







































Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics 
and kinematics with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 

 

 

 

 

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 2019 

 

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  1 

 
OPEN  ACCESS 

GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

Volume 2, Issue 2, Article No.1, 2019 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

RESEARCH ARTICLE 

 

GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES ON LEVEL GROUND IN A COHORT 
OF 53 AMPUTEES - COMPARISON OF KINETICS AND KINEMATICS WITH NON-AMPUTEES   

 
Pröbsting E1*, Bellmann M1, Schmalz T2, Hahn A1 
 

1 Clinical Research & Services / Biomechanics, Ottobock SE & Co. KGaA, Hermann-Rein-Straße 2a, 37075 Göttingen, Germany. 

2 Clinical Research & Services, Ottobock Healthcare Products GmbH, Brehmstraße 16, 1110 Vienna, Austria. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ABSTRACT 

STUDY DESIGN: Retrospective analysis 

BACKGROUND: The gait characteristics of transtibial amputees (TTs) have been described many 

times. In general, the literature reported nearly consistent results for the kinematic and kinetic 

parameters of the prosthetic side. However, the literature revealed inconsistent findings on kinetic 

parameters for determining the risk of developing knee osteoarthritis, such as the peak knee adduction 

moment, knee flexion moment and vertical ground reaction forces.  

OBJECTIVES: The objective of our study was to describe the sagittal kinetic and kinematic gait 

characteristics of the ankle and residual knee joint of the prosthetic limb and the knee loading 

parameters of the sound side of unilateral TTs. This specific consideration may contribute to resolving 

the controversy of these parameters in the literature. 

METHODS: We analysed our database containing gait analyses from 53 unilateral TTs and compared 

data to a control group (CG), also taken from our database. The sagittal kinetic and kinematic gait 

characteristics of the ankle and residual knee joint of the prosthetic limb, and selected knee loading 

parameters of the sound side (the peak knee adduction moment, knee flexion moment and vertical 

ground reaction forces) were evaluated. Beside these parameters we reported typical spatiotemporal 

gait parameters as gait velocity, step length, step length asymmetry, stance phase duration and 

asymmetry of stance phase duration. 

RESULTS: The TTs walked slower and more asymmetrically than the CG. The kinematic pattern of 

the prosthetic ankle differed from that found in the CG. The largest difference was observed for the 

range of motion of the plantarflexion at push-off, which was significantly reduced for the prosthetic 

foot. The residual knee joint was generally affected with respect to decreased moments and reduced 

knee flexion during stance phase. The peaks of the vertical ground reaction forces and knee adduction 

moments showed no differences between the sound side of amputees and the CG. The peak knee 

flexion moment at midstance was significantly reduced for the sound side of amputees in comparison 

with the CG.  

CONCLUSION: The biomechanical data measured for the prosthetic side in a cohort of 53 unilateral 

TT amputees conformed with the literature. The parameters determining the risk of developing knee 

osteoarthritis investigated in our retrospective analysis were not increased on the sound side in 

comparison with non-amputees. We deem it reasonable to assume that an appropriate prosthesis will 

reduce the likelihood of overloading the knee on the sound side during normal walking. 

CITATION 

Pröbsting E, Bellmann M, Schmalz 

T, Hahn A. Gait characteristics of 

transtibial amputees on level 

ground in a cohort of 53 amputees 

- comparison of kinetics and 

kinematics with non-amputees. 

Canadian Prosthetics & Orthotics 

Journal. 2019;Volume2, Issue2, 

No.1. 

https://doi.org/10.33137/cpoj.v2i2.3

2955.  

 
KEYWORDS 

Prosthesis, Transtibial Amputees, 

Gait Analysis, Kinematic, Kinetic,  

Amputation, Gait Velocity, Step 

Length, Gait Asymmetry 

*CORRESPONDING AUTHOR 

Dipl.-Ing (FH) Eva Pröbsting,  

Clinical Research & Services / Biomechanics, Ottobock SE & Co. KGaA, Hermann-Rein-Straße 2a, 37075 Göttingen, Germany. 

ORCID: https://orcid.org/0000-0002-6349-2992 

E-MAIL: Eva.Proebsting@ottobock.de 

 

DOI: https://doi.org/10.33137/cpoj.v2i2.32955 

ARTICLE INFO 

Received: August 6, 2019 

Accepted: January 10, 2020 

Published: January 15, 2020 

 

https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v2i2.32955
https://doi.org/10.33137/cpoj.v2i2.32955
https://orcid.org/0000-0002-6349-2992
file:///D:/CPOJ%20Submitted%20Articles/ACCEPTED-Completed/27-Twenty%20seven%20Article-CPOJ-27-17A-2019-Ottobock/Proof-Read/Eva.Proebsting@ottobock.de
https://doi.org/10.33137/cpoj.v2i2.32955


 

 

Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

2 

CPOJ 

 

Pröbsting et al. 2019 

 GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

INTRODUCTION   

The gait characteristics of a transtibial amputee (TT) with 

a prosthesis significantly deviate from normal gait 

patterns.1,2 Literature primarily analysed the effect of 

components, weight distributions or sockets, typically for a 

small number of patients.1,2 In general, from all of these 

studies, it can be concluded that TT amputees walk with 

slower velocity,3,4 shorter steps3,4 and longer stance 

duration on the sound limb5 compared to non-amputees.  

Beside these temporalspatial parameters the results of 

kinetic and kinematic parameters enable a more detailed 

evaluation for the gait of TTs. Research studies3-18 

reporting such findings for TTs in comparison to non-

amputees were summarized in Table 1.  

Most kinematic analyses of the prosthetic side reported a 

reduced range of plantarflexion in late stance and early 

swing5,7,16 in TTs in comparison with non-amputees. 

Furthermore, knee flexion was altered on the prosthetic 

side. Knee flexion was reduced during stance  

phase4,5,6,9,11,16 and some studies showed a reduced peak 

knee flexion angle during swing.5,16 The kinematic pattern 

of the sound limb in TTs appeared to be comparable to 

that of non-amputees.7 

Kinetic analyses of the prosthetic side consistently 

reported a lower external dorsiflexion moment in late 

stance with the prosthetic foot as compared to non-

amputees.3,7 Furthermore, the knee joint on the affected 

side showed a markedly reduced external flexion moment 

during midstance.4, 9 

However, literature revealed inconsistent results with 

respect to kinetic compensatory adaptations on the sound 

side, specifically the peak knee adduction moment, knee 

flexion moment and vertical ground reaction forces. 

Reports on the knee adduction moments on the sound 

side were conflicting: Some studies showed no 

differences,12,16,17 others reported increases13,18 by trend, 

and a few studies14,15 found a reduction in comparison to 

controls. A similar controversy could be found for the 

comparison of the sound side knee flexion moments at 

midstance. A few studies showed a significant increase on 

the sound side in comparison to the controls8,14 others 

reported no differences7,9,17 or a decrease by trend.16  

Both parameters knee flexion and adduction moment refer 

to knee loading parameters influencing the risk of 

developing knee osteoarthritis. The relevance of the 

external knee adduction moment regarding the 

development of knee joint degeneration in the general 

population19 was highlighted. Particularly, the first peak of 

the external knee adduction moment during stance has 

been associated with the severity of knee 

osteoarthritis.20,21 Furthermore, the peak external knee 

flexion moment during midstance was considered as 

another predictor of knee loading22 and the first peak of the 

vertical ground reaction force was also increased for 

patients with knee osteoarthritis.20 The latter also showed 

diverging results for the sound side of TTs in the literature: 

A significantly increased first peak on the sound side in 

comparison to healthy controls was reported in two 

studies.10,13 Some studies showed a statistically non-

significant increase,11,14,15,17 while other studies showed 

no differences at all.6, 7  

As the investigations cited did not show consistent results, 

the described higher prevalence of knee osteoarthritis on 

the sound side in TTs21 could not be explained with 

certainty to be caused by higher loads on this knee.  

Different studies showed that the parameters on the sound 

side are mainly influenced by the prosthesis13,14,23 

therefore the prosthetic side should also be analysed to 

evaluate compensatory adaptations on the sound side. 

In the present study we retrospectively analysed the TT 

population from our database including a large sample 

size to generate a representative cross section of this 

cohort and compared it to able-bodied individuals. The 

objective of our study was to compare the gait 

characteristics regarding the sagittal kinetic and kinematic 

parameters of the ankle and knee joints of the prosthetic 

limb for a large sample of unilateral TTs. Additionally, we 

have also examined the knee loading parameters on the 

sound side as indicators for determining the risk of 

developing knee osteoarthritis. This specific consideration 

may contribute to resolving the controversy of these 

parameters in the literature. 

METHODOLOGY 

Data collection 

Gait analyses with amputees have been performed in the 

Ottobock gait lab in Göttingen since 2002, a VICON 

system has been available and only data obtained from 

this system were analysed retrospectively for this study. 

From 2002 to 2013, the experimental setup consisted of a 

6 MX camera motion capture system (120 Hz; VICON, 

Oxford Metrics, UK) and from 2013 onwards of a 12-

BONITA camera motion capture system (200 Hz; VICON, 

Oxford Metrics, Yarnton, UK). Two force plates (400 Hz; 

Kistler 9287A, Winterthur, CH) were positioned in the 

centre of the 12-metre walkway for measuring the bilateral 

ground reaction forces during one gait cycle. 

Both systems were synchronised, they started 

simultaneously via a light triggered photo cell. Each 

subject conducted 8 to 15 single measurements of walking 

trials.  

The database included 279 amputees of different 

amputation levels with 5594 different measurement 

situations. We identified one characteristic session for 

each TT with the following inclusion criteria:  

-Unilaterally amputated 

-Adults > 18 years 

-No additional health impairment 

-Walking with their self-selected velocity on level ground 

-Prosthesis with a commercially available foot 

-Prosthesis to be aligned according to the criteria defined 

by Blumentritt 24 

https://doi.org/10.33137/cpoj.v2i2.32955


 

 

Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

3 

CPOJ 

 

Pröbsting et al. 2019 

 GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

Data from a control group (CG), which had been included 

for comparison purposes, were obtained from the same 

database. These adult individuals were screened for 

orthopaedic and neurologic impairments and were not 

limited by conditions that could have affected their gait. 

The CG consisted of 52 individuals (25 male/27 female). 

They were on average 32 (SD=12) years old, 1.75 

(SD=0.10) m tall and weighed 72.6 (SD=12.2) kg. 

All data analysed were collected at preferred self-selected 

and therefore comfortable and individually used walking 

speeds. The parameters of the groups were compared 

directly, even though the mean walking velocity differed 

between the amputees and the controls. The aim was to 

investigate the effect of normal, self-selected walking 

speed as an indication of the daily demands.  

Data analysis 

Three-dimensional marker trajectories were tracked from 

17 markers placed on anatomical landmarks (both sides: 

acromion, Epicondylus lateralis humeri, Processus 

styloideus ulnare, Trochanter major, compromise knee 

centre of rotation according to Nietert,25 Malleolus lateralis, 

Caput os metartasale IV and three asymmetric markers: 

left tibia, right thigh and left shoulder blade). This marker 

set has been used since 1998 and was created to analyse 

essential gait parameters for amputees. External joint 

moments were calculated based on ground reaction forces 

and coordinates of joint axes according to a previously 

described method.26 

For the typical characteristics of the TT gait, the ankle and 

knee angle in the sagittal plane of both prosthetic and 

sound limbs and also the sagittal moments of these joints 

were evaluated. 

Due to the different results in literature, the vertical ground 

reaction force, and the sagittal and frontal moments acting 

on the sound knee joint were evaluated in this study. The 

first peak of vertical ground reaction forces, the peak knee 

flexion moment during midstance and the first peak knee 

adduction moment were used for the statistical analysis as 

a possible key factor for developing osteoarthritis. 

Moreover, spatiotemporal gait parameters were reported 

as well: 

•Gait velocity 

•Step length 

•Step length asymmetry (the difference between both legs) 

•Stance phase duration 

•Stance phase duration asymmetry (the difference 

between both legs) 

All kinetic and kinematic data were normalised to gait cycle 

(GC). The GC starts with the heel strike of one foot on the 

first force plate and ends with the following heel strike of 

the same side without touching the second force plate.  

The peaks of the kinetic data used for the statistical 

analysis are defined in Table 1 and of the kinematic data 

are defined as follows: 

-First plantarflexion max.: range of motion from ankle 

angle at heel strike to maximum of plantarflexion (at 5-20% 

GC) 

-Dorsiflexion max.: range of motion from maximum of 

plantarflexion (at 5-20% GC) to maximum of dorsiflexion 

(at 40-60% GC) 

-Plantarflexion max.: range of motion from maximum of 

dorsiflexion (at 40-60% GC) to maximum of plantarflexion 

(at 50-70% GC) 

-Knee joint stance flexion: range of motion from knee angle 

at heel strike to maximum of knee flexion (at 10-30% GC) 

-Knee joint swing flexion: range of motion from maximum 

of knee extension (at 30-50% GC) to maximum of knee 

flexion (at 50-70% GC) 

Since all prosthetic feet used in this study have no ankle 

joints, terms like "dorsiflexion" and "plantarflexion" have to 

be handled with care in kinematic as well as in kinetic 

analyses. They were used to explain the deflection of the 

foot related to the natural motion.  

Statistical analysis 

Mean values for all parameters were determined based on 

8 to 12 gait cycles for the prosthetic and the sound limb. 

For the CG, the kinetic and kinematic data of the right leg 

and the spatiotemporal gait parameters were evaluated. 

Group means were calculated separately for each group 

based on the values of all TTs and the CG. Differences in 

peak values of biomechanical parameters between 

amputees and the CG were tested with the Mann-Whitney 

U-test, based on a non-normal distribution of all gait 

parameters tested with the Shapiro-Wilk test. The 

significance level was set at p < 0.05 for two-tailed tests. 

The peaks of the knee adduction moment, of the knee 

flexion moment during midstance and of the vertical 

ground reaction forces on the sound side are reported 

contradictorily in literature. Thus, their effect size (r=z/√N)) 

was calculated to assess the magnitude of the 

difference.27 As Cohen suggested, the effect size was 

defined with d=0.2 being considered a 'small' effect size, 

0.3 represents a 'medium' effect size and 0.5 a 'large' 

effect size.27 If the effect size of the group comparison is 

0.2 or smaller, the difference is marginal. Thus, the null 

hypothesis of the Mann-Whitney U-test stating that the two 

samples come from the same population and therefore 

show no differences is confirmed. 

RESULTS  

Individuals 

The database contained data from 67 TTs, whereby 53 (39 

male, 14 female) met the inclusion criteria. 

The amputees were on average 48 (SD=16) years old, 

1.77 (SD=0.09) m tall and weighed 84.3 (SD=17.8) kg. 

Twenty five individuals were amputated on the right and 

28 on the left side. All individuals used passive prosthetic 

feet. The amputees' mobility level (K-Level) was 

determined by subjective judgment of the prosthetist using 

the Medicare functional classification system (MFCL).28 

Detailed information on the amputees is shown in Table 2. 

https://doi.org/10.33137/cpoj.v2i2.32955


 

 

Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

4 

CPOJ 

 

Pröbsting et al. 2019 

 GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

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https://doi.org/10.33137/cpoj.v2i2.32955


 

 

Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

5 

CPOJ 

 

Pröbsting et al. 2019 

 GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

Table 2: Transtibial amputees’ anthropometric data. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient  Height 
(cm) 

Body mass 
with prosthesis 

(kg) 

Age 
(yrs) 

Follow up 
after amputation 

(yrs) 

Reason for 
amputation 

Gender 
(m/f) 

Affected 
limb 

K-level 
(1-4) 

Prosthetic foot 
model 

1 188 99 63 8 malignancy m right 2-3 C-Walk1 

2 167 69 85 50 trauma m left 2 C-Walk1 

3 181 113 48 23 trauma m right 3 Advantage DP1 

4 182 72 22 8 trauma m left 3-4 C-Walk1 

5 173 76 76 59 trauma m left 3 Dynamic Motion1 

6 181 81 34 n.a. trauma f left 3-4 C-Walk1 

7 175 92 63 44 trauma m left 3 Dynamic Motion1 

8 190 92 63 n.a. arterial disease m left 2-3 C-Walk1 

9 185 87 62 n.a. n.a. m left 3 C-Walk1 

10 182 79 41 9 trauma m left 4 Triton1 

11 181 86 22 6 trauma m left 2 n.a. 

12 172 87 66 2 arterial disease m left 1-2 Dynamic Foot1 

13 160 61 46 21 trauma f left 2 Multiflex2 

14 180 85 52 29 trauma m left 4 Triton1 

15 193 115 43 15 trauma m left 4 Trias1 

16 175 94 62 1 arterial disease m right 3 Dynamic Motion1 

17 176 75 63 39 trauma m right 3 C-Walk1 

18 171 69 22 3 trauma f right 3 C-Walk1 

19 179 71 68 1 arterial disease m right 2 Dynamic Foot1 

20 179 80 47 0 trauma m left 3 C-Walk1 

21 187 88 71 8 trauma m left 3 C-Walk1 

22 172 60 27 3 trauma f left 2-3 C-Walk1 

23 170 70 34 6 arterial disease f left 3 Dynamic Motion1 

24 156 63 44 1 arterial disease f right 2 SACH1 

25 179 95 64 3 arterial disease m left 2-3 Dynamic Foot1 

26 176 67 28 3 trauma m left 3 Dynamic Foot1 

27 159 64 46 24 trauma f left 3 C-Walk1 

28 186 79 29 29 congenital m left 4 C-Walk1 

29 174 92 62 3 arterial disease m right 2 Dynamic Foot1 

30 173 91 59 4 arterial disease m right 1-2 Greissinger Plus1 

31 176 73 43 26 trauma m left 3-4 Dynamic Motion1 

32 175 80,5 73 54 trauma m right 3 Dynamic Motion1 

33 181 84 52 20 trauma f right 3 C-Walk1 

34 180 92 65 4 arterial disease m left 3 C-Walk1 

35 169 76,5 70 71 trauma m left 3 SACH1 

36 203 144 25 8 trauma m right 2-3 Ceterus3 

37 173 77 50 31 trauma m right 4 Triton1 

38 176 93,5 53 1 sepsis m right 3-4 C-Walk1 

39 178 117 28 1 trauma m right 3 Trias1 

40 189 126 39 31 trauma m left 3 Axtion1 

41 168 76 37 24 malignancy f right 3 Triton1 

42 175 88 51 3 trauma m right 3 C-Walk1 

43 174 75 43 n.a. n.a. f left 2 n.a. 

44 176 78 44 15 trauma f left 4 Triton1 

45 183 113 26 2 malignancy m right 4 Triton1 

46 165 69 47 2 arterial disease f right 3 Ceterus LP3 

47 172 72 41 20 trauma f left 4 C-Walk1 

48 156 53 40 33 trauma f right 3 Axtion1 

49 177 79 47 10 arterial disease m right 4 Triton1 

50 188 109 50 8 trauma m right 3-4 n.a. 

51 168 70 28 20 trauma m right 4 Advantage DP1 

52 187 102 33 17 trauma m right 4 Advantage DP1 

53 183 69 48 2 infection m right 3 Trias1 

mean 176.9 84.3 48.0 16.7  39 m 25 right   
SD 9.1 17.8 15.7 17.3  14 f 28 left   

 
Abbreviations: 1 Ottobock, Duderstadt D. 2 Endolite Blatchford, Hampshire, UK. 3 Össur, Reykjavík, ISL 

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Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

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 GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

Spatiotemporal gait parameters  

TTs walked significantly slower than the CG (1.26 m/s vs. 

1.43 m/s; p<0.001). Step length was significantly reduced: 

prosthetic side (0.71 m vs. CG: 0.76 m; p<0.05) and sound 

side (0.67 m vs. CG: 0.76 m; p<0.001). Step length 

asymmetry was significantly higher for the amputees 

(0.046 m; p<0.001) than for the CG (0.01 m). Stance 

phase duration on the sound side (65% of the gait cycle, 

GC) was significantly longer than on the prosthetic side 

(62% GC; p<0.001) and in the CG (61% GC; p<0.001). 

The asymmetry of the stance phase duration of 3% GC 

was significantly (p<0.001) increased. 

Foot/ankle kinematics and kinetics prosthetic side 

The kinematic pattern (Figure1A) of the prosthetic ankle 

differed from that found in the CG. The range of motion of 

plantarflexion in early stance on the prosthetic side (5.8°) 

was comparable to that of the CG (6.5°, p=0.2), while the 

movement was slower on the prosthetic side. The range of 

motion of the following dorsiflexion was also similar 

between both groups (15.4° vs. CG 16.5°; p=0.35). In the 

CG the movement was initially fast (up to 15% GC) and 

then it slowed down; between 10 and 50% GC, amputees’ 

dorsiflexion movement showed a constant velocity. The 

range of plantarflexion at the end of stance was 

significantly reduced on the prosthetic side (P: 13.9° and 

CG: 34.6°, Table 1). Additionally, there was negligible 

dorsiflexion during the swing phase of the prosthetic foot. 

Figure 1: Mean parameters for the prosthetic side foot/ankle of 

the TTs with standard deviation (grey) and for the control group 

(dotted, black). A: mean pattern of foot/ankle motion, B: external 

sagittal moment acting on the ankle joint. 

The maximum initial plantarflexion moment (Figure 1B) 

was significantly increased on the prosthetic side (-0.26 

Nm/kg and CG: -0.19 Nm/kg; p=0.001). Peak dorsiflexion 

moment was significantly reduced for the prosthetic side 

(P: 1.34 Nm/kg and CG: 1.77 Nm/kg; p<0.001). 

Knee kinematics and kinetics prosthetic side 

For 46 out of 53 TTs, the prosthetic side showed a knee 

flexion during stance phase. The remaining seven TTs 

walked with fully extended knee. This motion ranged 

between 4 and 26 degrees with a mean stance phase 

flexion of 11.4° (Figure 2A, Table 1). This was significantly 

lower than in the CG (17.9°, p<0.001). 

The range of motion during swing on the patients’ 

prosthetic side (60.2°) was similar to that of the CG (59.6°). 

The moment acting on the knee joint in the sagittal plane 

was generally reduced on the prosthetic side (Figure 2B). 

Figure 2: Mean parameters for the residual knee joint of the TTs 

with standard deviation (grey) and for the control group (dotted, 

black). A: mean pattern of knee motion, B: external sagittal 

moment acting on the knee joint. 

Sound side knee loading  

The peak values of the external knee extension moment 

showed no significant differences between TTs and CG. 

However, the peak external knee flexion moment was 

significantly reduced on the sound side ( 0.47 Nm/kg and 

CG: -0.64 Nm/kg; p<0.001; r=0.3) (Figure 3A and Table 1). 

The first peak of the knee adduction moment showed no 

difference between the TTs (0.51 Nm/kg) and the CG (0.49 

Nm/kg; p=0.747; r=0.03). Only the second peak was 

significantly reduced for the amputees (p=0.008) (Figure 

3B). The mean first peak of vertical ground reaction force 

showed no significant difference between the sound side 

of amputees (115.0 %BW) and the CG (115.4 %BW, 

p=0.686). Only the mean second peak was significantly 

reduced for the amputees (p<0.001; r=0.04, Figure 3C). 

https://doi.org/10.33137/cpoj.v2i2.32955


 

 

Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

7 

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 GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

Figure 3: Selected mean parameters for the sound side of the 

TTs with standard deviation (grey) and for the control group 

(dotted, black). A: external sagittal moment acting on the knee 

joint, B: external frontal moment acting on the knee joint, C: 

vertical ground reaction force. 

DISCUSSION  

The objective of this study was to describe the gait 

characteristics with respect to the sagittal kinetic and 

kinematic parameters of the ankle and knee joints of the 

prosthetic limb of unilateral TTs. In view of the 

discrepancies of the sound side knee loading parameters 

found in the literature, these parameters were analysed in 

a representative large cross section of TTs (n=53) as well. 

In the present study the TTs walked with a self-selected 

speed comparable with velocities cited in other studies 

(see Table 1), but significantly slower than the CG. The 

asymmetrical stance phase duration was also in 

accordance with the literature and was explained as “being 

the result of an early toe-off by the amputated limb owing 

to loss of the push-off function of ankle plantar-flexion”.5 

The most obvious differences between TTs and the CG 

were seen at the prosthetic ankle, as previously described 

by Sanderson et al.7 With the TTs, the external 

plantarflexion moment in early stance was clearly 

increased and acts for a longer period. Also, plantarflexion 

was slower. This is in accordance with results of Breakey, 

who argued that the compression of the prosthetic heel 

could be responsible for the longer period between heel-

contact and foot-flat in the amputated limb5 as well as the 

missing ankle joint. The constant velocity of the 

subsequent dorsiflexion and the steady increase of the 

corresponding moment are results of the lack of muscular 

control, especially of the triceps surae. Due to the removed 

plantar flexor muscles, the final plantarflexion at the end of 

stance was markedly reduced. As a result of this missing 

movement the peak dorsiflexion moment was 

subsequently reduced.7 The missing muscles controlling 

the ankle also affect the swing phase, because the 

prosthetic foot showed only a slight dorsiflexion, which 

could be due to elastic recoil after compression. In addition 

to the changes at the ankle, the residual knee of the 

prosthetic limb was systematically affected. 

During stance, the range of motion of the residual knee of 

the prosthetic limb was significantly reduced, although TTs 

rarely suffer from pathological flexion or extension deficits 

of these joints. A long-term adaptation to the amputation is 

the reduction in strength29,30 and cross-sectional area9,31 of 

the muscles crossing the proximal joints. A possible 

consequence could be a reduction of the joint moments, 

which have to be compensated by the muscles.9 This 

reduction was also seen at the knee joint in this study as 

in other studies.4,16  

The difference of the knee moments during midstance 

between the prosthetic side and the CG in this study was 

0.46 Nm/kg with a difference in gait velocity of 0.17 m/s. In 

general walking speed influences the magnitude of joint 

moment peaks. However, Lelas et al.32 identified a 

parameter regression equation for this parameter. The 

result of this equation is that a reduction of velocity of 0.17 

m/s will reduce the knee moment by 0.06 NM/kg.32  The 

difference of 0.46 Nm/kg in this study with TTs are more 

pronounced and therefore the reduction of the knee 

moment during midstance was attributed to the 

amputation. 

The absence of a forceful push-off in prosthetic feet during 

late stance caused by the lack of plantar flexor muscles 

could explain the reduction of moments in late stance. 

However, Esposito et al. reported no differences for this 

parameter between a powered (BiOM) and a passive 

prosthetic foot.14  For the cohort analysed here, the mean 

stance phase knee flexion of 11.4° is was slightly more 

pronounced than reported in other studies with 

 7° to 9.5°.4,5,16 Generally, knee flexion in early stance is 

significantly determined by the prosthetic alignment and 

the foot properties.26,33 The foot designs used here varied, 

but in all cases the foot was the “everyday foot” of the 

patients. The alignment used in this study was consistently 

biomechanically optimised24 for the patient group 

investigated. The comparably enhanced knee flexion 

during stance phase and the high percentage of amputees 

(87%) flexing the knee were achieved by an alignment 

which consistently followed Blumentritt’s 

recommendations.24 This is an indicator for the importance 

of biomechanically optimised alignment and individually 

customised foot properties.  

https://doi.org/10.33137/cpoj.v2i2.32955


 

 

Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

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The kinematic changes compared to controls were only 

obvious during stance, when the prosthetic alignment and 

foot design are of importance. During swing the residual 

knee of the prosthetic limb showed no effects. This is in 

agreement with Sanderson et al.7 and Powers et al.4 but in 

contrast to the reduced peak knee flexion shown by 

Breakey5 and Rabago et al.16  

The most inconsistent results in the literature were found 

with respect to kinetic compensatory adaptations on the 

sound side,17 especially the parameters that were 

assumed to be indicators for the risk of developing 

osteoarthritis.  

The present study shows no difference of the external 

knee adduction moment on the sound side compared to 

non-amputees. This concurs with Lloyd et al.12, Rabago et 

al.16 and Karimi et al.17 In contrast, Grabowski et al.13 and 

Royer et al.18 showed an increase by trend, whereas 

Esposito et al.14 and Pruziner et al.15 showed a decrease 

by trend. None of the results shown by these studies are 

statistically significant. The sample of 53 subjects allows 

to claim equivalence within an effect size of r=0.03. 

Therefore, it can be generally assumed that the knee 

adduction moment on the sound side does not differ 

between TTs and non-amputees.  

The findings regarding peak external knee flexion 

moments on the sound side were also controversial. 

Esposito (n=10)14 and Nolan (n=4)8 reported a significant 

increase, whereas Rabago et al. (n=16) showed a 

decrease by trend.16 This trend was supported with the 

results of this study showing a significant reduction in 

comparison to the controls with a medium effect. From 

these data with a large sample size it can be concluded 

that there is definitively no increase of knee flexion 

moment of TTs compared with non-amputees. 

The vertical component of the ground reaction forces were 

also not consistently reported. Some studies reported that 

the first ground reaction force peak was significantly 

greater on the sound side compared to healthy 

controls.10,13 Other studies reported a statistically non-

significant increase.14,15,17 The results of this study concur 

with Sanderson et al.7 showing no difference between the 

sound side of the amputees and the CG. The effect size of 

r=0.04 also supports the null hypothesis that the two 

samples come from the same population and therefore 

show no differences.  

An essential factor influencing the sound side lower limb 

joint loading of TT amputees is the prosthetic alignment.24 

In this context, Grumillier demonstrated the influence of 

systematic prosthetic mal-alignment. Particularly, the 

sound side’s hip work was increased, when the prosthetic 

foot was internally rotated.23 Pinzur showed higher forces 

and moments on the sound side, when tilting the socket 

from an optimally aligned prosthesis.34  

With a biomechanically optimised alignment as defined by 

Blumentritt24 in the present study and in the results of 

Karimi et al.17 no significant increase of knee moments and 

ground reaction forces could be measured on the sound 

side. Furthermore, Karimi et al. showed no significant 

increase of joint contact forces calculated by a 

musculoskeletal model in the intact knee joint of TTs. 

Hence, they could neither find any “biomechanical 

indicator for a possible early onset of osteoarthritis”.17 

Therefore, it seems reasonable to assume that an 

appropriately aligned prosthesis does not cause 

overloading of the sound side during walking. This concurs 

with Hurley et al., who analysed the load of the 

contralateral limb in TT gait.35 

It is questionable whether other parameters could explain 

the higher risk of knee osteoarthritis on the sound side 

knee of TTs. Proebsting et al. discussed the influence of 

sound side knee load during other activities e.g. hopping 

or walking with crutches without prosthesis.21 Although an 

influence of trauma, infection or rheumatism on knee 

osteoarthritis is generally known. 

Limitations 

It should be noted that the amputees in the analysed group 

used different models of prosthetic feet. Furthermore, the 

amputees’ K-levels varied (Table 2). However, since the 

aim of the study was to evaluate the general gait of a group 

of TTs, we did not want to limit ourselves to investigating 

the specific gait with only one foot model or in one selected 

K-Level and therefore decided to use a heterogeneous 

patient group. 

CONCLUSION 

The biomechanical data measured for the prosthetic side 

in a cohort of 53 unilateral TT amputees concur with 

findings of other studies. These results indicate that 

besides the missing plantarflexion of the foot at late 

stance, the residual knee joint is generally affected with 

respect to a decreased sagittal plane moment and 

reduced knee flexion during stance phase.  

The parameters influencing the risk of developing knee 

osteoarthritis are discussed controversially in the literature 

for the sound side, but are by contrast not increased in the 

cohort of 53 unilateral TT amputees investigated here.  

Hence, we deem it reasonable to assume that an 

appropriate prosthesis will reduce the likelihood of 

overloading the knee on the sound side during normal 

walking. Nevertheless, other influencing factors next to 

biomechanical parameters during level walking (e.g. 

trauma, infection, rheumatism, etc.) could explain the 

higher risk of developing knee osteoarthritis in the sound 

side knee of TTs. 

ACKNOWLEDGEMENTS 

The authors gratefully acknowledge Prof. D. Rosenbaum 

for his valuable contributions to the preparation of this 

article. 

DECLARATION OF CONFLICTING 

INTERESTS 

Eva Pröbsting, Malte Bellmann, Thomas Schmalz and 

Andreas Hahn are employees of Ottobock, the 

manufacturer of prosthetic components. The authors 

alone are responsible for the content and writing of the 

paper. 

 

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Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

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 GAIT CHARACTERISTICS OF TRANSTIBIAL AMPUTEES 

ETHICAL APPROVAL 

The study is in full accordance with the requirements 

of the German medical device act and data 

protection legislation. 

AUTHOR CONTRIBUTION 

• Dipl.-Ing (FH) Eva Pröbsting,  

investigated, analysed the data and wrote the 

manuscript 

• Dr. Malte Bellmann,  

investigated, analysed the data and reviewed 

• Dr. Andreas Hahn,  

conceived the idea of the work and reviewed 

• Dr. Thomas Schmalz,  

investigated, analysed the data and reviewed 

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Pröbsting E, Bellmann M, Schmalz T, Hahn A. Gait characteristics of transtibial amputees on level ground in a cohort of 53 amputees - comparison of kinetics and kinematics 
with non-amputees. Canadian Prosthetics & Orthotics Journal. 2019;Volume2, Issue2, No.1. https://doi.org/10.33137/cpoj.v2i2.32955 

 

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