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Below-Knee Amputation Physiotherapy

Transtibial amputation, or commonly known as below-knee amputation, is a surgical procedure performed to fully remove a lower limb that has been damaged due to

  • trauma
  • congenital defect
  • disease

Transtibial amputation represents 23% of all lower-limb amputations. Amputation is possible in any age group, but generally it affects (or is highest) among people aged 65 years and older.

What is a Below-Knee Amputation?

Transtibial amputation, or below-knee amputation, is a surgical procedure performed to remove the lower limb below the knee when that limb has been severely damaged or is diseased.

Most of the time, below-knee amputations (60%–70%) are decisions due to

  • peripheral vascular disease
  • disease of the circulation in the lower limb

Poor circulation decreases healing and immune responses to injury; and this may lead to foot or leg ulcers. The poor circulation may compromise healing of such ulcers and may lead to an infection that can spread to the bone and become life-threatening.

Amputation is usually a last-line of decision and performed to remove the diseased tissue and prevent the further spread of infection.

Transtibial amputation surgery is usually performed by a vascular or orthopedic surgeon. The diseased or severely injured part of the limb is removed, and the doctor will try their best to preserve and keep as much of the healthy limb as possible. The surgeon will also shape the remaining limb to allow the best use of a prosthetic leg after recovery.

The need for below-knee amputation is caused by conditions including:

  • Peripheral vascular disease (poor circulation)
  • Diabetes
  • Infection
  • Foot ulcers
  • Trauma causing the lower leg to be crushed or severed
  • Tumors

How our senior physiotherapists can help

Our senior physiotherapists help people who receive a below-knee amputation prepare for surgery, and regain strength, movement, and function following surgery.

Prior/Before to Surgery

Before your surgery, our senior physiotherapist may:

  • Prescribe exercises for preoperative conditioning, and to improve the strength and flexibility of the hip and knee
  • Teach you how to walk with a walker or crutches
  • Educate you about what to expect after the procedure

Immediately After Surgery

Your hospital stay will be between 5 to 14 days after surgery. Your wound will be bandaged, and you may also have a drain at the surgery site—a tube that is inserted into the area to help remove excess fluid.

Pain will be managed with medication and painkillers (this will be tapered off with time and with observing how you cope/your pain experience).

You may see our senior physiotherapy as soon as possible after surgery when your condition is stable and the doctor clears you to start below-knee amputation physiotherapy. Our senior physiotherapist will review your medical and surgical history, and visit you at your bedside.

Your first 2 to 3 days of treatment may include:

  • Gentle stretching and range-of-motion exercises
  • Learning to roll in bed, sit on the side of the bed, and move safely to a chair
  • Learning how to position your surgical limb to prevent joint stiffness and joint contractures (the inability to straighten the knee joint fully, which results from keeping the limb bent too much)

When you are medically stable, our senior physiotherapist will help you learn to move about in a wheelchair, and stand and walk with an assistive device.

below-knee amputation physiotherapy

Our senior orthopedic physiotherapists will work with you as you heal following the amputation, help to

  • fit your prosthesis
  • guide your rehabilitation to ensure you regain your strength and movement in the safest way possible.

Your treatments may include:

Prevention of joint stiffness and contractures. A contracture is the development of soft-tissue tightness that limits joint motion. The condition occurs when muscles and soft tissues become stiff from lack of movement. The most common contracture following below-knee amputation occurs at the knee when it becomes flexed and unable to straighten. The hip also may become stiff.

It is important to prevent contractures early; they can become permanent if not addressed following surgery, throughout recovery, and after below-knee amputation physiotherapy is completed. Contractures can make it difficult to wear your prosthesis and make walking more difficult, increasing the need for an assistive device like a walker.

Our senior physiotherapists will help you maintain normal posture and range of motion at your knee and hip. We will also teach you how to position your limb to avoid development of a contracture, and show you stretching and positioning exercises to maintain normal range of motion.

Compression to reduce swelling. It is normal to experience postoperative swelling. We will help you maintain compression on your residual limb to protect it, reduce and control swelling, and help it heal. Compression can be accomplished by:

  • Wrapping the limb with elastic bandages
  • Wearing an elastic shrinker sock

These methods also help shape the below-knee amputated limb to prepare it for fitting the prosthetic leg.

In some cases a rigid dressing, or plaster cast, may be used instead of elastic bandages. An immediate postoperative prosthesis made with plaster or plastic also may be applied. The method chosen depends on each person’s situation. Our senior physiotherapist will help monitor the fit of these devices and instruct you in their use. The main goal of your care during this time is to reduce swelling.

Pain management. Our senior physiotherapist will help with pain management in a variety of ways, including:

  • Manual therapy, which may include hands-on treatments performed by our senior physiotherapist, including soft tissue (ie, muscle, tendon) mobilization, joint manipulation, or gentle range-of-motion exercises, in order to improve circulation and joint motion
  • Stump management, including skin care and stump sock use
  • Desensitization physiotherapy to help modify how sensitive an area is to clothing, pressure, or touch. Desensitization therapy involves stroking the skin with different types of touch to help reduce or eliminate sensitivity
  • Mirror therapy and/or graded motor imagery

Approximately 80% of people who undergo amputations experience a phenomenon called phantom limb pain, a condition in which some of their pain feels like it is actually coming from the amputated limb. We will work with you to lessen and eliminate the sensation.

Prosthetic fitting and training. We will work with a prosthetist to prescribe the best prosthesis for your life situation and activity goals. You will receive a temporary prosthesis at first while your residual limb continues to heal and shrink/shape over the first 6 to 9 months of healing. The prosthesis will be modified to fit as needed over this time.

Most people with below-knee amputations learn to walk well with a prosthesis. Physicians use the following criteria to determine when you are ready for a temporary prosthesis, or your first artificial limb.

  • Your incision should be almost healed or completely healed.
  • Your swelling should have decreased to an acceptable amount.
  • You will have regained sufficient overall strength to be able to walk safely.

After the limb has reached a stable shape, and your physician approves your condition, you will be fitted for a permanent prosthesis.

Functional training. After you move from acute care to rehabilitation, you will learn to function more independently. We will help you master wheelchair mobility and walking with an assistive device like crutches or a walker. We also will teach you the skills you need for successful use of your new prosthetic limb. You will learn how to care for your residual limb with skin checks and hygiene, and continue contracture prevention with exercise and positioning.

We will teach you how to put your new prosthesis on and take it off, and how to manage a good fit with the socket type you receive. We will also help you to gradually build up tolerance for wearing your prosthesis for increasingly longer times, while protecting the skin integrity of your residual limb. You will continue to use a wheelchair for getting around, even after you get your permanent prosthesis, for times when you are not wearing the limb.

Guided rehabilitation. Prosthetic training is a process that can last up to a full year. You will begin when your physician clears you for putting weight on the prosthesis. We will help you learn to stand, balance, and walk with the prosthetic limb.

Most likely you will begin walking in parallel bars, then progress to a walker, and later as you get stronger, you may progress to using a cane before walking independently without any assistance. You will also need to continue strengthening and stretching exercises to achieve your fullest potential, as you return to many of the activities you performed before your amputation.

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