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VOLUME 3, ISSUE 2 

 2020 

 

RESEARCH ARTICLE 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower 

limb prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

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1 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

 

 

 
RESEARCH ARTICLE 

 

USING PERFORATED LINERS TO COMBAT THE DETRIMENTAL EFFECTS OF EXCESSIVE 
SWEATING IN LOWER LIMB PROSTHESIS USERS    

 
Davies K.C1*, McGrath M1, Savage Z2, Stenson A2, Moser D1, Zahedi S1         
 

1 Blatchford Group, Unit D Antura, Bond Close, Basingstoke, RG24 8PZ, UK. 

2 Sheffield Mobility & Specialised Rehabilitation Centre, Northern General Hospital, Sheffield, UK. 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 
 

INTRODUCTION   

Excessive sweating at the residual limb affects the quality 

of life of up to 70% of people with amputation and is one of 

the most common complaints reported by prosthetic 

users.1–3 Indeed over 53% of lower limb amputees reported 

discomfort due to heat and/or perspiration4 while 66% felt 

that sweating impacted on their daily activities.5 

Comparatively, only 2.9% of the general population have 

been medically diagnosed as suffering from excessive 

sweating, or “hyperhidrosis”.6 

Sweating forms an effective way for reducing temperature 

and is an essential component of the body’s cooling 

process.7 When the skin is disrupted in some way, the body 

adapts in order to achieve the same cooling benefits and it 

is this adaptation that can prove problematic within 

prosthetics. People with lower limb amputation generally 

exert higher levels of energy during ambulation compared 

to able-bodied people. For unilateral transtibial amputees, 

this was around 16%,8 while with bilateral transtibial 

amputations, it is closer to 40%.9 Consequentially, body 

 
OPEN  ACCESS Volume 3, Issue 2, Article No.1. 2020 

 

 

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

 

ABSTRACT 

BACKGROUND: Excessive sweating of the residual limb has a substantial effect on the daily activities 

of people with lower limb amputation. Prosthetic liners offer protection and comfort to sensitive areas but 

often exacerbate perspiration. They act as insulators, trapping sweat on the skin’s surface to the 

detriment of skin health. Recently, liners with perforations have been developed, allowing the moisture 

to escape. The goal of this study was to assess the impact of such liners. 

METHODS: A sample group of 13 patients with unilateral transtibial amputation, who wore a perforated 

liner (PL) as part of their current prescription, was compared to 20 control patients who wore non-

perforated liners (NPL). During their routine appointments, they completed a survey of scientifically 

validated outcome measures relating to their limb health, pain and the impact on daily life over a 12-

month period. 

RESULTS: Patients using the PL had healthier residual limbs, reporting higher scores on questions 

relating to limb health, experiencing fewer skin issues (p<0.001) and estimating a 61.8% lower rating in 

perceived sweat (p=0.004). Perhaps consequentially, there was a lower incidence of residual (p=0.012) 

and phantom (p=0.001) limb pain when compared to the control group. The prevalence of individual 

issues affecting the residual limbs of PL users was also lower. Of the issues that remained, only 23% 

were attributed to sweating in PL users, compared to 49% for the NPL group (p=0.066). PL users missed 

fewer days of work in the year (2.4 vs 11.6, p=0.267) and were also limited on fewer days (1.4 vs 75.4, 

p=0.009). 

CONCLUSION: The use of perforated liners shows much promise within prosthetic care, significantly 

improving the health of the residual limb. The observed effects on perceived sweat reduction, residual 

skin health, pain levels and patient limitation suggest that perforated liners are highly beneficial to 

patients. 

ARTICLE INFO 

Received: July 16, 2020 

Accepted: August 29, 2020 

Published: September 3, 2020 

CITATION 

Davies K.C, McGrath M, 

Savage Z, Stenson A, Moser D, 

Zahedi S. Using perforated 

liners to combat the detrimental 

effects of excessive sweating in 

lower limb prosthesis users. 

Canadian Prosthetics & 

Orthotics Journal. 2020;Volume 

3, Issue 2, No.1. 

https://doi.org/10.33137/cpoj.v3i

2.34610 

KEYWORDS 

Prosthetics, Sweat, Prosthetic 

Liner, Perforated, Amputation, 

Residual limb  health, Silicone 

liner, Amputee, Dysvascular, 

Temperature 

 

* CORRESPONDING AUTHOR: 
K.C Davies,  
Blatchford Group, Unit D Antura, Bond Close,  
Basingstoke, RG24 8PZ, UK. 
E-mail: katherine.davies@blatchford.co.uk 
ORCID: https://orcid.org/0000-0003-2933-4365 
 

https://doi.org/10.33137/cpoj.v3i2.34610
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v3i2.34610
https://doi.org/10.33137/cpoj.v3i2.34610
https://orcid.org/0000-0003-2933-4365
https://orcid.org/0000-0003-2933-4365


 

2 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 
temperature rises and the body reacts accordingly. A 

transtibial amputation also reduces the skin’s surface area 

by around 10-15%,10 so in order to achieve the same 

cooling effect, the rate of sweat production from the 

remaining surface must increase proportionally. The 

combination of these factors means that people with 

amputation may produce more sweat. 

Prosthetic liners increase layers above the skin, offering 

protection and comfort to sensitive areas, but the materials 

are not breathable and act as insulators.11 This exacerbates 

the rise in temperature and traps the resultant sweat on the 

skin’s surface. Sustained exposure to moisture has a 

detrimental effect on the skin,12 leaving it more susceptible 

to injury. Skin disorders also become more problematic 

within the amputee population due to scar tissue and the 

high prevalence of vascular disease.13 This compromises 

blood flow, reducing healing capabilities and making the 

skin vulnerable.14,15 Renshaw found that skin previously 

wetted with water was more likely to blister than when it was 

dry.16 In addition, Hurkmans et al. found that sweat 

accumulation contributed towards skin irritation, perhaps 

even more so than infection.17 Perhaps unsurprisingly then, 

skin disorders are prevalent in this vulnerable population18 

with wound infection rates ranging between 13-40%19 

following amputation and residual limb pressure ulcers 

causing the majority of re-amputations.20–22  

Various approaches have been trialled to improve 

excessive perspiration and heat,4 from the use of 

commercial or prescription anti-perspirants23 to more 

extreme options such as Botulinum Toxin injections.24,25 

More prosthetic-specific solutions have also been tried and 

evaluated.26 Wernke et al. investigated the SmartTemp 

liner27 (Ohio WillowWood, Mt Sterling, OH, USA), which 

uses Phase Change Material in order to store and release 

heat energy. The liner effectively reduced the initial 

temperature of the residual limb and therefore the volume 

of sweat produced. However, these materials have a limit 

on the amount of cooling they provide28 and in another 

study29 thermally conductive silicone did not result in a 

significant improvement in climate control over plain silicone 

liners. More recently, a liner with perforations has been 

developed (Silcare Breathe, Blatchford, Hampshire, UK) 

allowing moisture to escape and keeping the residual limb 

dry.30 These liners reduced the prevalence of sweat 

remaining on the skin in all participants during trials30 and in 

published case studies.31 Evidence has suggested they are 

effective in the management of wounds and beneficial to 

residuum skin health, especially when used in combination 

with elevated vacuum.31 

This study sought to determine the efficacy of perforated 

prosthetic liners for the purpose of sweat management, 

investigating what impact, if any, this made on patient 

outcomes.  

METHODOLOGY 

Evaluated technology 

This study examines the effects of a perforated liner (PL - 

Silcare Breathe, Blatchford Products Ltd., Hampshire, UK)I,II 

on patient outcome measures and residual limb health. It 

differs from previous silicone designs because it 

incorporates perforations along the length, and at the distal 

end, with the intention of improving skin interface 

microclimate control and hygiene of the residual limb 

(Figure 1).   

 

 

Figure 1: A cross-sectional image of the Silcare Breathe liner 

(Blatchford).I,II Moisture is transported away from the skin through 

perforations located along the sides and at the distal end of the 

liner. 

These perforations allow moisture produced by the body to 

be transported to the outside of the liner, so that it doesn’t 

remain on the surface of the skin. Moisture is then readily 

absorbed by the fabric on the outside of the liner, rather than 

by the silicone, so that it does not migrate back towards the 

skin and the liner can be more easily cleaned. 

Participants 

Suitable candidates (n=41) for the study were identified and 

approached by their prosthetists during routine 

appointments at Northern General Hospital in Sheffield. The 

cohort was then divided into PL users and a control group 

who wore conventional non-perforated liners (NPL). 

Participants had to have a transtibial amputation and were 

required to have been using their current prescription for a 

minimum of 12 months. All participants were established 

prosthesis users with a mobility level of K2 or above and 

were able to read and write in English, with sufficient 

cognitive ability. 

All patients provided informed, written consent. The study 

was approved by the Clinical Effectiveness Unit at Sheffield 

Teaching Hospitals. No interventional actions were taken 

and the ethics of the study conformed with the World Health 

Organisation Declaration of Helsinki.32 

Data collection and measures 

All participants completed a survey of scientifically validated 

outcome measures during routine appointments. The 

Perforations transport 

moisture away from the skin 

Silicone liner  

(3.7mm mid-thickness) 

Material on outside of the liner  

absorbs moisture, preventing  

it from travelling back to the 

 skin’s surface 

Residual limb 

Socket 

https://doi.org/10.33137/cpoj.v3i2.34610


 

3 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 
surveys were comprised of selected sections of the Patient 

Evaluation Questionnaire33 (PEQ); a clinically validated 

patient-reported outcome measure that has been used 

successfully to analyse the use of prosthetic liners in 

previous studies.34–36 This questionnaire is organised into 

independent functional domain subsections,37 where the 

patient indicates a score out of 100 using a visual analogue 

scale (VAS) for each individual question. Every question 

relates to the previous four weeks and the overall average 

gives the score for the subset. 

For this study, the residual limb health subset was used, 

made up of questions about sweat inside the liner, 

smelliness, swelling, rashes, ingrown hairs and blisters. As 

well, individual PEQ questions relating to frequency, 

intensity and ‘bothersomeness’ of residual and phantom 

limb pain were included. Following PEQ scoring, lower 

scores indicated worse symptoms (e.g. 0 = extremely 

intense, 100 = extremely mild). For frequency of pain, a 

seven-point multiple choice format was used, rather than 

the visual analogue scale. These choices were “Never", 

"Only once or twice", "A few times (about once/week)", 

“Fairly often (2-3 times/week)", "Very often (4-6 

times/week)", "Several times every day" and "All the time or 

almost all the time". In order to allow a quantifiable 

comparison between groups, these responses were 

assigned a score from 1 (least frequent) to 7 (most 

frequent), from which the mean and SD were calculated. 

In addition, questions specifically designed for this study 

were included in the surveys which related to the previous 

12 months. These enquired about excessive sweating, 

number of socket adjustments required, what issues the 

patient experienced on their residual limb and the number 

of days work that had been missed or limited because of 

issues caused by sweating. 

Study group participants also filled out the survey 

retrospectively, with regards to their previous prescription. 

Due to the retrospective nature of these responses, it was 

thought that results might be unreliable and affected by bias. 

While the retrospective responses were comparable to 

those of the control group, the principal comparison 

reported in this work is between the study group’s current 

responses and responses from the control group. 

Data processing and analysis 

Residual limb issues were categorised into conditions and 

the frequency of each was recorded as a percentage of the 

population so that an objective comparison could be made. 

Participants were asked to estimate what percentage of 

their issues they attributed directly to sweat. This figure was 

then multiplied by the total number of issues each 

participant suffered from, to calculate the number of issues 

that each participant attributed to sweating. 

For all VAS and numerical responses, the mean and 

standard deviation for each outcome measure were found 

and used for comparisons. Data were tested for normality 

using the Shapiro-Wilk test. Homogeneity of variance was 

assessed using F tests for normal data and a Fligner-Killeen 

test in cases where the data were not normal. Dependent 

on the outcome, comparisons of means were made using t-

tests, Wilcoxon tests or Kruskal-Wallis tests. For ordinal or 

nominal data (e.g. frequency of pain and prevalence of 

issues), comparisons were made using a chi-squared 

analysis. For all tests, p<0.05 indicated significance. 

RESULTS 

Demographics 

Of the overall cohort (n=41), 21 were identified as PL users. 

Out of these, eight patients did not use the liner consistently, 

or discontinued use, and were excluded.  Of the remaining 

13 participants, ten were male and three were female (age: 

49 (SD=10) years; weight: 96 (SD=26) kg. Nine had used 

silicone liners in their previous prescription and four used 

conventional pelite liners in conjunction with a suspension 

sleeve; all now wore perforated silicone liners with either 

suction or pinlock suspension (Table 1).  

Table 1: Study group participant demographics. 

 

 
Gender 

Age 

(years) 

Weight 

(kg) 
Aetiology Previous prescription (suspension) Current prescription (suspension) 

PL01 M 57 92.5 Unknown Pelite liner and silo sheath (sleeve) Blatchford Silcare Breathe Cushion (suction) 

PL02 F 37 103 Infection Pelite liner and silipos sock (sleeve) Blatchford Silcare Breathe (pinlock) 

PL03 M 54 112 Trauma Össur liner (pinlock) Blatchford Silcare Breathe (pinlock) 

PL04 M 41 100.6 Trauma Blatchford liner (pinlock)  Blatchford Silcare Breathe (pinlock) 

PL05 F 55 77 Congenital Össur liner (pinlock) Blatchford Silcare Breathe (pinlock) 

PL06 M 35 81.4 Infection Pelite liner (sleeve) Blatchford Silcare Breathe (pinlock) 

PL07 M 62 99.3 Unknown Össur liner (pinlock) Blatchford Silcare Breathe (pinlock) 

PL08 M 57 82.1 Vascular Össur liner (pinlock) Blatchford Silcare Breathe (pinlock) 

PL09 F 38 79.2 Trauma Blatchford cushioned liner (suction) Blatchford Silcare Breathe (pinlock) 

PL10 M 46 88.2 Trauma Alps liner (pinlock) Blatchford Silcare Breathe (pinlock) 

PL11 M 59 104.8 Trauma Alps liner (pinlock) Blatchford Silcare Breathe (pinlock) 

PL12 M 59 169.6 Vascular Pelite liner (sleeve) Blatchford Silcare Breathe Cushion (suction) 

PL13 M 41 62.9 
Pain 

Management 
Blatchford cushioned liner (suction) Blatchford Silcare Breathe (pinlock) 

Mean - 49.3 96.4 - - - 

SD - 9.8 25.9 - - - 

 

https://doi.org/10.33137/cpoj.v3i2.34610


 

4 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 
The control group was made up of the remaining 20 

participants, 16 male and four female (age: 56 (SD=15) 

years; weight: 90 (SD=22) kg). All of them wore silicone 

prosthetic liners, using either suction or pinlock suspension, 

from various distributors (Table 2).  

Residual limb health and pain 

The mean residual limb health score for the PL group  

(75.0 (SD=22.9)) was significantly greater than that of the 

NPL group (58.4 (SD=22.7); p=0.046). For each of the six 

questions that constitute this subset, mean responses were 

higher for the PL group, indicating that problems were less 

prevalent, and that the limb was healthier. For two questions 

– the amount of sweat in their liner (p=0.004) and how 

smelly their limb was (p=0.012) – the difference in response 

reached statistical significance (Figure 2). Indeed, if the scale 

is inverted (so that a higher number indicates a higher 

quantity of sweat) PL users reported 61.8% less sweat 

remaining on the limb than the control group (p=0.004). 

When asked a binary yes/no question about whether they 

perceived the amount they sweat to be excessive (Table 3), 

85% of the control group answered yes. In the study group, 

this was significantly less (p<0.001) with only 15% reporting 

excessive sweating. It is also worth noting that these 

participants added the caveat that this occurred only very 

rarely. 

PL users reported less intense residual limb pain  

(66.3 (SD=32.0)) and less intense phantom limb pain  

(48.6 (SD=35.4)) than the NPL control group  

(38.5 (SD=29.9)) and 37.2 (SD=37.0) respectively). While 

neither of these changes reached statistical significance 

(p=0.071 and p=0.360 respectively), how “bothersome” 

participants found pain in their residual limb did, with the PL 

group reporting that it was less bothersome (68.5 

(SD=30.9)) than the NPL group (38.8 (SD=32.0), p=0.045). 

Significant differences were observed for the PL group, 

compared to the NPL group, in the frequency of residual 

limb pain (2.7 (SD=1.7) and 4.2 (SD=1.9), respectively; 

p=0.032) and the frequency of phantom limb pain (2.8 

(SD=1.6) and 4.3 (SD=2.1), respectively; p=0.042). These 

results are shown in Figure 3 and Figure 4. A clear skew 

towards lower frequencies in the PL group here, indicates 

fewer occurrences of pain. 

Issues at the residuum 

The mean number of residual limb issues reported was 

significantly higher in the NPL control group (2.8 (SD=1.5)) 

than the PL group (1.2 (SD=1.0), p<0.001).  

Issues that were reported by both groups were chaffing, 

blisters, rashes, heat rash and pressure sores, with chaffing 

being the most prevalent issue in both groups (Figure 5). The 

frequency of all issues was lower in the PL group; the 

percentage of the population affected by chaffing differed 

significantly from 80% in the control group, to 46% in the PL 

group (p=0.002). 

Table 2: Control group participant demographics. 

 
 

Gender 
Age  
(y) 

Weight 
(kg) 

Aetiology 
Prescription 
(suspension) 

NPL01 F 49 80.0 Infection Össur liner (pinlock) 

NPL02 M 76 83.5 Trauma Össur liner (pinlock) 

NPL03 M 67 91.8 Trauma Össur liner (pinlock) 

NPL04 M 66 106.4 Infection Alps liner (pinlock) 

NPL05 M 30 69.3 Trauma Össur liner (pinlock) 

NPL06 M 70 79.6 Trauma Össur liner (pinlock) 

NPL07 M 31 83.6 Infection Alps liner (pinlock) 

NPL08 M 81 71.8 Vascular 
Blatchford liner 
(pinlock) 

NPL09 M 59 94.6 Trauma Alps liner (pinlock) 

NPL10 F 57 84.6 Trauma Össur liner (pinlock) 

NPL11 M 70 74.4 Vascular Össur liner (pinlock) 

NPL12 M 56 97.6 Trauma 
Blatchford liner 
(pinlock) 

NPL13 M 47 85.0 Trauma Alps liner (pinlock) 

NPL14 M 63 97.5 Unknown 
Ottobock cushioned 
liner (suction) 

NPL15 M 48 166.0 Unknown Alps liner (pinlock) 

NPL16 M 47 67.0 Vascular Alps liner (pinlock) 

NPL17 M 52 103.0 Unknown 
Össur cushioned 
liner (suction) 

NPL18 F 31 70.0 Trauma 
Blatchford liner 
(pinlock) 

NPL19 M 79 89.0 Trauma 
Ottobock custom 
silicone liner 
(pinlock) 

NPL20 F 47 116.0 Trauma Össur liner (pinlock) 

Mean - 56.3 90.5 - - 

SD - 15.4 22.1 - - 

 

Table 3: Results of additional questions included within survey. P 
values in bold text indicate significance (p<0.05). 

During the past 12 months… 
PL group 

(Mean (SD)) 

NPL 
group 
(Mean 
(SD)) 

p 
value 

Do you currently suffer from 
excessive sweating? 

Yes: 2 
(15.4%) 

No: 11 
(84.6%) 

Yes: 17 
(85.0%) 

No: 3 
(15.0%) 

<0.001 

Approximately, how many 
socket adjustment 
appointments have you 
required? 

1.8 (1.9) 2 (1.4) 0.610 

What % of your residual limb 
issues (skin/tissue breakdown) 
would you attribute to 
sweating? 

22.7 (33.2) 
49.0 

(39.5) 
0.066 

Have you taken any days off 
work, or were housebound, for 
skin issues? If so, how many 
days? 

N = 12 

2.4 (6.0) 

N = 16 

11.6 
(21.9) 

0.267 

Have you limited the use of 
your prosthesis and activities 
due to discomfort caused by 
sweating? If so, how many 
days? 

N = 12 

1.4 (2.9) 

N = 17 

75.4 
(130.6) 

0.009 

 

 

 

https://doi.org/10.33137/cpoj.v3i2.34610


 

5 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 
The occurrence of blisters also changed significantly from 

45% in the control group to 15% in the PL group (p=0.032); 

and differences in heat rashes (50% vs 23%) and fungal 
infection (20% vs 0%) approached significance (p=0.052 

and 0.071 respectively). Although not significant, the 

occurrence of pressure sores changed from 35% in the 

control group to 15% of the PL group (p=0.138). Least 

prevalent issues within the control group (fungal infection, 

callusing, abscess) were not seen at all in the PL group.  

Figure 2: Residual limb health PEQ subset score for the NPL control group (grey) and the PL group (green). The error bars indicate ± one 
standard deviation from the mean. Asterisks (*) indicate a statistically significant change (p<0.05). 

0

20

40

60

80

100

How much
sweat?

Smelliness Swelling Rashes Ingrown
hairs

Blisters Mean limb
health

P
a
rt

ic
ip

a
n
t 
s
c
o
re

<
-

E
x
tr

e
m

e
 i
s
s
u
e
s
  
  
  
  
N

o
 i
s
s
u
e
s
 -

>

Residual limb health PEQ score

NPL group

PL group

0

10

20

30

40

50

Never Only once or
twice

A few times
(about

once/week)

Fairly often (2-3
times/week)

Very often (4-6
times/week)

Several times
every day

All the time

P
e
rc

e
n
ta

g
e

o
f 

p
o

p
u

la
ti

o
n

 (
%

)

Frequency of residual limb pain

PL group

NPL group

Figure 3: PEQ pain subset results for the frequency of the residual limb pain experienced by both PL (striped) and NPL (grey) groups. A skew 

to the left indicates less pain. The difference between the group was significant (p<0.05) with PL users experiencing less pain. 

0

10

20

30

40

50

Never Only once or
twice

A few times
(about

once/week)

Fairly often (2-
3 times/week)

Very often (4-6
times/week)

Several times
every day

All the timeP
e
rc

e
n
ta

g
e
 o

f 
p
o
p
u
la

ti
o

n
 (

%
)

Frequency of phantom limb pain

PL group

NPL group

Figure 4: PEQ pain subset results for the frequency of phantom limb pain experienced by both PL (striped) and NPL (grey) groups. A skew to 
the left indicates less pain. The difference between groups was significant (p<0.05) with PL users experiencing less pain. 

https://doi.org/10.33137/cpoj.v3i2.34610


 

6 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 

When patients were asked to rate how many of their issues 
they attributed directly to sweating, the percentage was 

lower for the PL group (Table 3). The control group estimated 

that on average, 49% of all issues were due to sweating, 

whereas the PL group attributed only 23% to sweat (Figure 

6). 

 

Figure 6: The mean number of issues experienced by patients at 

their residual limb, and the percentage of those issues that were 

attributed to sweating (grey) or to other causes (green). Exact 

percentages are indicated within bars.  

This result did not reach statistical significance (p=0.066) 

due to the high variability between patients. When using the 

percentages to calculate the number of issues attributed to 

sweat however, the control group subjects averaged 1.7 

(SD=1.7), while in the study group this was 0.3 (SD=0.5); a 

result that was significant (p=0.007). 

The number of workdays missed was lower in the PL group 

with a mean of 2.4 (SD=6.0) days taken off work due to 

issues compared to 11.6 (SD=21.9) in the control group 

(p=0.267, Table 3). The number of days limited by issues 

surrounding the prosthesis was significantly less, with the 

PL group limited a mean of 1.4 (SD=2.9) days and the 

control group 75.4 (SD=130.6) days (p=0.009). 

DISCUSSION  

This report investigated the clinical consequences of 

perforated prosthetic liners based on the feedback provided 

by study participants and a comparable control group. While 

patient-reported outcome measures can be subjective, 

large trends in the data can imply significant changes in 

patient outcome over a wider population. The results 

suggest perforated liner users have significantly more 

successful patient outcomes and experiences through 

better residual limb health and less frequent outbursts of 

pain. 

Overall, the study group showed better PEQ residual limb 

health scores (Figure 2). Within this subset, the score for 

every question was higher, indicating an increase in health 

and therefore a reduction of each adverse factor. Significant 

changes were seen in the amount of sweat present on the 

limb as well as in the limb’s odour. Given that malodour is a 

direct result of the bacterial secretions following a 

transformation of the compounds found in sweat,38 it seems 

logical that a decrease in odour would be attributable to a 

decrease in the amount of sweat inside the liner. The design 

of the perforated liner is such that once the moisture 

migrates to the outside of the liner, it is absorbed by the 

fabric lining. To this end, the odour is more likely to develop 

on the outside of the liner, and can be easily washed, 

instead of impregnating into the inner silicone where it 

lingers. 

0

20

40

60

80

100

Chaffing Heat rash Blister Pressure
sore

Rash Fungal
infection

Callusing Abscess

P
e
rc

e
n
ta

g
e
 o

f 
p
o
p
u
la

ti
o

n
 (

%
)

Occurrence of issues at the residual limb

NPL group

PL group

Figure 5: Percentage of the group populations that were affected by individual issues at the residual limb. The NPL group are indicated in grey 
and the PL group in green. Asterisks (*) indicate statistically significant results (p<0.05) while obelisks (†) indicate results that approached 
significance (0.05<p<0.10). 

49%

23%

51%

77%

0

0.5

1

1.5

2

2.5

3

NPL group PL group

N
u
m

b
e
r 

o
f 
is

s
u
e
s

Mean number of issues experienced by 
patients at their residual limb

Issues attributed to other causes
Issues attributed to sweating

https://doi.org/10.33137/cpoj.v3i2.34610


 

7 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 
For clarification, it is worth highlighting that this study used 

patient reported outcome measures and so reported the 

patient’s perception of whether they sweat to excess and 

how much remained on their limb. This study cannot 

comment on whether the type of prosthetic liner used affects 

the actual quantity of sweat produced. However, sweat 

being transported away from the skin is likely to have 

positively affected the amount of sweat perceived by 

participants using the perforated liner, as well as 

contributing towards a healthier environment for the residual 

limb. 

There were notable differences in scores relating to rashes 

and blisters within the PEQ subset (Figure 2). Again, these 

are largely foreseeable. Rashes can be caused by infection, 

a known risk factor in the bacteria-rich environment caused 

by trapped sweat, but they can also be the result of friction.39 

Additional lubrication causes movement at the socket11 and 

moisture increases the coefficient of friction between the 

skin and materials in contact with it,40 imposing greater risk 

of tissue breakdown such as blisters. It follows then, that 

removing sweat from the skin’s surface might reduce the 

amount of irritation caused by movement at the residuum-

socket interface, therefore decreasing the likelihood of 

rashes and blisters. Scores regarding swelling and ingrown 

hairs also showed less prevalence in the PL group, but the 

difference was small, suggesting that climate control 

affected these to a lesser extent. However, previous 

studies41 have drawn links between water exposure and 

resulting inflammation of the skin, so it might be of interest 

to explore further the relationship of climate control to 

individual factors and conditions that affect the residual 

limb. 

For the PEQ questions relating to pain, both residual and 

phantom limb pain were significantly less frequent in the PL 

group (Figure 3 and Figure 4). The difference in residual limb 

pain might have been predicted due to the discomfort 

caused by physical skin conditions which were less 

prevalent. However, the cause of phantom limb pain, which 

occurs after up to 80% of amputations,42 is still a subject of 

speculation and continued investigations are needed.43 

Larbig et al.44 surmised that, along with other factors, 

physical pain following amputation was a risk factor for more 

intense phantom limb sensations, maybe providing some 

explanation of the reduction reported in this study. In 

addition, Fuchs et al.45 measured significantly higher 

intensities of phantom limb pain in upper limb amputees with 

lower heat pain thresholds. Although the difference in the 

intensity of phantom limb pain was not significant in this 

study, the suggested link between that and the temperature 

of the limb is an interesting one and may warrant further 

study. 

The proportional prevalence of specific skin conditions was 

consistent with that found in previous studies46,47 across both 

patient groups, however the frequency of issues was less 

with the use of the perforated liner. The reduction in the 

average number of skin issues in the study group reinforces 

the findings from a previous study.31 Not only was the 

number of issues present at the residual limb less, but the 

same was true with the occurrence of more severe 

conditions. As previously discussed, less perspiration on 

the skin’s surface might result in lower rates of infection and 

irritation; but it may also contribute to a reduction in calluses 

and pressure sores by reducing movement of the liner. The 

formation of ulcers is included within the category of 

pressure sores, which are arguably one of the most serious 

issues that can occur, linked to vascular disease for which 

a large number of lower limb amputations are attributable.13 

Historically, complications with the skin of the residual limb 

limit prosthetic use, interfering not only with an established 

patient’s ability to ambulate, but also with the rehabilitation 

process of primary amputees. This limits participation, 

affecting quality of life48,49 and patient wellbeing,46 leading to 

negative implications for the physical, psychological and 

emotional condition of the patient. Indeed primary patients 

who remained non-ambulatory for over 6 months were 

shown to have a much higher likelihood of developing 

complications,50 with several studies51–53 finding early 

prosthetic use in primary amputees had real benefits not just 

for the mental health of patients but for the subsequent 

outcome measures such as treatment compliance and 

prosthetic use. 

As such, it is important to minimise the time that patients 

spend without a prosthesis. Gallagher et al.54 found one of 

the top three factors affecting amputee participation was 

climate. Furthermore, pain in the residual and phantom 

limbs has been found to influence a patient’s ability of 

returning to work following amputation.55 Within this study, 

PL users had fewer days of limited prosthetic use and a 

lower number of workdays missed. This, combined with the 

perception of improved climate control and limb health 

reported, would indicate an improvement in patient 

outcomes. It is worth noting, that while these results 

accounted for the active employment status of participants, 

the type of employment was not considered. The type of 

work may have affected the ability of the individuals to work 

given socket discomfort and therefore the number of days 

missed. 

The primary aim of this study was to identify the health 

effects of different liners on the residual limb. However, the 

implications that patient health and reduction in 

rehabilitation times have in terms of health and economic 

cost is well documented.56,57 In addition, days of work that 

are either missed by patients or are limited, affect not only 

the individual’s salary but can increase vulnerability in the 

face of redundancy or promotion opportunities.58The health 

economic benefits require further investigation, however, 

the possible larger scale implications of this treatment 

pathway only increase the clinical significance of this study. 

https://doi.org/10.33137/cpoj.v3i2.34610


 

8 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 
Participants were selected by clinicians using inclusion 

criteria and asked to take part in the study during normal 

clinical visits. As this was not a blind recruitment process, it 

may have introduced a bias. The control group were 

selected at random from established patients attending the 

clinic, however the study group were selected because of 

their specific prescription. Patients are likely to be using this 

prescription because of higher activity levels or past 

problems related to sweating; equally the control group 

could have a large range in activity levels. All participants 

were activity level K2 or above, however the activities of 

each patient were not recorded. Although the data are likely 

to show a bias against perforated liners, potentially making 

the effects of this intervention more powerful, the lack of 

activity data is considered a large limitation of this study. 

Participants were asked a binary question about whether or 

not they considered their sweating excessive. The 

percentage of participants who answered yes was 

significantly less in the study group compared to the control 

group (p<0.001, Table 3). This is useful in that it provides an 

awareness of patient experience and satisfaction, but it 

does not show any variation between the patients that sweat 

to excess. Although still subjective, the nature of the PEQ 

requires participants to quantify the amount they think they 

sweat, thereby accounting for participants who felt they fell 

somewhere in the middle. This question gave a similar 

result, with the study group reporting significantly higher 

scores in the PEQ questions relating to the quantity of sweat 

present (p=0.004) on the residual limb. Both questions 

essentially give very similar data, but it could be argued that 

in this case, the PEQ provides more information. 

Although many patients with lower limb amputations suffer 

from it, vascular disease is the aetiology of surprisingly few 

participants within this study. The slower healing 

capabilities of this demographic, means these patients are 

more likely to suffer from skin conditions18 and so the lack 

of vascular participants might mean the study is not 

representative of the overall amputee population. However, 

the study and control groups are comparable in this respect, 

and there is still a significant difference seen in the 

prevalence and type of skin conditions.  

One aspect of the study population that is of note, is the 

complete absence of one or more skin conditions on the 

residual limb in the study group (Figure 5). This is a 

significant improvement; however, given the small sample 

size, the result is likely a false positive. If the number of 

participants had been larger, it is probable that these issues 

would have occurred, at least minimally, in both groups. 

There was a high variability in the percentage of issues that 

patients attributed to sweating, meaning that the result was 

not considered significant. This variation came from the 

balance between the number of issues caused by sweating 

compared with the total number of issues each participant 

experienced. For example, a patient may only have one 

issue, but it may be 100% the result of sweating. This 

variation calls into question the validity of the result. By 

multiplying the individual’s total number of issues by the 

percentage that they estimated were caused by sweat, the 

number of sweat resultant issues that each patient suffered 

from could be calculated. This showed a reduction in sweat 

related issues which did prove significant (p=0.007, Table 3) 

and so it must be noted that although the percentages may 

not be significant on their own, when applied to the data on 

issues suffered by the individual, the result is valid (Figure 

6). 

It is possible that some patients may experience iatrogenic 

affects from the perforations, however this was not reported 

by any of the participants in the study. Additional factors that 

could affect the outcome measures of this study included 

liner material and thickness, suspension type and socket 

comfort. The perforated liner used in this study is 3.7mm 

thick at its mid-point and so falls within the industry standard 

range (3mm to 6mm). Although manufacturers use different 

material compositions, Ali et al. found that the was no 

significant difference between the sweat complaints of 

patients using liners of different material and varying 

suspension method.59 Nevertheless, it should be noted that 

all participants used either pinlock or suction suspension 

systems. Socket comfort scores were not collected in this 

study, however the number of socket adjustments needed 

in the 12-month period was recorded (Table 3). Socket 

adjustments are often required if there is discomfort and so 

might indicate a level of socket comfort. The number of 

adjustments needed was comparable between groups, so 

this factor is unlikely to have had any significant impact on 

the results of this study. 

CONCLUSION 

This study shows promising results for the use of perforated 

liners within prosthetic care, with significant differences 

being observed between the two patient groups. Excessive 

sweating impacts many aspects of the patient’s life beyond 

just their physical health; resulting issues preventing 

prosthetic use and limiting patients’ mobility, in turn affecting 

their daily lives and causing frustration. Perforated liners 

help to manage excessive sweat levels. Improvements in 

patient health and the implications that this may have on 

quality of life often inform prescription guidelines, therefore 

technology that can positively impact these factors may 

prove highly beneficial.  

 

ACKNOWLEDGEMENTS 

Special thanks are extended to the clinical team at Sheffield 

Mobility and Specialised Rehabilitation Centre and Sheffield 

Teaching Hospitals, for participation and the collection, and initial 

collation of data for this study. 

https://doi.org/10.33137/cpoj.v3i2.34610


 

9 

Davies K.C, McGrath M, Savage Z, Stenson A, Moser D, Zahedi S. Using perforated liners to combat the detrimental effects of excessive sweating in lower limb 
prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

ISSN: 2561-987X USING PERFORATED LINERS IN LOWER LIMB PROSTHESIS USERS 

Davies et al. 2020 

 
CPOJ 

 
DECLARATION OF CONFLICTING 

INTERESTS 

The authors are full time employees of Blatchford, the manufacturer 

of the prosthetic liner evaluated in this study.  

AUTHOR CONTRIBUTION 

Katherine C. Davies: Data analysis, writing original, review and 

editing 

Mike McGrath: Conceptualisation, data analysis, writing original, 

review and editing 

Zoe Savage: Conceptualisation, data collection 

Alison Stenson: Conceptualisation, data collection 

David Moser: Review and editing 

Saeed Zahedi: Review and editing 

SOURCES OF SUPPORT 

Authors are employees of Blatchford Products Ltd. 

ETHICAL APPROVAL 

All patients provided informed, written consent. The study was 

approved by the Clinical Effectiveness Unit at Sheffield Teaching 

Hospitals. No interventional actions were taken and the ethics of 

the study conformed with the World Health Organisation 

Declaration of Helsinki. 

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prosthesis users. Canadian Prosthetics & Orthotics Journal. 2020;Volume 3, Issue 2, No.1. https://doi.org/10.33137/cpoj.v3i2.34610 

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