic bandage
Wheelchair residual limb support board Elevates the residuum when seated
Clinical Pearl: A Closer Look at Silicone Liners

A silicone liner is typically applied once a removable rigid dressing has been taken off. Its main practical advantage is consistency: because it's a manufactured product rather than a hand-applied wrap, it delivers the same level of compression regardless of who puts it on, which reduces the variability you get with bandaging technique between different staff members.[2][9] As oedema reduces over the following weeks, the liner will need to be replaced. This is also its main practical drawback: a new size may need to be sourced and isn't always readily available, adding cost and potential delay.[9] In practice, silicone liners are used far more often in well-resourced settings with reliable prosthetic component supply chains than as a first-line option globally; rigid dressings and bandaging remain the more universally available choice.

Adapting practice where resources are limited

The evidence above clearly favours rigid dressings, PPAM aids, and liners over plain elastic bandaging for oedema control. However, in services where these aren't available, elastic bandaging may still be the only realistic option.

If bandaging is the only option available, technique matters considerably more than with a manufactured compression product, since poor technique carries a real risk of pressure injury.[14] Specific risks include uneven pressure, which can worsen rather than reduce oedema, and excessive tightness or poor technique, which can create a tourniquet effect that restricts circulation.[14][15]

Important considerations when applying elastic bandaging:

  • Apply in a figure-of-eight pattern rather than straight circular turns, to avoid a tourniquet effect.
  • Apply firmer tension distally and progressively looser tension proximally, so pressure decreases up the limb.
  • Rewrap regularly through the day, since bandages loosen with movement or changes in oedema and lose their effect.
  • Monitor the limb for signs of impaired circulation (e.g. colour, temperature, pain) with every application.

Because incorrect technique can cause harm, clinicians, patients, and carers should all complete supervised practice and demonstrate competence before applying bandaging independently.

If you would like to read more about post-operative dressings, see: Acute post-surgical management of the amputee.

See the videos and diagrams below on how to perform residuum bandaging for a transtibial and transfemoral amputation.

Transtibial Residuum Bandaging:
Transfemoral Residuum Bandaging:
5. Care of the Remaining (contralateral) Limb

The physiotherapist should observe and document the condition of the remaining limb at every assessment, actively participate in its care (e.g. positioning, pressure relief, appropriate footwear), and educate vascular and diabetic patients and their carers on how to reduce risk to that limb. Establishing relationships with local podiatry/chiropody services will allow for prompt referral if any concerns are identified.[2]

6. Building Strength, Balance, and Pre-gait Skills

Contracture prevention has the strongest evidence of the exercise-related recommendations, with active exercise, appropriate positioning, and the use of splints or above-knee removable rigid dressings all supported. Early education about the impact of knee/hip flexion contractures on future prosthetic rehabilitation improves compliance with splint-wearing and active exercise.[16]

Exercise more broadly also has a reasonable evidence base behind it. A 2024 systematic review found that 1–3 sessions per week of 20–60 minutes, combining aerobic exercise with strengthening or balance work, may improve balance, walking speed, walking endurance, and transfer ability in adults with lower limb amputation.[17]

Basic training and skills include:

  • Lower limb, abdominal, and back extensor strengthening
  • Upper limb strengthening
  • Proximal range of motion exercises
  • Functional bed mobility and transfers
  • General conditioning
  • Wheelchair propulsion
  • Unsupported standing balance
  • Ambulation with assistive devices

Pre-gait training:

  • Single-limb balance; seated balance on a BOSU/therapy ball; transitions between lying/sitting/standing, ideally within parallel bars for safety
  • Orientation to centre of gravity and base of support
  • Remaining-limb and prosthetic-limb gait training, pelvic motions
  • Where an immediate post-operative prosthesis is used, training typically progresses in stages rather than moving straight to walking practice: standing balance on both limbs first, then pelvic motions, then sit-to-stand practice, then gait training

Exercise videos:

Strengthening of residual limb with and without a Thera-Band Transfemoral amputation BOSU ball balance retraining

For a collection of below- and above-knee post-amputation exercises, see:

7. Restoring Mobility, Transfers, and Independence

Early Walking Aids (EWAs), including the PPAM aid. Randomised and cohort evidence supports EWA use as both an assessment and treatment tool. EWAs reduce post-operative complications and speed achievement of rehabilitation milestones. EWAs must be used only under the supervision of therapists trained in their safe application, with cardiovascular monitoring during use.[2]

An alternative in some settings is the Immediate Post-operative Prosthesis (IPOP), a non-removable rigid dressing applied by the prosthetist in theatre. It is shaped for patellar-tendon weight-bearing to protect the wound during very early mobilisation.

[18]

Crutches. Where crutches are used, the general clinical convention is that axillary (underarm) crutches suit short-term use - they are faster to learn and more stable for new users.[19] Elbow/forearm crutches tend to suit longer-term users, since prolonged axillary crutch use carries a risk of radial nerve or brachial plexus compression ("crutch palsy"). Since most people with a lower limb amputation are longer-term crutch users, elbow crutches are often the more appropriate long-term choice for people who have adequate grip strength and balance to manage the learning curve. Axillary crutches may still suit patients who need more initial trunk support while their grip strength and balance develop.

[20]

Hands-free crutch alternatives also exist and are worth knowing about for people with upper limb impairments that make conventional crutch use difficult.

Hands-free crutch alternatives. These are strap-on devices (commercial examples include the iWALKFree and Freedom Leg) with a padded platform that straps around the thigh and lower leg. The patient kneels onto this platform with their affected leg, so their weight is taken through the knee and shin rather than through the hands and underarms. This frees both hands completely and allows a more natural reciprocal walking pattern than standard crutches.[21] Two important limitations to know before suggesting hands-free crutch alternatives to a patient:

  • They are only suitable for below-knee (transtibial) amputation. The device relies on kneeling the residual limb onto the platform and bearing weight through it, which requires an intact knee and enough residual shin length (commercial guidance typically specifies a minimum of around 10 cm) to tolerate that loading.
  • The patient needs reasonable strength and balance to use one safely.

Wheelchair provision and transfers. After surgery, patients should mobilise by wheelchair unless there is a specific documented reason not to. Bed mobility should ideally be taught from day one post-operatively, and safe transfers taught as early as possible using appropriate equipment.[2] A seated method for ascending/descending stairs is considered an effective, safe, and well-tolerated technique for people with unilateral lower limb amputation.[22]

Falls prevention. A falls risk assessment is recommended for every person with a lower limb amputation, since amputation carries a well-documented increased falls risk.[23] Falls prevention should be tailored to the stage of rehabilitation, since risk factors differ across the post-operative, inpatient, and community-living phases.[2] Patients and carers should be taught how to get up from the floor in the event of a fall.[23]

Transfers to teach include:

  • Bed ↔ fixed chair
  • Bed ↔ wheelchair
  • Wheelchair ↔ floor
  • Wheelchair ↔ toilet
  • Wheelchair ↔ shower/bath
  • Wheelchair ↔ car
[24]
[25]
8. Pain Management

Phantom limb sensation, phantom limb pain, and residual limb pain are common in the early post-operative period and can significantly affect quality of life, sleep, mood, and relationships.[26][27] As early as possible, patients should be made aware of and prepared for the possibility that they may experience phantom sensation or pain after surgery. That information, and the treatment that follows it, should come from clinicians with appropriate knowledge and training in the area. It should include teaching the patient self-management techniques for phantom limb pain. This puts the patient in control of their pain, making its management something they do themselves rather than something done to them.[2]

Evidence-supported physiotherapy interventions for pain management include: mirror therapy, phantom limb exercises, progressive muscle relaxation, and mental imagery.[28] Mirror therapy is the most widely used of these approaches, but a 2025 scoping review found wide inconsistency in how it is actually delivered across studies with no consensus yet on a standard protocol.[29] More broadly, the evidence is not yet strong enough to say any one of these approaches clearly outperforms the others, so the choice between them often comes down to what suits the individual patient and what the treating therapist is trained to deliver well.[2]

9. Psychosocial Support

People commonly experience significant emotional distress after amputation and are at risk of anxiety and depression.[30] A qualitative study proposed three phases that patients move through in the period following a vascular amputation: losing control, digesting the shock, and regaining control.[31] Knowledge of this framework can be helpful for a treating therapist to understand what they might be observing, though not every patient will follow it neatly.

As the physiotherapist, you do not need to be a psychologist, but you do need basic counselling knowledge and a clear sense of when to refer on to a clinical psychologist.[2]

An understanding of what tends to protect people through this adjustment is also key: coping skills, cognitive flexibility, optimism, and social support are all associated with better outcomes.[32] Where possible, help facilitate contact with other people living with amputation, and make sure patients have the space to raise concerns openly, rather than feeling they need to push through in silence.[2]

10. Developing Specialist Knowledge

Physiotherapists working in this area are expected to keep up to date with rehabilitation developments, understand prosthetic prescription principles, and be aware of the wider socioeconomic impact of limb loss.[2] This is an ongoing professional responsibility, not a one-off induction task.

Useful Resources

References

  1. ↑ Esquenazi A. Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disability and rehabilitation. 2004 Jul 22;26(14-15):831-6.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 British Association of Chartered Physiotherapists in Limb Absence Rehabilitation (BACPAR). Clinical guidelines for the pre and post-operative physiotherapy management of adults with lower limb amputations. 3rd ed. 2025. Available at: https://www.bacpar.org/Data/Resource_Downloads/FINALpreandpostopProcessdocument3rdedition.pdf?date=29/03/2026%2011:00:22 (accessed 23/July/2026).
  3. ↑ Budinski S, Manojlović V, Knežević A. Predictive factors for successful prosthetic rehabilitation after vascular transtibial amputation. Acta Clinica Croatica. 2021 Dec;60(4):657.
  4. ↑ Erjavec T, Vidmar G, Burger H. Exercise testing as a screening measure for ability to walk with aprosthesis after transfemoral amputation due to peripheral vascular disease. Disability and rehabilitation. 2014 Jul 1;36(14):1148-55.
  5. ↑ Coffey L, O’Keeffe F, Gallagher P, Desmond D, Lombard-Vance R. Cognitive functioning in persons with lower limb amputations: a review. Disability and rehabilitation. 2012 Nov 1;34(23):1950-64.
  6. ↑ AmputeeOT: Massage, Scar Mobilization, Desensitization, and End-Bearing Exercises for New Amputees. Jan 2014. Available from: https://youtu.be/AqmKhuT-mWw
  7. ↑ Ottobock. Skin care after amputation. Jan 2019. Available from: https://youtu.be/15gsqIrz8Ps
  8. ↑ Ottobock. Scar care & scar mobilisation after amputation. Available from: https://youtu.be/-IMV8j21kLw
  9. ↑ 9.0 9.1 9.2 9.3 Bouch E, Burns K, Geer E, Fuller M, Rose A, Broomhead P. Guidance for the multi disciplinary team on the management of post operative residuum oedema in lower limb amputees. Bradford: British Association of Chartered Physiotherapists in Amputee Rehabilitation. 2012.
  10. ↑ Koonalinthip N, Stonsaovapak C, Vitoonpong T, Jaroenarpornwatana A. Rigid dressings for lower limb amputees: a systematic review and meta-analysis. Current Physical Medicine and Rehabilitation Reports. 2023 Sep;11(3):352-66.
  11. ↑ Reichmann JP, Stevens PM, Rheinstein J, Kreulen CD. Removable rigid dressings for postoperative management of transtibial amputations: a review of published evidence. PM&R. 2018 May 1;10(5):516-23.
  12. ↑ Sumpio B, Shine SR, Mahler D, Sumpio BE. A comparison of immediate postoperative rigid and soft dressings for below-knee amputations. Annals of Vascular Surgery. 2013 Aug 1;27(6):774-80.
  13. ↑ Churilov I, Churilov L, Murphy D. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Annals of vascular surgery. 2014 Oct 1;28(7):1801-8.
  14. ↑ 14.0 14.1 Sivarasu S, Lalla B, Mbanefo C, Dey R, Awood M. Residual limb modelling for optimal shape and bandaging in transfemoral amputees. Results in Engineering. 2025 Sep 1;27:106830.
  15. ↑ Lusardi MM. Postoperative and preprosthetic care. In: Lusardi MM, Jorge M, Nielsen CC, eds. Orthotics and Prosthetics in Rehabilitation. 3rd ed. Missouri: Elsevier; 2013:532–594.
  16. ↑ Ghazali MF, Abd Razak NA, Osman NA, Gholizadeh H. Awareness, potential factors, and post-amputation care of stump flexion contractures among transtibial amputees. Turkish journal of physical medicine and rehabilitation. 2018 Jul 12;64(3):268.
  17. ↑ Dupuis F, Ginis KA, MacKay C, Best KL, Blanchette V, Cherif A, Robert MT, Miller WC, Gee C, Habra N, Brousseau-Foley M. Do exercise programs improve fitness, mobility, and functional capacity in adults with lower limb amputation? A systematic review on the type and minimal dose needed. Archives of physical medicine and rehabilitation. 2024 Jun 1;105(6):1194-211.
  18. ↑ IPOP Immediate Postoperative Prosthesis. Available from: https://youtu.be/9voyLE_9IMU[last accessed 16/12/17]
  19. ↑ Yap WM, Hairodin Z, Kwek EB. Axillary versus forearm crutches: A prospective cohort comparing which is superior for 3-point crutch gait. Malaysian orthopaedic journal. 2021 Jul;15(2):36.
  20. ↑ AmputeeOT: Using crutches etc to get around after amputation. Available from: https://www.youtube.com/watch?v=lugS_AmY2BU&t=86s[last accessed 16/12/17]
  21. ↑ Dewar C, Martin KD. Comparison of lower extremity EMG muscle testing with hands-free single crutch vs standard axillary crutches. Foot & Ankle Orthopaedics. 2020 Sep 2;5(3):2473011420939875.
  22. ↑ Kirby RL, Brown BA, Connolly CM, McRae S, Phillips PL. Handling stairs in the seated position for people with unilateral lower-limb amputations. Arch Phys Med Rehabil. 2009 Jul;90(7):1250-3.
  23. ↑ 23.0 23.1 Blundell R, Bow D, Donald J, Drury S, Hirst L. Guidelines for the prevention of falls in lower limb amputees. British Association of Chartered Physiotherapists in Amputee Rehabilitation. 2008.
  24. ↑ Double amputee transferring from wheelchair to floor . Available from: https://www.youtube.com/watch?v=1l5447Hhfxc[last accessed 16/12/17]
  25. ↑ AmputeeOT: Safe Showers and Baths for Amputees . Available from: https://www.youtube.com/watch?v=16qdl_25xmQ[last accessed 16/12/17]
  26. ↑ Trevelyan EG, Turner WA, Robinson N. Perceptions of phantom limb pain in lower limb amputees and its effect on quality of life: a qualitative study. British journal of pain. 2016 May;10(2):70-7.
  27. ↑ Polat CS, Konak HE, Altas EU, Akıncı MG, S. Onat S. Factors related to phantom limb pain and its effect on quality of life. Somatosensory & motor research. 2021 Oct 2;38(4):322-6.
  28. ↑ Gautam S, Srivastav AK, Sharma D. Physiotherapy: A potential and novel treatment approach for phantom limb pain in post-amputee patients–A systematic review. British Journal of Pain. 2024 Feb;18(1):5-27.
  29. ↑ Limakatso K, McGowan E, Ortiz-Catalan M. Evaluating mirror therapy protocols in phantom limb pain clinical trials: a scoping review. Journal of Pain Research. 2025 Dec 31:619-29.
  30. ↑ Mayo AL, Fung V, Hitzig SL, Gould S, Posa S, Summers deLuca L, Kayssi A. Exploring the psychosocial needs of persons with lower extremity amputation and feasibility of internet cognitive behavioural therapy: a qualitative study. Disability and Rehabilitation. 2023 Nov 20;45(24):4025-34.
  31. ↑ Madsen UR, Hommel A, Bååth C, Berthelsen CB. Pendulating—A grounded theory explaining patients’ behavior shortly after having a leg amputated due to vascular disease. International journal of qualitative studies on health and well-being. 2016 Jan 1;11(1):32739.
  32. ↑ Miller MJ, Mealer ML, Cook PF, So N, Morris MA, Christiansen CL. Qualitative analysis of resilience characteristics of people with unilateral transtibial amputation. Disability and health journal. 2020 Oct 1;13(4):100925.
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