Prosthetics and Orthotics International

September 2009; 33(3): 230–241

Lower limb strength in sports-active transtibial amputees

LEE NOLAN

Karolinska Institute and GIH, Biomechanics and Motor Control, Stockholm, and Jönköping
University, Rehabilitation, Jönköping, Sweden

Abstract
The aim of this study was to compare hip strength in sports-active transtibial (TT) amputees, sedentary
TT amputees and sports-active non-amputees. Three ‘active’ (exercising recreationally at least three
times per week) TT amputees, four ‘inactive’ or sedentary TT amputees and nine ‘active’ able-bodied
persons (AB) underwent concentric and eccentric hip flexion and extension strength testing on both
limbs on an isokinetic dynamometer at 60 and 1208/s. Little strength asymmetry was noted between
the limbs of the active TT amputees (8% and 14% at 60 and 1208/s, respectively), their residual limb
being slightly stronger. Inactive TT amputees demonstrated up to 49% strength asymmetry, their intact
limb being the stronger. Active TT amputees demonstrated greater peak hip torques (Nm/kg) for all
conditions and speeds compared to inactive TT amputees. Peak hip torques (Nm/kg), were greater in
the active TT amputees’ residual limb compared to AB. While inactive TT amputees and AB had
similar flexion/extension ratios, active TT amputees exhibited a lower ratio indicating overdeveloped
hip extensors with respect to their hip flexors. It is not known whether this is due to the demands of
sport or exercise with a prosthetic limb, or remaining residual thigh atrophy.

Keywords: Biomechanics, rehabilitation of amputees, exercise, sport, isokinetic

Introduction
It is observed, both in practice and in scientific studies, that thigh muscle atrophy and a
reduction in thigh muscle strength is common following transtibial amputation.1–3 Strength
differences between limbs, measured as flexion and extension torques at the knee1,2,4,5 or
hip isometric strength,6 have previously been reported of up to 47% in sedentary transtibial
(TT) amputees, the residual limb being weaker than the intact limb. These studies are in
agreement that the quadriceps tend to be more atrophied and weaker than the hamstrings.
Muscle atrophy and a reduction in muscle strength, though, is associated with inactivity and
can be reversed with training or exercise.
After rehabilitation, few amputees become involved in sport or take regular exercise. The
most common reasons for this are an inability to run or jump, becoming easily fatigued,
having decreased speed of movement and decreased endurance,7 which paradoxically, can
all be improved with training. Training studies for TT amputees have been found in the
literature aimed at increasing either isokinetic knee strength2 or residual limb (stump)
volume,8 but none have been found targeting any other lower limb muscles.

Correspondence: Dr L. Nolan, Karolinska Institute and GIH, Biomechanics and Motor Control, Stockholm, Sweden.
E-mail: lee.nolan@gih.se

ISSN 0309-3646 print/ISSN 1746-1553 online Ó 2009 ISPO

DOI: 10.1080/03093640903082118
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 Special Sports Edition Hip strength in active amputees 231

It is known that lower limb amputees compensate at the hip (in terms of increased range
of movement and torque) during walking, running and jumping.9–11 Thus greater demands
are made on the muscles surrounding the hips for prosthesis users than for able-bodied
persons. In addition, authors have suggested that a deficiency in hip muscle strength may
12,
contribute to poor walking ability 13 and an inability to run or walk quickly would be expected
to be a result of inadequate training of the hip flexors.6 Thus it appears that for lower limb
amputees, the important muscle groups for good walking or running, and thus ability to be
sports-active, are the muscles surrounding the hip joint. To date, no published studies have
either investigated the amount of hip flexion or extension strength asymmetry or, in a
training study, tried to increase hip strength in lower limb amputees in order to investigate
whether this improves their walking or running or ability to be sports-active.
To successfully take part in sports or exercise, one needs to be in fairly good condition
and be sufficiently strong in the appropriate muscles. This is achieved in itself via
progressive training of the cardiovascular system and muscles. Unilateral TT amputees at
elite level have run 100 m in 10.91 s, jumped 6.79 m in the long jump and cleared 2.11 m in
the high jump (current World Records) which is beyond the performance of many non-
amputees. As success in these events require strong lower limb muscles, it is clear these
athletes cannot have the same degree of residual limb muscle atrophy or loss of muscle
strength as has been reported in sedentary TT amputees. Thus it can be inferred that lower
limb amputees are able to train their muscles to a degree that will allow them to compete in
sport at the highest level. However, whereas few amputees have the ability or inclination to
train to elite level, a greater number would like to be able to return to participating in sport or
exercise on a recreational level. Understanding strength requirements for lower limb
amputees to participate in sport at this level would be of interest for practitioners and
coaches working in this field. As nothing has yet been reported about strength requirements
or strength magnitudes in sports-active lower limb amputees at any level, it is necessary to
first determine how strong recreational exercisers are compared to those who do not
exercise. The aim of this study is to compare hip strength in sports-active TT amputees,
sedentary TT amputees and sports-active non-amputees.

Method
Subjects
Three ‘active’ transtibial (TT) amputees who exercised at least three times per week for
recreational purposes (including running), four sedentary, or ‘inactive’ TT amputees who
walked and completed normal everyday activities but did not partake in any exercise
sessions, and nine ‘active’ able-bodied (AB) persons (exercising at least three times per
week for recreational purposes) took part in the study. None of the ‘active’ persons, either
TT or AB were considered competitive sportsmen or women. All amputees were established
(mean + SD years as an amputee 12.4 + 13.4) unilateral amputees, six resulting from
trauma, one resulting from a congenital deformity, and walked using their prosthesis every
day. (See Table I for subject characteristics). Subjects were excluded if they had vascular
problems or diabetes, did not use their prosthesis daily, competed in sport, or exercised 1–2
times per week only.
Able-bodied participants were recruited from a Physical Education College in Sweden.
The amputee participants were initially contacted by a physiotherapist or prosthetist with
general information about the study and those interested in participating were requested to
contact the author for more information and the possibility of volunteering. Due to ethical

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232 Special Sports Edition L. Nolan
Table I. Subjects’ characteristics. Individual characteristics are given for all TT amputees, while group means + SD
are given for the able-bodied (AB) persons.

Sports/exercise
Age Height Mass Stump length Years since participating in
Gender (years) (m) (kg) (m) (% of intact) amputation (all recreational)

Active
M 33 1.85 86.8 0.17 (38%) 17 Cycling, running, gym
F 44 1.60 54.8 0.18 (45%) 7 Running, aerobics, gym,
M 28 1.76 56.0 0.43 (93%) 8 Running (sprinting), gym
Inactive
F 40 1.65 77.9 0.37 (90%) 1 —
M 46 1.97 129.4 0.45 (88%) 2 —
M 52 1.65 63.0 0.20 (53%) 12 —
F 40 1.63 65.0 0.15 (37%) 40 —
AB
7M, 2F 32 + 4 1.81 + 0.09 77.5 + 11.4 — — Running, gym, cycling,
rugby, tennis

requirements, the author was not allowed to make initial contact with potential amputee
participants. Ethical approval was given by the institutional ethics committee and written
informed consent was obtained from all participants.

Apparatus
An isokinetic dynamometer,14 controlled by a PC, was used to measure hip flexor and
extensor strength during concentric and eccentric actions with the subjects lying prone. A
custom made cuff to be placed around the most distal part of the thigh was constructed. Pilot
work determined the best type of cuff to minimize errors in strength measurement due to
pain or discomfort. The hip range of motion, selected to include hip range of motion
during running at all speeds up to sprinting, was from 108 hip extension to 708 hip
flexion. The dynamometer was set with a 58 ramp, i.e., it took 58 to reach the selected
speed, and 58 to slow down. Thus the range 58 hip extension to 658 hip flexion was
guaranteed to be at the selected speeds. The isokinetic dynamometer was calibrated prior
to each testing session.

Procedure
The subject lay in a prone position and the dynamometer was adjusted so that the hip joint
centre corresponded with the position of the axis of rotation of the lever arm. The cuff was
placed around the thigh of the limb being measured, as distally as possible, adjusting the
lever arm length for each subject. The free limb and lower back were strapped down to try to
isolate hip flexion and extension movement (see Figure 1 for an example of the set-up). Hip
strength in both limbs was measured, intact limb first, with measurements on the residual
limb being made without a prosthesis.
Each subject underwent a warm-up. This consisted of flexing and extending the hip
throughout the measuring range of motion. Each trial required progressively more effort until
the subject was ready to perform a maximal movement. The subjects then completely
relaxed and an initial flexion/extension trial was collected to determine the torque due to
gravity and the mass of the leg.

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 Special Sports Edition Hip strength in active amputees 233

Figure 1. An example of the isokinetic dynamometer set-up for testing hip strength in the right limb of an able-bodied
subject. For testing hip strength in the left limb, the subject lies on the right bench and the free leg support and cuff
with lever arm are transferred to the right side. The set-up is identical for the TT amputees with the exception of
when the amputated leg is the free leg, a pillow is provided for use between the residual stump and the leg support.

Maximal concentric and eccentric flexor and extensor strength measurements at 608/s
and 1208/s were performed in random order with verbal encouragement. Two trials, each
trial consisting of one flexion and one extension movement, for each condition were
performed so as not to fatigue the subjects, particularly the inactive amputees. A short rest
period of at least 60 s was allowed between each trial. For the eccentric strength actions,
the subjects were allowed several practice trials at both speeds to familiarize themselves
with the movement. Output angle (degrees) and torque data (Nm) for each trial was
collected on a second computer, sampled at 100 Hz, using a Powerlab1 data acquisition
system (AD Instruments Ltd, Oxfordshire, UK).

Data analysis
Five degrees were removed from the start and the end of the range of motion prior to
further processing (resulting in 75 to 658) to ensure the correct speed was present
throughout the whole range of motion. Of the two trials for each condition, the trial
showing the largest peak torque was chosen for further analysis. The gravity torque
was then taken from, or added to, the flexion and extension trials, respectively, to take
into account the effect of gravity and the mass of the leg when lying in the prone
position.
Peak torque, during the analyzed range of motion (75 to 658) was calculated for
concentric hip flexion, concentric hip extension, eccentric hip flexion and eccentric hip
extension at both speeds. All values were normalized to body mass for each individual. An

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234 Special Sports Edition L. Nolan

asymmetry index was used to indicate peak torque differences between the residual and
intact limbs of the TT amputees where amount of asymmetry (ASI):15
ASI ¼ ðL  RÞ=0:5  ðL þ RÞ  100

Here, left (L) and right (R) limb values were replaced by intact and residual limb values,
respectively. Thus a positive number (%) will indicate a stronger intact limb and a negative
number (%) a stronger residual limb.
In order to determine the relative strength of the hip flexors to the hip extensors, a flexion
extension ratio (peak flexion torque/peak extension torque) was calculated for each
contraction type (concentric or eccentric) and for each speed.

Statistical analysis
For the able-bodied persons, a paired t-test, with level of significance set to p 5 0.05, was
performed to determine any differences between left/right limb peak torques for all speeds
and conditions. None were found and so an average of the left and right limbs were
calculated for all able-bodied individuals to avoid reporting either dominant or non-dominant
limb values as the basis of a comparison value for the TT amputees. Due to having so few
TT amputees in each group, n ¼ 3 and n ¼ 4, only descriptive statistics, such as group
means, standard errors and percentage asymmetry, calculated using the mentioned
asymmetry index, could be presented.

Results
Muscle contractions at 608/s
Asymmetry. Looking at Table II, little asymmetry was seen between the limbs of the active
amputees. Maximum asymmetry at 608/s, regardless of muscle action or contraction
was 78%, with the negative signs indicating a greater torque produced by the residual limb
compared to the intact limb. The opposite was seen for the inactive amputees. A greater
torque was always produced by their intact limb, resulting in up to 49% inter-limb
asymmetry.

Table II. Strength asymmetry between the residual and intact limbs for the active and sedentary (‘inactive’)
transtibial amputees. A positive sign indicates the intact limb is the stronger, while a negative indicates the residual
limb is the stronger.

Active TT Inactive TT
Contraction Speed Muscle action asymmetry (%) asymmetry (%)

Concentric 608/s Flexion 78 26

Extension 76 25
Eccentric 608/s Flexion 72 49
Extension 78 28
Concentric 1208/s Flexion 11 20
Extension 714 30
Eccentric 1208/s Flexion 0 6
Extension 75 17

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 Special Sports Edition Hip strength in active amputees 235

Concentric flexion and extension peak torques

Figure 2 shows peak concentric hip flexion and extension torque at the slower speed of
608/s. Both active and inactive TT amputees had smaller hip flexion peak torques than the
AB group, with the active amputees being stronger than the inactive (13% stronger intact
limb, 59% stronger residual limb). What is particularly interesting is the active amputees
had greater hip extensor peak torques than the able-bodied persons (12% greater on the
residual limb, 6% greater on the intact limb). Peak hip extension torque differences were
seen between the active and inactive persons, the active TT amputees having 53%
stronger intact limb and 109% stronger residual limb than the inactive.

Eccentric flexion and extension peak torques

Eccentrically, the active amputees were again stronger than the inactive amputees
(Figure 3). The active individuals exhibited similar magnitude hip flexion peak torques in
both their residual and intact limbs, while the inactive individuals had a much smaller

Figure 2. (A) Concentric hip flexion and (B) extension strength, normalized to body mass, at 608/s. Mean (þ SE)
values shown for active (black) and inactive (grey) TT amputees. Solid block indicates intact limb, striped block
residual limb. The corresponding able-bodied value (average of both limbs) is indicated by the white block.

Figure 3. (A) Eccentric hip flexion and (B) extension strength, normalized to body mass, at 608/s. Mean (þ SE)
values shown for active (black) and inactive (grey) TT amputees. Solid block indicates intact limb, striped block
residual limb. The corresponding able-bodied value (average of both limbs) is indicated by the white block.

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236 Special Sports Edition L. Nolan

residual hip flexion peak torque compared to their intact limb. Comparing the TT amputee
groups, the active persons produced a 91% greater eccentric hip flexion peak torque in their
residual limb than the inactive persons.
While all amputees exhibited weaker smaller hip flexion peak torques than AB persons,
the active individuals had a similar magnitude hip extension peak torque in their residual
limb compared to the AB group. Again for the active persons, their residual limb hip muscles
were stronger than their intact limb hip muscles, and this is where the difference between
the active and inactive individuals was seen clearest (active amputees had a 187% greater
residual limb eccentric hip extension peak torque than inactive).

Muscle contractions at 1208/s

Asymmetry. Looking at Table II, a little more asymmetry was seen between the limbs of the
active amputees for concentric contractions at this speed than for the slower speed.
Maximum asymmetry at 1208/s, regardless of muscle action (flexion or extension) or
contraction (concentric or eccentric) was 714%, indicating a greater peak torque was
produced by the residual limb than the intact limb for all muscle actions and contractions
except concentric flexion. For the inactive amputees, up to 30% asymmetry was seen
between the limbs, where in all cases a greater peak torque was produced by their intact
limb compared to their residual limb.

Concentric flexion and extension peak torques

At the faster speed of 1208/s, both active and inactive TT amputees had smaller
concentric hip flexion peak torques than the AB group (Figure 4). Comparing the TT
amputee groups, the active individuals were stronger, producing a 25% greater peak
torque on their intact limb and a 36% greater torque on their residual limb compared to
the inactive individuals. For concentric hip extension peak torques at this speed, active
amputees had a similar magnitude intact limb peak torque, but greater residual limb peak
torque (16%) compared to the able-bodied group. Again, hip extensor torque in the
residual limb was where the largest difference was seen between the active and inactive
amputees, the active persons having a 124% greater hip extension peak torque than the
inactive.

Figure 4. (A) Concentric hip flexion and (B) extension strength, normalized to body mass, at 1208/s. Mean (þ SE)
values shown for active (black) and inactive (grey) TT amputees. Solid block indicates intact limb, striped block
residual limb. The corresponding able-bodied value (average of both limbs) is indicated by the white block.

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 Special Sports Edition Hip strength in active amputees 237

Eccentric flexion and extension peak torques

The active amputees were again stronger than the inactive amputees (Figure 5). The able-
bodied persons exhibited a greater peak hip flexion torque than the amputees. However, for
hip extension, the active amputees produced a greater peak torque than the able-bodied
persons in both their intact limb (20%) and residual limb (26%). In addition, eccentric hip
extension at the fast speed of 1208/s is where the largest difference in peak torque was seen
between the active and inactive amputees. In the intact limb, the active persons produced
an 80% greater peak torque and in the residual limb they produced a 123% greater peak
torque than those amputees who did not exercise.

Flexion/extension ratio
The able-bodied persons exhibited similar flexion/extension ratios of around 0.6 regardless
of contraction type or speed (Table III). The active TT amputees had a smaller ratio of 0.4–
0.5, while the inactive exhibited a generally larger ratio of 0.6–0.7.

Discussion
On comparing the three groups descriptively, it is clear from the results that active TT
amputees have stronger hip muscles than inactive amputees, as is to be expected. The

Figure 5. (A) Eccentric hip flexion and (B) extension strength, normalized to body mass, at 1208/s. Mean (þSE)
values shown for active (black) and inactive (grey) TT amputees. Solid block indicates intact limb, striped block
residual limb. The corresponding able-bodied value (average of both limbs) is indicated by the white block.

Table III. Hip flexion/extension ratios for able-bodied persons (AB), active TT amputees and inactive TT amputees.
Ratios are presented for concentric (conc) and eccentric (ecc) contractions at both tested speeds of 60 and 1208/s.

Group Limb Conc 608/s Ecc 608/s Conc 1208/s Ecc 1208/s

AB 0.56 0.54 0.56 0.59

Active TT Residual 0.46 0.47 0.40 0.44
Intact 0.45 0.50 0.53 0.46
Inactive TT Residual 0.68 0.46 0.66 0.73
Intact 0.61 0.57 0.60 0.65

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238 Special Sports Edition L. Nolan

inactive amputees tested were on average a little older than the sports-active group
(mean + SD age 44.5 + 5.7 and 35.0 + 8.2 years, respectively), which could have
accounted for some strength difference, but the differences between these two groups
are so large that it cannot be only due to age.
More interestingly, the active TT amputees have as strong or stronger (depending on
limb, contraction type or speed) hip extensor muscles than active able-bodied persons. In
particular, residual limb concentric hip extensor torque at both speeds and both the residual
and intact limb eccentric hip extensor torque at the faster speed, were 12–26% stronger
than the able-bodied group. To the author’s knowledge there are no published studies on
isokinetic hip torque in sports-active unilateral TT amputees, and so there are no values to
compare these findings to. The able-bodied persons and active TT amputees recruited for
the present study all claimed to regularly exercise at least three times per week at the time of
testing, but no measurements were performed to assess their general level of fitness, nor to
question their training intensity. Thus it could be, although it is not known, that the active TT
amputees exercised more than the AB persons and that could account for their stronger hip
muscles. Thus in future studies of this nature it is recommended that training intensity as
well as training duration and frequency are recorded. On the other hand, the problems
associated with performing sports with a prosthetic foot may force active TT amputees to
become so much stronger in their residual limb hip compared to both their intact limb hip and
to the hips of AB persons as many studies have reported that TT amputees compensate at
the hip during walking, running and jumping.9–11 Whatever the reason, this study illustrates
descriptively that TT amputees, despite residual limb atrophy following amputation, can
strengthen their hip muscles to a level that surpasses age-matched sports-active AB
persons. Thus in terms of limb strength, there should be no barriers to sports participation
for healthy TT amputees. Further study is needed to determine if these amounts of hip
strength are the necessary minimum for lower limb amputees to participate in sport or
exercise at recreational level. This information would provide a basis for the development of
effective and efficient training programmes for currently sedentary amputees.
On looking at the descriptive results of inter-limb symmetry within each group, for each
contraction type, speed and muscle action, the inactive TT amputees displayed the most
asymmetry. The large asymmetry values were seen as much larger hip peak torques on
their intact limb than their residual limb. Similar findings for sedentary TT amputees have
been reported previously for thigh strength (knee torque) measured at the same speed as
the present study2,4,5,16 although no comparable studies have been found reporting hip
strength torques. In the present study, the differences between the limbs of the inactive TT
amputees were seen as large amounts of asymmetry, regardless of muscle action,
contraction or speed, of up to 49%, which is comparable with previous studies reporting,
either by measuring isokinetic knee strength or isometric hip strength, inter-limb asymmetry
of up to 47%.1,2,4–6 As residual limb atrophy is less pronounced in the hamstrings than
3
quadriceps, hip flexion asymmetry should be greater than hip extension asymmetry. This
was true for the present study’s inactive persons for both eccentric and concentric
contractions at the slower speed, but not at the faster speed where the opposite was true.
This could have been due to the speed of motor unit recruitment in untrained persons.
Muscle fibre type has been found to differ in the residual limb thigh of inactive TT amputees
compared to their intact limb thigh.2,3 A greater percentage of Type II fast twitch fibres and
reduced percentage of Type I slow twitch fibres compared to the intact limb were found in
the vastus lateralis, which interestingly was redressed with training.2
While these results are only descriptive due to the small group numbers involved, these
findings suggest that active TT amputees exhibit the opposite of the inactive TT amputees in

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 Special Sports Edition Hip strength in active amputees 239

terms of inter-limb asymmetry. In all measurements except concentric flexion at 1208/s, their
residual limb hip muscles were stronger than their intact limb hip muscles. Indeed inter-limb
asymmetry at the slower contraction speed was 8% or less regardless of contraction type or
muscle action, and there was no pattern of the hip flexors being more asymmetrical than hip
extensors or vice versa. Thus, the results for the active TT amputees show, and these are
not elite athletes but individuals who exercise on a recreational level, it is not only possible to
redress muscle atrophy and reduced strength in the residual limb, but also to have greater
residual limb strength than in both their intact limb, and in the limbs of sports-active AB
persons. Further study needs to be done to determine whether the use of sport or exercise
is an effective tool to help reduce the levels of muscle and gait asymmetry commonly seen in
lower limb amputees.
For all able-bodied persons, and all amputees in this study, regardless of whether active
or inactive, hip extensor muscles were stronger than hip flexor muscles both concentrically,
eccentrically, and at both contraction speeds. This is in agreement with previous studies.17–21
On comparing how strong the hip flexors are relative to the hip extensors in an able-bodied
population, authors have reported isokinetic (concentric and eccentric) hip flexor/extensor
ratios of 0.58–0.75.20,21 The able-bodied persons in the present study exhibited a concentric
flexion/extension ratio of 0.56 and an eccentric ratio of 0.54–0.59 indicating this group is at
the lower end of the reported AB range. Bäcklund et al.6 reported isometric hip extension
strength was greater than isometric hip flexion strength in sedentary TT amputees, and
proposed that this was due to the fact that hip flexors are less exercised than hip extensors.
Hip extensor muscles function as antigravity muscles and thus are naturally exercised more
than hip flexor muscles. In the present study, the hip flexion/extension ratio for the active TT
amputees was 0.40–0.47 for their residual limb and 0.45–0.53 for their intact limb. While
these results are only descriptive due to the small group numbers involved, these findings
suggest much weaker hip flexors with respect to extensors in both limbs, particularly in the
residual limb, compared to the able-bodied population. For the inactive TT amputees, the
ratios were higher; 0.46–0.73 for their residual limb and 0.57–0.65 for their intact limb
indicating similarities with the able-bodied population. Thus while the active TT amputees in
this study were stronger than the inactive amputees, their hip extensor muscles were
excessively strong compared to their hip flexors. It may be that either their chosen sports
demand high levels of hip extension strength, or that hip flexor strength cannot be increased
much more than this, particularly in the residual limb as atrophy of the hamstring muscles is
less pronounced than for the quadriceps muscles.3 Perhaps due to this, active amputees
need to ‘overdevelop’ their hip extensors in compensation, resulting in the need to be
stronger than able-bodied persons in order to perform similar sport or exercise movements.
Further study is needed to determine the effect of hip flexor strength training in a similarly
active TT amputee population.
A limitation of the study was, as with all isokinetic or maximum strength testing studies,
knowing whether or not the subjects were performing maximum effort on the strength tests.
Fear, particularly for the inactive group on the residual limb tests could have been a factor,
and reproducibility was not tested in order to avoid fatigue. However as much as possible
was done to reduce this particular limitation such as acclimatising and warming up using the
same movements as in the test, and also testing the intact limb first. In addition, the cuff of
the isokinetic dynamomenter was placed on the distal end of the thigh and thus nothing was
touching the stump, avoiding excess pressure or discomfort.
The low numbers of sports-active amputee subjects available was the limiting factor of
group size. Due to ethical requirements, the author was not allowed to approach any
potential amputee participants and thus cooperation from prosthetists and physiotherapists

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240 Special Sports Edition L. Nolan

treating these amputees was required. Due to this fact, it is not known how many amputees
were informed about the study and how many of these were interested enough to take it
further. The strict inclusion criteria, not least that all should be trauma or congenital
amputees, limited further the group numbers as two sports-active amputees had to be
rejected because they were competitive athletes. It was thought that including competitive
athletes could skew the results somewhat as it is expected they will be stronger than those
exercising recreationally. Due to these constraints, it was not possible to include more
subjects within the time period for the study. With these small group sizes all results are
presented on a descriptive level and the findings cannot be generalised to all TT amputees.
However, the standard error for measured variables in this group was small so it may be that
other young, healthy, sports-active TT amputees with amputations resulting from trauma
could show similar findings to the present study.

Conclusion
Little hip strength asymmetry was seen in the limbs of the three active TT amputees, where
their residual limb was slightly stronger than their intact. The opposite was found for the four
inactive TT amputees who displayed up to 49% inter-limb asymmetry, where their residual
limb was weaker than their intact.
The sports-active amputees had more than double the size hip extensor peak torques
on their residual limb compared to inactive TT amputees, and were also up to 26%
greater than similarly sports-active AB persons. However, their flexion/extension ratio
was much smaller than both the other groups indicating their hip extensors were
overdeveloped compared to their hip flexors. It is not known if this is due to the
demands or sport or exercise with a prosthetic limb resulting in the need to be stronger
than able-bodied persons in order to perform similar sport or exercise movements, or
remaining amounts of thigh muscle atrophy. However, these are preliminary findings due
to the low subject numbers in the study. Further research needs to be undertaken in this
area.

Acknowledgements
The author gratefully acknowledges the help of Socrates Deligeorges, and financial support
from CIF (Centre for Sport Research, Stockholm) and Allmänna Arvsfonden (Stockholm,
Sweden).

Declaration of interest: The author reports no conflicts of interest. The author alone is
responsible for the content and writing of the paper.

References
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1983b;(Suppl. 9):163–173.
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