Progression Planning for a New Transfemoral Amputee Who Will Not Weight-Bear
Mr A, 62, had a vascular transfemoral amputation 4 months ago and was fitted 5 weeks ago with an ischial containment socket, a single-axis knee and a cushioned-heel foot. He has a 10° hip flexion contracture, hip abductor strength 3/5 on the prosthetic side, knee extension 4/5, and cannot stand on the prosthetic limb without holding on with both hands. He walks about 10 metres with two crutches, resting heart rate 88 rising to 128, and reports that the leg 'gives way' so he keeps most of his weight on the crutches. The residual limb is well healed but the distal scar is adherent, and he has a 2 cm area of redness at the ischial seat that fades in 30 minutes. He lives alone in a first-floor flat with a shared external staircase and one handrail, and his goal is to walk to the local shop 200 metres away.
1. Prioritise his rehabilitation goals and define measurable criteria for progressing from two crutches to one cane.
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Prioritise in the order that protects the limb and the patient's safety, not the order that reaches walking fastest.
- Skin and socket fit. The fading redness at the ischial seat needs a fit check and a defined observation period; a red area that does not resolve, or pain, stops all progression.
- Contracture and strength. A 10° flexion contracture and 3/5 abductors produce a lateral trunk lean and an unstable base. Daily sustained stretching and progressive hip abductor work with the prosthesis on come before distance work.
- Balance and confidence. Standing balance on the prosthetic side with decreasing hand support, weight shifting onto a bathroom scale for visual feedback, and sit-to-stand practice.
- Gait with aids. Parallel bars then two crutches over increasing distance; then one crutch and cane on the sound side.
Measurable criteria for moving to one cane: able to stand on the prosthetic limb for 10 seconds with fingertip support and no lateral lean; able to shift at least 70% of body weight onto it on scales; walks 50 metres with two crutches without stopping and with a stable knee in stance; no skin reaction after a full day; Borg rating in the 11–13 range and heart rate recovering within a few minutes. Document the date each criterion is met.
2. He lives alone upstairs with one handrail and wants to walk to the shop. What discharge and home-safety planning is needed, and how do you teach stair technique?
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Plan the environment before the ambition.
Home assessment: the shared external staircase with one handrail is the main constraint. Check step height and depth, lighting, surface, whether a second temporary handrail can be fitted, and whether he can manage keys, door and crutches together. Indoors, remove loose rugs, secure cables, reorganise the kitchen and bathroom so he can carry nothing hot while using aids, and plan the night-time toilet route with lighting. A perching stool, a trolley and a grab rail are cheap and effective.
Contingency: he lives alone, so agree a daily check-in, a charged phone carried on his person, and what he does if he falls. Discuss whether a ground-floor room is available for the first weeks. Do not discharge to the stairs until stair practice has been completed in the department.
Stair teaching: teach 'up with the good leg, down with the bad' – lead upstairs with the sound limb, lead downstairs with the prosthesis – with one hand on the rail and the crutch or cane in the other hand, one step per cycle, and a rest point. Practise on a training staircase with a rail before trying the real one, and have someone present the first time.
Shop goal: treat the 200 metres as a graded target, building distance weekly with a rest point identified en route, and record the walked distance rather than judging by impression.
3. He says the leg 'gives way' and refuses to take full weight. How do you assess the cause rather than label him non-compliant, and what would you do for each possible cause?
Read the worked answer
Refusal to weight-bear is information, not a personality trait. Assess before you encourage.
Possible causes and responses:
- Socket or skin pain at the ischial seat. Inspect after walking, palpate the area, and check the fit and suspension. If pain is reproduced, adjust or remake rather than push through it.
- Knee instability. Watch the knee in early stance. If the force line is behind the knee axis, the knee will flex however hard he tries; this is an alignment problem and needs the prosthetist, not more encouragement.
- Fear of falling, especially living alone. Use graded exposure: parallel bars, then one crutch, with a belt and a second person; agree what happens if he falls; build a success record.
- Adherent distal scar. Check whether loading pulls the scar; desensitisation and scar mobilisation may be needed.
- Contralateral or general deconditioning. Check the sound knee and hip, and his cardiovascular status; he is a vascular patient with a heart rate rising 40 beats on 10 metres, so endurance work must be graded and medical review may be needed.
Communication: tell him what you observed and what you will change, ask what he fears most, and agree one small target for the next session. Label nothing 'non-compliant' in the notes; record the barrier and the action taken.