This document provides guidance on checking various aspects of a lower limb prosthesis. It discusses checking the prosthesis and patient's stump in general, as well as when sitting, standing, walking, and with the prosthesis removed. Checks include ensuring proper fit and alignment of socket components, comfort and stability of the patient, and identification of any potential issues. The document focuses on checkouts for above knee prosthetics but also briefly discusses below knee prosthetics. The goal of prosthetic checkouts is to assess proper functioning and make any necessary adjustments before training the patient.

1. LOWER LIMB PROSTHETIC
CHECKOUTS
Abey P Rajan
Department Of Orthopedics physiotherapy
KLEU Institute Of Physiotherapy

2. Contents
1. Introduction
2. General prosthetic checkouts
3. Checkouts in sitting
4. Checkouts in standing
5. Check outs in walking
6. Above knee prosthetic checkouts
7. Below knee prosthetic checkouts
8. References

3. INTRODUCTION
What Is Amputation?
 An amputation is the surgical or accidental removal of all or part of a
limb or extremity such as an arm, leg, foot, hand, toe, or finger.
What Is Prosthesis?
 Is an artificial device that replaces a missing body which are
individually prescribed, designed, manufactured and fitted to
substitute for a lost part and to restore lost function.

4. Prosthetic Check Outs And Its Importance?

5.  After an amputee has been fitted with a prosthesis they will be seen
by Physiotherapists for gait training to learn to use it correctly. This
can occur with a new amputee with their first limb, or experienced
amputees to either correct bad habits or learn to gain the most from
new components.
 When seeing the amputee in any of these situations, the first thing the
Physiotherapist should do is perform a prosthetic checkout that is,
examine the fitting, alignment and functioning of the prosthesis to
make sure it can be used during training and rehabilitation without
risk to the amputee’s stump or skin, or risk of falls.
 If potential problems are found, some can be remedied on the spot,
such as adding extra socks in a loosely fitting socket, while others
must be referred back to the Prosthetist for correction.

6. The prosthetic check outs can be assessed in
1) General
2) Standing
3) Sitting
4) Walking
5) Prosthesis off
 During the initial checkout attention should be given to the patient’s
Comfort, Stability and Effort required.
 Ability of the patient to use the prosthesis should be evaluate
carefully.

7. 1. General Prosthetic Checkouts
Before donning the prosthesis for the checkouts, check the stump
properly for any wounds, abrasions, blisters, redness or discoloration,
excessive bony protuberances or scars. Note for any effect of prosthesis
on the stump and skin. Also check for contractures.
►Checkout the prosthesis before the patient donned it.
 Is the prosthesis constructed of the components that were prescribed
at the clinic?
 Check all the screws and adaptors are tightened and make sure that
there are no loose parts.
 Is the interior of the socket free from ridges or excessive bulges or
areas of coarseness.

8.  Do articulated components move as expected, without noise?
 Does bench alignment looks satisfactory?
 Check that the foot wear is firmly on the foot and not too loose or
excessively worn and check weather the socket is on the stump
correctly.
Ask the amputee to don their prosthesis.
 Can the prosthesis be donned easily, including socks and liners, belts
and cuffs?

9. 2.In Sitting
Ask the amputee to remain sitting , hip and knee around 90 degrees
with feet flat and check for-:
TTA- Trans tibial amputation
TFA- Trans femoral amputation
 If patient can flex his knee or not- if not the possible cause TTA
will be too high popliteal brim or insufficient hamstring relief
 Check for anterior superior brim-if it is too high
then the patient cannot sit forward which limit hip flexion TFA
 Knee sits level with intact knee?
 Ask the patient whether is he feeling any kind of excessive pressure
or pain.

10. 2.In Standing
 When performing checkouts in standing, remember that the initial
goal is to assess the fit and alignment of the prosthesis especially
the new amputees trailing their first prosthesis.
 The amputee should stand on parallel bar or any other secure
environment.
 Encourage equal weight distribution as much as possible.

11. 3.In Walking
 Check for dynamic fit and alignment of the prosthesis while the
wearer walking
 Ask for any kind of pain or discomfort while walking
 Observe for any gross gait deviations or excessive pistoning.

12. Above Knee Prosthetic Checkouts
The prosthesis is examined with the patient in standing, sitting, walking
and with the prosthesis removed as mentioned above.
 During the prosthetic evaluation it is important to check the socket is
on the stump correctly.
 Is the prosthesis as prescribed?
 The following checkout procedure is meant for Above knee
prosthesis consisted of 38 checklists.

13.  CHECK WITH THE PATIENT IN STANDING
1.The amputee should be able to stand erect as comfortably as possible
 Equal weight on both feet
 Heel centres not more than 150mm apart
 Amputees shoes should match and show no sign of uneven wear
2. Is the patient comfortable while standing with the mid lines of the heel not
more than 150mm apart?
 Amputee is asked for any pain or discomfort, If he does have then ask and
note the details to find out the location and degree of pain/discomfort.

14. 3. Is the adductor longus tendon properly located in its channel and is the
patient free from excessive pressure in the antero-medial aspect of the
socket?
 This can be checked by visually and palpation
 Socket’s correct position on the stump is determined by the proper fit of
adductor longus tendon into its channel. If it is not fitting properly the
reliefs and contours of the socket will not correspond to the areas of the
stump for which they were intended.
 POSSIBLE CAUSES?
• Improper relief
• Too small A-P dimension of medial wall
• Too small M-L dimension of the socket
• Downward slant of the ischial seat from lateral to medial
4. Is the ischial tuberosity rest properly on the ischial seat?
 It rest approximately 12mm behind the inner surface of rear wall and 20-
25mm lateral to the inner surface of medial wall.

15.  Check the location of ischial tuberosity on the ischial seat, if the ischial
seat is too far posterior it may cause pressure on the hamstring tendons and
gluteal muscles and the usual cause is small A-P socket dimension.
 If ischial seat is medially displaced , may be caused by small M-L or
medial downward slant of the posterior wall. This will cause the crowding
of the adductors and create a filling of tightness in the crotch area.
5. Is the prosthesis of correct length?
 Compare the height of iliac crest levels.
 An imaginary line along the crest should parallel to ground.
 ASIS or PSIS may also be used as reference points, if the reference points
are not in levelled or the patient feels that the prosthesis is not of correct
length.

16.  If the prosthesis is too short , check for lumbar scoliosis with the convexity
towards the prosthesis.
 If the prosthesis is long then the scoliosis will be reversed with the
convexity towards the sound side.
 Check for all these points and after satisfying about them and still there is
discrepancy in the length then correct it as per the requirement.
6. Is the knee stable on weight bearing?
 The amputee have to stand in the parallel bar with his weight equally
distributed on his both legs, strike moderately behind the prosthetic knee.
The knee should remain stable and if it flexes it should come back to
extension immediately.

17. The prosthetic alignment should be such that the amputee should not exert
excessive muscular effort to control the knee joint of his/her prosthesis.
Check for TKA alignment if the prosthetic knee is unstable. For
medium/long stump, knee axis may be close to TKA line, for short stumps
it should be farther to TKA line.
7. Is the brim of posterior wall parallel to the ground?
 If the brim deviates more than 5 degree from the horizontal, there will be a
poor distribution of weight between the ischium and gluteal muscles.
8. Is the patient free from vertical pressure in the area of perineum?
 Pressure of inferior ramus against the medial brim or the pressure of
medial brim against adductor roll are intolerable.
 Most common causes are:
• Insufficient counter force from anterior wall
• Anterior pelvic tilt
• Adductor longus not in its channel
• Too high medial wall

18. • Large A-P dimension
• Insufficient radius of medial brim
9. When the valve is removed, does the stump tissue protrude slightly into the
valve hole and have satisfactory consistency?
 Distal compression of stump tissue should cause the tissues to be forced
slightly into the valve hole when the valve is removed. This signifies
sufficient compression to aid to the venous return.

19. 10. Are the lateral and anterior attachments of the silesian belt correctly
located?
 The lateral attachment point should be about 6mm above and 6mm
posteriors to the greater trochanter.
 Anterior attachments are equidistant from a point of intersection of
horizontal line at ischial level and vertical bisection of anterior aspect of
the socket.
Silesian belt
TES belt

20. 11. Does the pelvic band accurately fit the contours of the body?
 The pelvic band should fit with the contours of the pelvis. It minimizes
piston action, it can be check by visual inspection and palpation.
12. Is the valve located properly to pull the stump sock?
 The preferred position of the location is antero-medial aspect of the
prosthesis and as far below the end of the stump as seal permits.
 It should have vertical inclination to minimize the friction while pulling the
stump sock.

21.  CHECK WITH THE PATIENT IN SITTING
13. Does the socket remains secure on the stump?
 Socket should remain on the stump while the patient in sitting.
 Ask the patient to bend to touch his/her shoes and see that socket remain
on the stump.
 If the stump changes position, it may be because of any of the following
reason-
 Loss of suction due to poor fit
 Pressure of the socket against abdomen or in the crotch area
 Excessive thickness of posterior wall resulting in the gapping of the
anterior wall.
14. Does the shank remain in good alignment?
 While sitting the feet should be flat and shank vertical.
 If sitting alignment is faulty, check for uncomfortable pressure in the area
of adductors, scarpa’s triangle and gluteal crease.

22. Posterior brim should be flat, knee axis should be horizontal..
15. Is the knee bolt 12 to 20mm above the medial tibial plateau?
If the knee joint is low the prosthetic knee will be projected ahead of sound
knee and thigh piece would be too long.
Since there is no true knee bolt in polycentric knee joint, the relative
position of thigh and shank should be compared.
16. Can the patient remain seated with out the burning sensation in the
hamstring area?
Check for – posterior wall too thick, insufficient radius at the posterior
brim, insufficient channel for hamstring tendons at the posterior medial
corner.
17. Can the patient rise to standing position without objection alee air noise?
When the amputee stands from a sitting position air escapes from the
socket noise indicates incorrect socket fit.
Check particularly for looseness of lateral and anterior walls.

23.  CHECK WITH THE PATIENT IN WALKING
18. Is the performance of the patient in level walking satisfactory? Indicate
the gait compensation that require attention?
 This may not be possible to ascertain during the initial checkout. Also
considering the initial capabilities of the amputee while assessing this
point.
 Have the amputee walks at normal speed, for about 20m.
 Observe from front, side and back then note for any gait compensations
and take necessary action to correct it if possible.

24. 19. Is suction maintained during walking?
 There should not be any piston action
 The patient should not have to pump his stump to maintain the suction
 The cause of failure of suction may be accumulation of glue, powder or
any other foreign materials over the threads of the suction valve,
Inadequate seal around the suction valve, flesh obstructing the valve, air
leakage from anterior or lateral wall.

25. 20. Is there total contact between stump and socket through out the stance
and swing phase?
During walking there is greater compression of soft tissues in stance phase
and lesser compression during swing phase.
The negative pressure then becomes very high causing oedema
There should be total contact during the complete gait cycle
Ask the amputee if he feels total contact during complete gait cycle
Check amputee’s stump immediately after the prosthesis is removed
21/22. Does the patient go up and down inclines satisfactorily? Does the
patient go up and down stairs satisfactorily?

26. 23. Does the ischial tuberosity maintain its position on the ischial seat?
The position of ischial tuberosity is rechecked after the amputee has walked
for a while
The ischium should not change its position on the ischial seat during
walking
24. Is any flesh roll above the socket brim?
 Check by visual inspection and palpation
 There should not be any flesh rolls on medial and anterior brims of the
socket
 The medial brim should not be more than 6mm lower than the ischial
tuberosity
 If any adductor roll is present, it should be accommodated by the provision
of an undercut immediately below the brim so the tissues can be pulled
into the socket.

27. 25. Does the lateral wall maintain firm and even contact with the lateral
aspect of the stump?
Ask the amputee for any kind of lateral discomfort on weight bearing
particularly on the greater trochanter and lateral distal aspect of the stump.
26. Does the prosthesis operate quietly?
Check for loose or worn ankle, knee or hip joint
Air leakage from the socket
Loose extension stop in the knee unit
Loose shoe
27. Are the size shape and contour of the prosthesis approximately the same as
those of the sound limb?
The size, shape, contour and colour of the prosthesis should be compared
28. Does the patient consider prosthesis satisfactory as to comfort, function
and appearance?
 Ask the amputee about his opinion

28. After his reaction, try to obtain further information in relation to comfort,
stability, effort and appearance.
 CHECK THE PATIENT WITH PROSTHESIS OFF
29. Is the stump of the amputee free from abrasions, discolorations, and
excessive perspiration immediately after the prosthesis is removed?
 Examine the stump irritation, localized pressure, oedema or any other
indication of poor socket fit
 Previously noted areas should be examined carefully
 If the patient has used a prosthesis before discoloration may present
 Areas of redness which disappear within 10 minutes after removal of the
prosthesis are not significant usually unless accompanied by discomfort
 If the amputee complains of tightness distally, look for oedema of the distal
end.
 Oedema disappears after the socket is removed suggest poor socket fit
 Among the possible cause are tight proximal brim, piston action, absent total
contact

29. 30. Are the anterior and lateral walls 50mm higher than the posterior wall?
 This is required to support and stabilize the stump in the socket
 Too short anterior and lateral wall fail to do this
 Too high anterior wall may cause discomfort in the area of ASIS while the
amputee is sitting
31. Does the inside of the socket has a smooth finish?
 The inside of the socket should be smooth so that to avoid any skin
abrasions
 To allow stockinet to be pulled easily in case of suction socket is used.
32. Is there sufficient clearance between the knee and ankle articulations?
 There should be sufficient clearance between the proximal portion of the
shank and knee unit so that rubbing between these parts can be prevented
when knee flexes and extends
 However, if the clearance is too great, the clothing may get caught in the
opening
 Similarly, there should be enough clearance between the ankle articulation,
but not too great that hosiery catches in between the adjacent areas.

30. 33. Are the posterior surface of the thigh and the shank shaped so that there
should be minimum concentration of pressure when the knee is fully flexed?
 The back of the shank should make an even contact with the back of thigh
piece when the knee is fully flexed
 Any uneven contact will create undue pressure to cause either to split.
34. With the prosthesis in the kneeling position, can the thigh piece be brought
into vertical position?
 It should be possible to flex the knee for enough that the thigh piece
inclines backward.
 Unless this position of thigh piece inclining backward is assumed, the
prosthesis will tend to force the wearer forward when he kneels
35. Is the total contact socket, is the bottom of the valve hole at the level of
the bottom of the socket?
 If it is above this level there will be unnecessary friction on the pull sock
will result when the prosthesis is put on.
 In addition, air may be trapped inside of the socket .

31. 36. Is the back pad attached to the posterior wall of the socket?
A back pad reduces wear on troushers and muffles noise when the amputee
sits on hard surface.
37. Is the general workmanship satisfactory?
Leather works should be done firmly and neatly
The joint should be operate without play
Socket brim must be adequate flared
Sharp edges should be removed
The foot should fit the shoes snugly
Valve thread should be free from glue and dirt
38. Do the components functions properly?
It is important that a check be made of all controls such as mechanical
friction or fluid control, locks and extension aids.
They should be functioning properly and easily adjustable.

32. Below Knee Prosthetic Checkouts
1. Is the prosthesis as prescribed?
 The prosthesis should be compared with the prescription
2. Can the client don the prosthesis easily?
 CHECK WITH THE PATIENT IN STANDING
3. Is the client comfortable when standing with the heel midline 6
inches(15 cm) apart?
 The wearer should stand in the parallel bar or other secure
environment, attempting to bear equal weight on both feet. The
therapist solicit subjective comments about comfort.
4. Is the anterior- posterior and medial-lateral alignment satisfactorily?
 Estimates of anterior-posterior and medial- lateral alignment are
aided by slipping a sheet of paper under various parts of the shoe.
 Ideally, the patient should stand with both the heels and soles flat on
the floor.

33. Malalignment, indicated by excessive weight bearing on one portion
of shoe may be confirmed by subsequent analysis of gait.
5. Is the prosthesis the correct length?
Most prosthesis are constructed so that when the individual stands the
pelvis is level. If the pelvis tilts, the therapist should place lifts under
the foot on shorter side to restore the level of pelvis.
If the Total lift measures ½ inch (1cm) or less then there is no
attention is needed
For greater discrepancy – seek for the causative factors and note it.
An amputed limb that sinks too far into the socket will make the
prosthetic side appear shorter and the wearer will probably complain
discomfort.
6. Do the contour and colour of the prosthesis match the opposite limb?
 Compare the prosthetic limb with the normal side

34. 7. Is the piston movement is minimal?
Piston action refers to vertical motion of the socket when the patient
elevate the pelvis. Socket slippage is caused by looseness, inadequate
suspension or both.
8. Does the socket contact the amputation limb without pinching or
gapping?
The socket walls should fit snugly, as should the thigh corset if it is
part of the prosthesis.

35.  CHECK WITH THE PATIENT IN SITTING
9. Can the client’s sit comfortably with hips and knees flexed 90
degree?
 Comfortable sitting is a primary need for all people. The posterior
brim should brim should not impinge into the popliteal fossa and
hamstring reliefs should be adequate, especially on the medial side
where the semitendinosus and semimembranosus insert relatively
distally, placement of the cuff or the joints of the corset also
influences sitting comfort.

36.  CHECK THE PATIENT IN WALKING
 Analysis of the gait pattern and performance of other ambulatory
activities is an essential part of rehabilitation.
 For most patients, a major reason for being fitted with a prosthesis is
to resume walking.
 Nevertheless, there is no prosthesis eradicates entirely the
anatomical and physiological changes produced by amputation.
10. Is the client’s performance in level walking satisfactory?
 When walking, the person who wears the prosthesis compensates for
anatomical and prosthetic deficiencies.
 Some are inherent to amputation others are abnormalities of the body
or the prosthesis, check carefully note the cause is prosthetic or body
problem.

37. No prosthesis restores skeletal continuity, muscle integrity etc.
Anatomical deficiencies are aggravated in the presence of pain,
contracture, weakness, instability or incoordination.
The gait deviation can be present due to poorly fitted socket,
prosthetic malalignment, malfunctioning component, improper height
of the prosthesis, incorrect donning and wearing inappropriate shoes.
Remedial action should be taken in great “gait compensation” during
the walking checkout analysis.
The term “gait compensation may
be more accurate descriptor than
the more commonly used “gait
deviation” inasmuch as the patient
with amputation is most unlikely
ever to walk exactly like a
nondisabled person.

38. Compensation/deviation Prosthetic causes Anatomical causes
Early stance
1. Excessive knee flexion High shoe heel
Insufficient plantar flexion
Socket excessively flexed
Flexion contracture
Weak quadriceps
2. Insufficient knee flexion Low shoe heel
Excessive plantar flexion
Socket insufficiently flexed
Extensor spasticity
Weak quadriceps
Midstance
1. Lateral thrust Excessive foot inset
2. Medial thrust Excessive foot outset
Late stance
1. Early knee flexion: also
referred to as “drop off”
High shoe heel
Socket excessively flexed
Flexion contracture
2. Delayed knee flexion Low shoe heel
Socket insufficiently flexed
Extensor spasticity

39. 11. Can the client kneel satisfactorily?
Check are knee movements are satisfactory
Is socket displacing from the stump?
Check for the patellar seat
Ask the wearer any discomfort or pain
12. Does the prosthesis operates quietly?
13. Does the client consider the prosthesis satisfactory as to comfort,
function and appearance?

40. CHECK WITH PROSTHESIS OFF THE CLIENT
Inspection of the prosthesis off the patient
14. Is the skin free of abrasions or other discolorations attributable to
this prosthesis?
15. Is the socket interior smooth?
16. Is the construction satisfactory?
17. Do all the components functions satisfactorily?

41. 18. Is the prosthesis wall of the socket of adequate height?
 The posterior wall should be at the same level as the build up for the
patellar ligament when the patient stands.
 Stand the prosthesis on a table; place the end of a long pencil or ruler
on the anterior socket bulge and rest on the posterior brim. In a well
constructed prosthesis, the ruler will slant upward towards the rear
 Indicating that when the wearer stands in the prosthesis and
compresses the heel cushion, the wall will be at proper height.

42. References
1. http://www.austpar.com/portals/prosthetics/prosthetic_checkout.php
2. O’Sullivan, SB,Schmitz TJ. Physical Rehabilitation,8th edition. Chapter :lowerlimb
prosthesis:Piladelphia
3. Lusardi MM, Jorge M, Nielsen CC. Orthotics and prosthetics in rehabilitation. Elsevier
Health Sciences; 2013 Dec 23.
4. Anderson MH. Clinical prosthetics for physicians and therapists: a handbook of clinical
practices related to artificial limbs. Charles C Thomas Pub Ltd; 1959.
5. Gage RJ, Hicks R. Gait analysis in prosthetics. Clinical Prosthetics & Orthotics.
1989;9(3):17-21.
6. Staros A, Director MS, Center VP. The Veterans Administration's standards program in
prosthetics, orthotics, and orthopedic aids. Bulletin of prosthetics research. 1970 Jan
1;10(13):6-24.
7. Wahba WE. Above knee prosthesis assessment in egyptian patients and value of
physiological cost index.
8. Jensen E. Prosthetics and orthotics in Latin America. Prosthetics and orthotics international.
1979 Jan 1;3(3):155-6.