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Journal. Volume1, Issue2, No.1, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 

 
 

 

 

 

 

 

 

 

 

 

 

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Lechler K, and Kristjansson K. The importance of additional mid swing toe clearance for amputees. Canadian Prosthetics & 

Orthotics Journal. Volume1, Issue2, No.1, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

1 

 
OPEN  ACCESS 

The Importance Of Additional Mid Swing  

Toe Clearance For Amputees 

 
 

Volume 1, Issue 2, Article No.1, September 2018 

 

 PROFESSIONAL OPINION 

THE IMPORTANCE OF ADDITIONAL MID SWING TOE CLEARANCE FOR AMPUTEES 

 
Lechler K*, Kristjansson K 

 
Össur Medical Office, R&D Össur ehf, Reykjavik, Iceland.  

 

INTRODUCTION 

The shortest distance between the ground and the 

toe during level ground walking, referred to as the 

minimum toe clearance (MTC), occurs during mid 

swing phase (mid swing toe clearance: MSTC) and 

for abled bodies this averages to be around 15 mm.1 

This is the point in time during the gait phase where 

tripping is most likely to occur.2–4 Trip-related falls 

have been identified as the leading cause of falls for 

community-dwelling, middle-aged and older adults.5–

7 Looking at elderly non-amputated women only, trips 

amount for up to 33% of the causes for their falling.8 

Whereas women are more likely to fall while walking 

men are more likely to fall from loss of support by an 

external object rather than tripping, as well as falling 

while sitting down or rising from sitting.9  While most 

elderly amputees are men10 the risk of amputees in 

general to fall over a one-year period is 50% or 

higher.11  

Historically the first reported prosthetic leg offering 

additional toe clearance in swing dates back to 1805 

(Fig. 1,2,3)12, but still today most conventional 

prosthetic feet do not provide features for additional 

MSTC. This is despite the fact that historically 

various stumble preventing mechanisms for both 

trans-tibial and trans-femoral community ambulators 

have been offered since the early days of the 

industrial revolution, underlining the longstanding 

awareness of the importance of trips and stumbles 

as a cause for falls by amputtees.12 

WHY DO MANY PROSTHETICS SOLUTIONS 
NOT PROVIDE FOR MINIMUM TOE 
CLEARANCE?  

The main reason for insufficient MSTC is the fact that 

conventional prosthetic feet do not dorsiflex during 

swing which places the MSTC on the prosthetic side 

below the MTC.13 Another well recognized reason is 

the vertical displacement between the socket and the 

residual during swing phase (pistoning) resulting in 

functional elongation of the prosthetic leg.14-16     

CITATION 

Lechler K, and Kristjansson K. 

The importance of additional mid 

swing toe clearance for 

amputees. Canadian Prosthetics 

& Orthotics Journal. Volume1, 

Issue2, No.1, 2018. DOI: 

https://doi.org/10.33137/cpoj.v1i2

.30813 

KEYWORDS 

Prosthetics, Toe clearance, 

Lower limb prosthesis, Mobility, 

Prosthetic foot, Polycentric axis 

knees, Amputee. 

*CORRESPONDING AUTHOR 

Knut Lechler, Medical Director Prosthetics, Össur ehf, Grjothals 1-5, 110 Reykjavik, Iceland. 

Email: klechler@ossur.com 

Tel: +49 151 50459110. 

Disclosure: Full time employees of a medical device manufacturer, Össur ehf. 

DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

 

 

ABSTRACT  

Increased prosthetic hip to toe distance and insufficient mid swing toe clearance 

of a prosthetic foot is a well-recognized inadequacy for lower limb prosthesis 

users with wide and possible grave consequences on their ambulation 

capabilities.  Most important are increased risk of falls and abnormal 

compensatory gait patterns with secondary unwanted physical effect like 

generally deceased mobility, muscular-skeletal pain and joint degeneration, i.e. 

osteoarthritis, with possible significant health economic effect.  Even though 

insufficient toe clearance can be device related and technically or even 

intentionally induced for attaining equal length of the lower extremities in a 

neutral standing position or the stance phase, it is important to be aware of 

available technical solutions that can counteract the problem, like swing phase 

dorsiflexing feet, vacuum suspension systems, polycentric axis knees rather 

than single-axis knees and adequate knee flexion in early swing and swing-

flexion assistance in the case of bionic knees. 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v1i2.30813
https://doi.org/10.33137/cpoj.v1i2.30813
mailto:klechler@ossur.com
https://doi.org/10.33137/cpoj.v1i2.30813


 

 

Lechler K, and Kristjansson K. The importance of additional mid swing toe clearance for amputees. Canadian Prosthetics & 

Orthotics Journal. Volume1, Issue2, No.1, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

2 

 
OPEN  ACCESS 

The Importance Of Additional Mid Swing  

Toe Clearance For Amputees 

 
 

Volume 1, Issue 2, Article No.1, September 2018 

 

 Equal leg length in the stance phase yields an 

increased functional leg length in the swing phase of 

at least 16mm for a non-amputee.17,18 The functional 

prosthetic leg length with single axis knee is even 

further increased,18 resulting in a  22 mm lower 

MSTC compared to polycentric knees.19 In a 3D 

simulation with data from trans-femoral amputees’ 

single-axis knees provided the least clearance (4.6 

cm) during prosthetic swing phase, followed by four-

bar knees (5.8 cm), and the two ankle mechanisms 

(6.4 and 8.7 cm).19 

BIOMECHANICAL AND PHYSICAL EFFECT OF 
INSUFFICIENT TOE CLEARANCE 

For the purpose of overcoming amputees’ 

experience of vertical displacement between socket 

and residual and the associated functional 

elongation of the prosthetic leg in swing phase14–16 

the prosthesis is commonly aligned significantly 

shorter than the sound side. Amongst 113 trans-

femoral and trans-tibial amputees 70 % were found 

to have a significant leg length discrepancy 

radiographically while balanced standing due to 

shorter alignment of the prosthesis compared to the 

sound side.20 Gaunaurd et. al.  showed that 66% of 

trans-femoral amputees had leg length 

discrepancies and for 57% the prosthetic side was 

shorter.21   

Back pain is very common in lower limb amputees22 

and has been linked to poor prosthetic fit and 

alignment, postural changes, leg-length 

discrepancy, amputation level, and general 

deconditioning.23 The significance of this approach 

of leg length misalignment for the purpose of trying 

to make up for functional leg length increase during 

swing and the associated decrease in the MSTC is 

that leg length discrepancy can lead to various 

health problems like back pain24 and studies have 

shown it to contribute to back pain in amputees.25,26   

Not trying to adjust for the functional prosthetic leg 

length increase and to fit the prosthesis at an equal 

length to the sound side also carries with it a problem 

as pistoning in the socket and the changes in the 

trajectory of the prosthetic foot changes the point in 

time at which the physical maximum functional leg 

length occurs. For this additional functional swing 

phase leg length and time shift the amputees will try 

to compensate by developing their individual 

adaptation mechanisms. One is to elevate the 

contralateral side by early heel rise resulting in what 

is referred to as “Vaulting”. Another is an arc-like 

movement of the prosthetic limb referred to as 

“Circumduction” and thirdly a lateral trunk inclination 

with definite raising of the hip on the prosthesis side. 

As a matter of fact, these three are the basic and 

main gait abnormalities characteristic for lower limb 

amputee in various degrees of combinations, even 

obvious to a lay observer.  

Both stationary and functional leg length 

discrepancies cause abnormal forces on bones and 

joints likely to lead to degenerative conditions like 

osteoarthritis which has been found to be more 

prevalent in the contralateral limb than the residual 

limb of people with amputation. 27,28 The increased 

prevalence of osteoarthritis is of concern, especially 

for people who have lived with an amputation for a 

longer time.28 This actually turns out to be the case 

for many traumatic amputees who have been shown 

to have a significantly increased risk of suffering from 

osteoarthritis.29   

THE HEALTH ECONOMIC RELEVANCE OF TOE 
CLEARANCE 

The proven relationship between insufficient toe 

clearance to trips and hence falls bring this feature 

into the scope of possible significant health 

economic effects. Although there is scarce published 

literature on the economic costs of falls within the 

amputee population, the costs of falls among older 

adults have been well studied. The estimated 

average one-year cost attributed to an elderly adult 

falling and requiring subsequent medical attention is 

between $3,408 and $4,872. Furthermore, if the fall 

results in a hospitalization, the cost may increase up 

to $35,144 on average. Within this population, it is 

estimated that up to 1 in every 9 falls will lead to 

hospitalization.30  

Figure 1. Anglesey 
TT and TF (1805) 

Figure 2. Erfurt 
TF (1880) 

Figure 3. Martin 
TT (1857) 



 

 

Lechler K, and Kristjansson K. The importance of additional mid swing toe clearance for amputees. Canadian Prosthetics & 

Orthotics Journal. Volume1, Issue2, No.1, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

3 

 
OPEN  ACCESS 

The Importance Of Additional Mid Swing  

Toe Clearance For Amputees 

 
 

Volume 1, Issue 2, Article No.1, September 2018 

 

 A study on falls of amputees shows that up to 40% 

of their falls result in an injury and every other fall 

necessitates medical attention, which is higher than 

for the non-amputated elderly which has been 

estimated to be 30%.31 One study on trans-femorals 

indicated an estimated cost of $25,652 at 6 months, 

for falls resulting in hospitalization, similar to the 

costs within the elderly.32 Direct medical costs of all 

falls in the USA was $31.3 billion in 2015, up from 

$30.3 billion in 2012.33 

Possible secondary health economic effect through 

back- and musculoskeletal pain and degenerative 

joint disease is also of real significance with 

osteoarthritis already accounting for 2% of years 

lived with disabilities.34 OA is a rising concern 

specifically to amputees because they have a higher 

risk to suffer from hip and knee osteoarthritis.35 

Osteoarthritis often coexist with an amputation as 

pain does28 and even further limits amputees in their 

mobility.36 Osteoarthritis in the contralateral limb 

knee is 17 times higher than in age-matched non-

amputees35 and knee pain in unilateral amputees is 

twice as common.35 Imaging studies have confirmed 

the increased prevalence of degenerative changes 

in the contralateral knee.37,38  

Since TTAs are known to load their intact limb to a 

greater extent than their prosthetic limb during gait,23 

the marked asymmetry in knee pain and 

degeneration suggests that mechanical loading 

factors are likely an important contributor to the 

increased incidence of OA. Not only asymmetries 

but also minor compensations can increase stress 

on the contralateral limb and possibly predispose the 

long-term prosthesis wearer to premature 

degenerative arthritis.39-40 

REMEDIES FOR INSUFFICIENT TOE 
CLEARANCE  

The most straight forward and natural action is the 

provision of prosthetic feet that dorsiflex in the swing  

phase and thereby compensating for the elongation 

in swing phase at the same time allowing for leg 

length equality in the stance phase or when 

standing. 

Motorized and actively dorsiflexing prosthetic ankles 

have shown to significantly increase MSTC41 by 

about 70% and increase in MSTC of 25.6 ± 5.4 mm 

has been shown to lead to a reduction in falls42 over 

a one-year period for community dwelling amputees. 

Hydraulic ankles with dorsiflexion in swing have also 

been shown to  increase the MSTC.43 

A recent study has shown in addition to increased 

MSTC during level ground walking that  this can also 

be provided for during incline and decline walking 

(Figure 4).44  An anecdotal user report from this 

same trial states: “My work environment involves 

walking through sloped tunnels and up/down stairs. 

I usually trip 1-3 times per day with my prescribed 

foot, but I never tripped with the Proprio-Foot!”. 

Several studies had previously looked at and 

compared the MSTC of conventional ESAR feet 

versus dorsiflexing ankles (Table 1). 

Table 1: Comparison of prosthetic side toe clearances in 

mm. 

Other technical solutions that can improve the MSTC 

are vacuum suspension systems for reduced 

pistoning and functional swing phase prosthetic leg 

length increase. A study by Rosenblatt where falling 

rate and pattern was tracked over a one-year period 

for 27 amputees (15 vacuum assisted socket 

suspension (VASS) users, 12 non-VASS users) 

showed 75% less risk of VASS trans-tibial amputee 

users having multiple falls compared to non-VASS 

users. 

  
  

Toe Clearance on the 
Prosthetic Side 

Level 
(mm) 

Slope 
(mm) 

Decline 
(mm) 

Fallers, Rosenblatt 2017 12.3     

Non-Fallers, Rosenblatt 
2017 

25.6     

Hydraulic, Johnson 2014 20.7     

Motorized, Fradet 2010   16.0 12.0 

Motorized, Rosenblatt 
2014 

33.6     

Motorized, Lamers 2018* 14.6* 18.4* 11.7* 

* compared and in addition to sound side 
  
  
 
  

  

Figure 4. MTC with MPA(Proprio), MPA-Locked and 
conventional ESAR in level ground.44 



 

 

Lechler K, and Kristjansson K. The importance of additional mid swing toe clearance for amputees. Canadian Prosthetics & 

Orthotics Journal. Volume1, Issue2, No.1, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

4 

 
OPEN  ACCESS 

The Importance Of Additional Mid Swing  

Toe Clearance For Amputees 

 
 

Volume 1, Issue 2, Article No.1, September 2018 

 

 Even though less effective than providing 

dorsiflexion ankles, selecting polycentric knees over 

single axis knees also helps with the toe clearance 

as previously outlined.19  Also providing a bionic 

knee like the Rheo Knee that has a rapid foot off 

velocity results in a higher MSTC compared to single 

axis knees.45 Additionally, the rapid toe off velocity 

and lower hip torque qualities of the Rheo Knee 

results in earlier toe off at a slower than preferred 

walking speed and significantly less vaulting of the 

intact ankle, compared to for example a hydraulic 

knee (P = 0,028).46   

SUMMARY 

Providing sufficient toe clearance on the prosthetic 

side allows aligning the prosthesis more equally and 

favorable influence in short term on low back pain 

and in longer term on side effects like lumbar 

scoliosis and osteoarthritis. Most importantly added 

toe clearance should results in fewer trips and 

stumbles resulting in decrease in falls. All of this can 

possibly result in significantly less health economic 

burden. A large study on patients having undergone 

hip arthroplasty (n=753) shows that leg length 

discrepancy reduces satisfaction and functional 

outcome after hip arthroplasty.47 Reducing risks of 

falls reduces the degree of disability of amputees by 

improving their mobility and hence improves their 

quality of life.48 

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Lechler K, and Kristjansson K. The importance of additional mid swing toe clearance for amputees. Canadian Prosthetics & 

Orthotics Journal. Volume1, Issue2, No.1, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

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Lechler K, and Kristjansson K. The importance of additional mid swing toe clearance for amputees. Canadian Prosthetics & 

Orthotics Journal. Volume1, Issue2, No.1, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.30813 

6 

 
OPEN  ACCESS 

The Importance Of Additional Mid Swing  

Toe Clearance For Amputees 

 
 

Volume 1, Issue 2, Article No.1, September 2018 

 

  43.Johnson L, De AshaAR, Munjal R, Kulkarni J, Buckley 

JG. Toe clearance when walking in people with unilateral 

transtibial amputation: effects of passive hydraulic ankle. J 

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DOI:10.1682/JRRD.2013.05.0126 

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on level and sloped walking. 42nd Annu Meet Am Soc 

Biomech. Rochester MN USA (2018). 

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A clinical comparison of variable-damping and 
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46. Prinsen EC, Nederhand MJ, Sveinsdóttir HS, Prins 

MR, Van der Meer F, Koopman HFJM, Rietman JS. The 

influence of a user-adaptive prosthetic knee across 

varying walking speeds: A randomized cross-over trial. 

Gait Posture. 2017; 51, 254–260. 

DOI:10.1016/j.gaitpost.2016.11.015 

47.Röder C, Vogel R, Burri L, Dietrich D, Staub LP. Total 

hip arthroplasty: leg length inequality impairs functional 

outcomes and patient satisfaction. BMC Musculoskelet 

Disord.2012; 13, 95. DOI:10.1186/1471-2474-13-95 

48.Asano M, Rushton P, Miller WC, Deathe BA. Predictors 

of quality of life among individuals who have a lower limb 

amputation. Prosthet Orthot Int.2008; 32, 231–243. 

DOI:10.1080/03093640802024955 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

AUTHORS BIOGRAPHY  

Mr. Knut Lechler, Össur Medical 

Director Prosthetics, is a CPO-D at 

Ossur ehf, Reykjavik, Iceland and has 

been in that position for 7 years. He 

graduated in 1991 as CPO (Master) and 

used to work as a freelancer before he 

started in the industry in 1999 (Flex-Foot 

Inc.). Since 2001 he is with Össur. Knut 

Lechler is an active member of the ISO-

TC 168 WG1. 

 

Dr. Kristleifur Kristjansson, 

Medical Officer and VP of Clinical 

Affairs, is a medical doctor and has 

been in his current position at Össur for 

6 years. Dr. Kristjansson was a VP of 

Clinical Collaborations at deCODE 

genetics for 16 years and holds a 

consulting position at the University 

Hospital in Reykjavik Iceland as a 

pediatrician and geneticist.  

 

 

 

 

 

https://doi.org/10.1682/JRRD.2013.05.0126
https://doi.org/10.1016/j.gaitpost.2016.11.015
https://doi.org/10.1186/1471-2474-13-95
https://doi.org/10.1080/03093640802024955

