Move Forward Guide
Physical Therapist's Guide to
Below-Knee Amputation (Transtibial Amputation)
Transtibial amputation, or below-knee amputation, is a surgical procedure performed to fully remove a lower limb that has been damaged due to trauma, congenital defect, or disease. Transtibial amputation comprises 23% of all lower-limb amputations. Amputation is possible in any age group, but the prevalence 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 transtibial amputations (60%–70%) are due to peripheral vascular disease, or disease of the circulation in the lower limb. Poor circulation limits healing and immune responses to injury; foot or leg ulcers may form as a result. These ulcers may not heal and may develop an infection that can spread to the bone and become life-threatening. Amputation is 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, keeping as much of the healthy limb as possible. The surgeon shapes the remaining limb to allow the best use of a prosthetic leg after recovery.
The need for transtibial amputation is caused by conditions including:
- Peripheral vascular disease (poor circulation)
- Foot ulcers
- Trauma causing the lower leg to be crushed or severed
- Tumors (see link references at the bottom of the page for more information)
How Can a Physical Therapist Help?
Physical therapists help people who receive a below-knee amputation prepare for surgery, and regain strength, movement, and function following surgery.
Prior to Surgery
Before your surgery, your physical therapist 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 approximately 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 proper medication.
Physical therapy will begin soon after surgery when your condition is stable and the doctor clears you for rehabilitation. A physical therapist 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 contractures (the inability to straighten the knee joint fully, which results from keeping the limb bent too much)
When you are medically stable, the physical therapist will help you learn to move about in a wheelchair, and stand and walk with an assistive device.
Your physical therapist will work with you as you heal following the amputation, help to fit your prosthesis, and guide your rehabilitation to ensure you regain your strength and movement in the safest way possible. Your treatments may include:
Prevention of 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 transtibial 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 rehabilitation 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.
Your physical therapist will help you maintain normal posture and range of motion at your knee and hip. Your therapist will 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. Your physical therapist 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 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. Your physical therapist 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. Your physical therapist will help with pain management in a variety of ways, including:
- Manual therapy, which may include “hands-on” treatments performed by your physical therapist, 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 to help modify how sensitive an area is to clothing, pressure, or touch Desensitization 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. Your physical therapist will work with you to lessen and eliminate the sensation. Please see our guide on Phantom Limb Pain for more details.
Prosthetic fitting and training. Your physical therapist 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 transtibial 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. Your physical therapist will help you master wheelchair mobility and walking with an assistive device like crutches or a walker. Your therapist 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.
Your physical therapist 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. Your therapist will 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. Your physical therapist 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.
Return to Recreational and Sports Activities
If you are active or have a favorite sport you may also want to consult with a recreational physical therapist, who can help you choose appropriate adaptive recreation equipment. Depending on your personal goals and preferred leisure activities, the recreational physical therapist can help you return to sports such as golf, hiking, running, swimming, or cycling. A prosthetist can help you choose the best prosthetic device for taking part in these types of activities. You also may gain valuable advice from other individuals with amputations; your physical therapist can help you find support groups for people with amputations in your area.
Can this Injury or Condition be Prevented?
As many as 60% of vascular amputations may be preventable. The leading causes of transtibial amputation are complications from diabetes, such as peripheral vascular disease (poor circulation), open wounds, and infection. Prevention and management of diabetes and lower-extremity circulation problems can greatly reduce the risk of developing conditions that lead to the need for lower-extremity amputation. Make sure that you protect your feet by wearing adequate and appropriate footwear. It is also important to examine your lower extremities and feet daily for signs of skin problems, such as redness or discoloration, swelling, blisters, scratches, or open wounds. It is important to promptly consult your primary health care provider, should you notice a problem. Prevention of infection is an extremely important way to prevent transtibial amputation.
It is also important to stop smoking. Smoking cigarettes can significantly interfere with and delay the healing of limbs affected by any of the lower-limb problems mentioned here. Smokers with a previous amputation have a 25 times greater risk of reamputation than nonsmokers.
Real Life Experiences
Ed is a 75-year-old retired house painter who has diabetes and peripheral artery disease of the right lower leg. Due to the lack of circulation in his lower leg, Ed has developed an open wound that has become infected. Despite the best efforts of medical care, the infection has continued to spread. Because the infection is now threatening Ed’s health and well-being, the decision is made to amputate the diseased part of his lower leg. Ed is referred to physical therapy for preoperative exercise instruction, and to learn how to walk with a walker before his scheduled surgery.
The day after Ed’s surgery, a hospital physical therapist comes to Ed's room to begin treatment. She teaches him to perform some gentle exercises for the affected limb, and to exercise his uninvolved leg and arms. She teaches him how to safely roll in bed, to focus on keeping his knee straight on the amputated side, and to support his leg to reduce swelling.
As Ed's residual limb heals, his physical therapist helps him get out of bed and sit in a chair. He learns to stand on 1 leg with a walker next to his bed. As he gets stronger, he advances to 1-leg walking with a walker, with close assistance from the physical therapist.
When Ed is medically stable he transfers to a rehabilitation facility. There, he works closely with the rehabilitation physical therapist to learn how to care for the skin on the part of his leg above the amputation (the residual limb), how to position and stretch his leg to prevent contractures, and how to wrap the stump and use shrinker socks to reduce swelling and shape his residual limb. Soon, he is able to get around by propelling his wheelchair. He also works hard doing strengthening and stretching exercises as directed by his physical therapist. He gains strength and balance, allowing him to walk farther without becoming tired.
Ed receives a temporary, or preparatory, prosthesis. Ed is now ready to begin his gait training in physical therapy, and put his full weight on the new prosthesis. Ed and his physical therapist monitor the fit of the socket (where the prosthesis fits to the leg) several times a day to avoid pressure points on his residual limb.
After a few weeks of rehabilitation, Ed is able to function with minimal assistance and is discharged home. His family has been trained to help keep him safe and assist him. Ed continues physical therapy as an outpatient, and continues to build his strength and improve his walking ability. He is guided in the use of his temporary prosthesis as his stump continues to reshape. Adjustments to the prosthesis will be made as Ed continues rehabilitation and progresses over the next 1 to 2 months, prior to receiving his permanent prosthesis.
When Ed’s residual limb stops shrinking, about 8 months after his surgery, he receives his permanent prosthesis. He works with his physical therapist and prosthetist to ensure a good fit, and to learn to improve his walking pattern.
After much hard work, Ed is discharged from physical therapy, having achieved his goal of walking independently without an assistive device. He looks forward to his daily walks around his neighborhood after dinner, and plans to get back on the golf course—with the advice and guidance of his recreational physical therapist.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat below-knee amputation conditions. However, you may want to consider:
- A physical therapist who is experienced in treating people with rehabilitation and amputation conditions. Some physical therapists have a practice with a focus on rehabilitation and prosthetic training for extremity amputation.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have a below-knee amputation.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of transtibial amputation. The articles report recent research and give an overview of the standards of practice for treatment of it both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
US Department of Veterans Affairs website. VA/DoD clinical practice guidelines for rehabilitation of lower limb amputation. Accessed September 13, 2018.
Amputee Coalition Organization website. Accessed September 13, 2018.
Cancer Treatment Centers of America. Accessed September 13, 2018.
American Diabetes Association. Accessed September 13, 2018.
Digital Resource Foundation for the Orthotics & Prosthetics Community. Accessed September 13, 2018.
The O&P Edge. Accessed September 13, 2018.
Health.mil. Accessed September 13, 2018.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Brittney Mazzone, PT, DPT. Author Mary Kay Zane, PT, board-certified orthopaedic clinical specialist. Reviewed by the editorial board.