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VOLUME 8, ISSUE 1 

 2025 
 

RESEARCH ARTICLE 

 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & 

Orthotics Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416 

 

  

 

https://jps.library.utoronto.ca/index.php/cpoj/index
mailto:cpoj@online-publication.com
https://publicationethics.org/about/our-organisation
https://pmc.ncbi.nlm.nih.gov/journals/?term=%22Canadian+Prosthetics+%26+Orthotics+Journal%22
https://members.publicationethics.org/members/canadian-prosthetics-orthotics-journal
https://doi.org/10.33137/cpoj.v8i1.44416
https://pmc.ncbi.nlm.nih.gov/journals/?term=%22Canadian+Prosthetics+%26+Orthotics+Journal%22


 

1 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

 

 

RESEARCH ARTICLE 

 

IMPACT OF AMPUTATION LEVEL AND VAULTING ON LOADING PARAMETERS DURING 

LEVEL GROUND WALKING 

Pröbsting E1*, Schmalz T1, Bellmann M1, 2  

1. Clinical Research and Services, Research Biomechanics, Ottobock SE & Co. KGaA, Göttingen, Germany. 
2. HAWK University of Applied Sciences and Arts Göttingen, Germany. 
 
  
 

 

 

 

  

 

 

 

 

 

 

 

 

 

INTRODUCTION   

During the rehabilitation process after a lower limb 

amputation, one of the most important goals is the 

restoration of standing and level ground walking. Several 

studies have investigated level walking in individuals with 

lower limb amputation1-8 and compared their gait to that of 

able-bodied individuals.1,2,7,8 Most of these studies have 

analyzed effects of different prosthetic components, mainly 

different prosthetic feet3 and prosthetic knee joints,4,5 on 

improving safety and mobility. A small number of studies 

also analyzed possibilities and limitations of different 

prosthetic hip joints.6,9  

 

Studies have shown that gait asymmetry is common in 

people with lower limb amputation.1,2 Compared to able-

bodied individuals, people with lower limb amputation 

generally walk slower, including a prolonged stance phase 

duration on their contralateral limb compared to the residual 

one and to able-bodied individuals.1,8 Nolan and Lees7 have 

shown that people with amputation compensate the loss of 

one or more joints by increased net joint moments and 

power output at their contralateral ankle, knee and hip joint 

compared to able-bodied individuals.1,10 Pröbsting et al., 

found no increased joint moments on the contralateral limb 

in people with TT amputation.8   

The asymmetry in step length and stance phase duration 

increases with higher amputation level.2 However, the 

literature shows that individuals with TT amputation can still 

achieve a gait pattern similar to that of able-bodied 

individuals1,2,7,8 as they can actively control their knee joint,8 

compared to those with TF and HD amputation.5,6 Studies 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Previous studies show that during level walking, the load on the contralateral side increases 

with more proximal amputation levels. Furthermore, a typical compensation mechanism, vaulting on the 

contralateral side, may also influence the load. However, no study has compared the load applied to the 

contralateral side across more than two different amputation levels. 

OBJECTIVE: The objectives of this study were to analyze the biomechanical impact of different lower limb 

amputation levels and vaulting on the load applied to the locomotor system. 

METHODOLOGY: Gait data from 82 individuals with different amputation levels (44 transtibial (TT), 30 

transfemoral (TF), and 8 hip disarticulation (HD)) were retrospectively analyzed in this study. Peak knee 

adduction, flexion and extension moments, vertical ground reaction force peaks, and force rates were 

statistically analyzed between different amputation levels and between two groups “TF with vaulting” and “TF 

without vaulting”. 

FINDINGS: As the level of amputation increases, walking speed decreases and asymmetry of stance duration 

increases. TF individuals with vaulting tend to walk faster than those without vaulting. The first peak of vertical 

ground reaction forces, the peak knee adduction and extension moments increase, and the peak knee flexion 

moments decrease with higher amputation level. The higher the amputation level, the curve of the vertical 

ground reaction force becomes significantly steeper during the first 5% of the gait cycle (GC). The first peak 

of ground reaction forces, the knee flexion, extension and adduction moments tend to be higher in TF 

individuals with vaulting.   

CONCLUSION: In summary, a higher lower limb amputation level can increase loading on the contralateral 

limb and contribute to a higher incidence of vaulting during gait. The effect of vaulting as a compensation 

pattern leads to an additional increase in contralateral limb loading. 

 

 

ARTICLE INFO 

Received: November 27, 2024 

Accepted: February 28, 2025 

Published: March 7, 2025 
 

CITATION 

Pröbsting E, Schmalz T, 

Bellmann M. Impact of 

amputation level and vaulting 

on loading parameters during 

level ground walking. Canadian 

Prosthetics & Orthotics Journal. 

2025; Volume 8, Issue 1, No. 2. 

Https://doi.org/10.33137/cpoj.v

8i1.44416 

KEYWORDS 

Amputation; Lower Limb 

Amputation; Level Walking; 

Vaulting; Biomechanics; Gait; 

Transtibial; Transfemoral; Hip 

Disarticulation; Knee; Ground 

Reaction Force; Gait Analysis 

 

* CORRESPONDING AUTHOR: 

Eva Pröbsting, Dipl.-Ing (FH) 

Affiliation: Clinical Research and Services, Research Biomechanics, 
Ottobock SE & Co. KGaA, Göttingen, Germany. 

E-Mail: Eva.Proebsting@ottobock.de 

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

 

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

Volume 8, Issue 1, Article No. 2. 2025 

 

 

https://doi.org/10.33137/cpoj.v8i1.44416
https://doi.org/10.33137/cpoj.v8i1.44416
https://doi.org/10.33137/cpoj.v8i1.44416
mailto:Eva.Proebsting@ottobock.de
https://orcid.org/0000-0002-6349-2992
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X IMPACT OF AMPUTATION LEVEL AND VAULTING ON GAIT LOADING PARAMETERS 

Pröbsting et al., 2025 

state a more asymmetric gait, with prolonged stance phase 

duration and increased load on the contralateral side, in 

individuals with TF amputation compared to those with TT 

amputation.7,11,12 The latter explains the increased risk of 

contralateral knee joint osteoarthritis in individuals with TF 

amputation,13 as the increase in frontal and sagittal knee 

moments, and ground reaction forces, could contribute to 

development of knee joint degeneration in able-bodied 

individuals.14-16 

Able-bodied individuals are able to control the distance 

between the foot and the ground (foot clearance) through 

the coordination of ankle dorsiflexion, knee joint flexion and 

hip joint flexion.17,18 Missing active dorsiflexion (in TTs, TFs, 

and HDs), active knee joint flexion (in TFs and HDs) and/or 

active hip joint flexion (HDs) affect foot clearance. Catching 

the ground with the prosthetic foot can result in a fall. In 

order to reduce the risk of falling, individuals with lower limb 

amputation develop compensatory strategies, such as 

vaulting, hip hiking and circumduction,19 which could lead to 

gait asymmetry.  

Vaulting is the most prevalent method described by people 

with lower limb amputation and clinicians, yet it is not often 

discussed in the literature. Smith et al. described vaulting as 

“a premature midstance plantar flexion by the contralateral 

limb which assists toe clearance of the prosthetic limb by 

lifting the body”.20 In a big cohort of individuals with different 

lower limb amputation levels, vaulting occurred more 

frequently with higher amputation level,2 but no further 

analysis was conducted. Drevelle et al21 used quantitative 

gait analysis to evaluate vaulting motion pattern in 

individuals with TF amputation. Those who use vaulting as 

a compensatory movement exhibited a higher peak in 

generated power at the contralateral ankle during the 

contralateral single stance phase.21 Subsequently, vaulting 

and the level of amputation seem to influence the load on 

the contralateral side. To the knowledge of the authors, no 

study has yet analyzed the contralateral load for more than 

two different amputation levels and only one study has 

analyzed the influence of vaulting on the contralateral single 

stance phase.21 Therefore, the purpose of the present study 

was to describe the biomechanical effects of different 

amputation levels and vaulting on the loading parameters of 

the contralateral side, specially knee joint moments and 

vertical ground reaction force. The primary hypothesis was 

that as the level of amputation increases, the load on the 

contralateral side also increases during stance. The 

secondary hypothesis was that vaulting increases load on 

the contralateral side compared to non-vaulters between 

mid-stance to pre- swing. 

METHODOLOGY 

Data collection 

Gait data from 82 individuals with different lower limb 

amputation levels were retrospectively analyzed in this 

study. Gait analyses have been conducted at Ottobock's 

gait lab in Göttingen since 2002. Gait data were captured 

using a VICON system (8 M-cams with measurement 

frequency 100Hz till 2013 and subsequent 12 Bonita cams 

(200Hz), VICON PEAK, Oxford, GB) coupled with two force 

plates (measurement frequency 1000Hz; Kistler 9287A, 

Winterthur, CH).   

The study was conducted according to the declaration of 

Helsinki regarding human medical experimentation and 

entirely complies with the requirements of the German 

medical device act as well as the data protection law. 

Subjects gave their full verbal consent being measured and 

that pseudonymized data can be used for retrospective 

analyses and publication. 

The biomechanical data used for this retrospective analysis 

were recorded from patients fitted in an orthopedic 

workshop. Measurements were taken at the end of the 

fitting process for documentation and quality assurance of 

the regular everyday fitting.  

The following inclusion criteria were used in this study:  

• Individuals with unilateral amputation (TT, TF (no short 

stump ≤ 1/3 of contralateral femur length) or HD).  

• Age > 18 years. 

• No additional health impairment. 

• Able to walk at a self-selected velocity on level ground. 

• Use of a commercially available Energy Storing and 

Returning (ESR) foot. 

• TF prosthesis with Genium knee joint. 

• HD prosthesis with C-Leg knee joint and Helix3D hip 

joint. 

• Prosthesis aligned according to the criteria defined by 

Blumentritt22 for TTs and Bellmann for TFs23 and HD.24 

Furthermore, the group of TFs was divided into two groups: 

“TF with vaulting”, and “TF without vaulting”. To make this 

differentiation, we used the method described by Drevelle,21 

assuming that people with ankle flexion power values higher 

than 0.15 W/kg during single stance support conduct 

vaulting.21 

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 metatarsale 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 analyze 

essential gait parameters for people with amputation.8 

External joint moments were calculated based on ground 

reaction forces and coordinates of the joint centers as 

described in a previous study.8  

https://doi.org/10.33137/cpoj.v8i1.44416


 

3 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X IMPACT OF AMPUTATION LEVEL AND VAULTING ON GAIT LOADING PARAMETERS 

Pröbsting et al., 2025 

In order to quantify the load on the contralateral leg, to test 

both hypotheses, the vertical ground reaction force and the 

external sagittal and frontal moments acting on the 

contralateral knee joint were evaluated.14-16 The first and 

second peak of the vertical ground reaction forces, the peak 

flexion and extension knee moments and the first peak of 

the frontal knee moments were identified and statistically 

analyzed.  

Furthermore, the assessment of the force increase 

characteristic is a frequently used parameter to evaluate the 

load on the contralateral side.26-29 It is known from studies 

of running that a steeper increase correlates with a higher 

risk of injury.26,29 There are various analysis options for this 

parameter.26 In the present study, to test the first 

hypothesis, the increase of the vertical ground reaction 

force in the first 5% gait cycle (GC) was determined by the 

difference between the first value and the value at 5% GC. 

Moreover, spatiotemporal gait parameters were reported as 

well. All kinetic data were normalized to the stance phase of 

the gait cycle.  

Statistical analysis 

Mean values for all parameters were determined based on 

8 to 12 single gait cycles for the contralateral limb. Group 

means were calculated based on the values of all TTs, TFs 

and HDs and also for the two groups “TF with vaulting” and 

“TF without vaulting”. 

The Kolmogorov-Smirnov test was used to analyze the 

normal distribution of the data. Afterwards, the Bartlett's test 

was used to identify whether equal variances exist. Since 

these two requirements were met, the differences in the 

peak values of biomechanical parameters and 

spatiotemporal gait parameters between the amputee 

groups were tested with the one-way ANOVA for each 

evaluated parameter. Post-hoc analyses with Bonferroni’s 

corrections were performed when ANOVA showed 

significant differences. The significance level was set at p < 

0.05. All analyses were performed using the WinStat 

software (Version 2012.1.0.96). 

RESULTS 

Participants 

Data from 44 TTs, 30 TFs and 8 HDs were used for the 

analysis. Detailed information about the participants is 

shown in Table 1. 

The individuals with TT, TF, and HD amputation had an 

average age of 47 (SD=15), 45 (SD=14), and 43 (SD=12) 

years, respectively. Their average heights were 176 cm 

(SD=13), 183 cm (SD=5), and 175 cm (SD=10), while their 

respective weights, measured with the prosthesis, were 88 

kg (SD=24), 84 kg (SD=9), and 76 kg (SD=16). Using the 

method of Drevelle,21 12% of the TTs, 63% of the TFs and 

all HDs vaulted. 

Table 1: Participant anthropometric data.  

Amputation 
level  

TT TF HD 

   

Number of 
patients  

44 30 8 

Age [Years]* 47 ± 15 45 ± 14 43 ± 12 

Height [cm]* 176 ± 13 183 ± 5 175 ± 10 

Weight [kg]* 88 ± 24 84 ± 9 76 ± 16 

Vaulting 
rate** 

12% 63% 100% 

 

* Mean ± SD; ** Determined based on the assumption that the ankle power 

on the sound side is > 0.15 W/kg. 

 

Spatiotemporal gait parameters 

As the level of amputation increases, walking speed 

decreases from 1.31 ± 0.17 m/s to 1.13 ± 0.16 m/s with no 

significant differences across all amputation levels. Vaulting 

TFs tend to walk faster than TFs without vaulting (1.28 ± 

0.19 m/s vs. 1.22 ± 0.11 m/s). Likewise, the length of the 

stance phase decreases on the prosthetic side and 

increases on the contralateral side in correspondence with 

a more proximal amputation level. Only a few differences 

are statistically significant (Table 2). However, the 

asymmetry of the stance phase duration differed 

significantly between all amputation levels. The TTs show 

the lowest asymmetry with 2.7 ± 2.0% GC, while the HDs 

show the greatest with 9.3 ± 4.5% GC. 

In terms of step length asymmetry, the HD group differs 

significantly from all amputation levels as well as from the 

TFs with and without vaulting. This group is the only one 

showing longer step lengths on the contralateral side than 

on the prosthetic side (Table 2). 

Vertical ground reaction forces 

The values of the first and second peak of the contralateral 

vertical ground reaction forces did not show any significant 

differences between the amputation levels nor between the 

two TF groups (Figure 1). However, there is a tendency that 

the first peak increases with a higher amputation level (TTs: 

115 ± 11% BW, TFs: 115 ± 10% BW, HDs: 117 ± 9% BW) 

and also in the TFs with vaulting (118 ± 10% BW vs. 109 ± 

9% BW). 

ESR ESR 

Genium C-Leg 

Helix 

ESR 

https://doi.org/10.33137/cpoj.v8i1.44416


 

4 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X IMPACT OF AMPUTATION LEVEL AND VAULTING ON GAIT LOADING PARAMETERS 

Pröbsting et al., 2025 

 

Table 2: Spatiotemporal gait parameters and statistical data for all three amputation levels and the two subgroups, “TF with vaulting” and 

“TF without vaulting”. 

 TT TF HD 
TF 

without 
vaulting 

TF 
with 

vaulting 

significant differences 
p<0.05 

Velocity [m/s] 1.31 ± 0.17 1.26 ± 0.16 1.13 ± 0.16 1.22 ± 0.11 1.28 ± 0.19 Not significant 

Stance duration sound side [%gait 
cycle] 

64.3 ± 2.1 65.1 ± 2.2 67.6 ± 3.3 65.6 ± 1.8 64.9 ± 2.3 
HD vs. TT 

HD vs. TF with vaulting 

Stance duration prosthetic side  
[%gait cycle] 

61.7 ± 1.4 59.3 ± 1.8 58.5 ± 2.2 59.9 ± 1.5 58.9 ± 1.8 

HD vs. TT 
HD vs. TF 

HD vs. TF without vaulting 
HD vs. TF with vaulting 

Asymmetry stance duration sound 
side - Prosthetic side 
[%gait cycle] 

2.7 ± 2.0 5.9 ± 2.2 9.3 ± 4.5 5.6 ± 2.8 6.0 ± 1.9 

TT vs. TF 
TT vs. TF without vaulting 

TT vs. TF with vaulting 
TT vs. HD 
HD vs. TF 

HD vs. TF without vaulting 
HD vs. TF with vaulting 

Step length sound side [m] 0.69 ± 0.07 0.69 ± 0.06 0.71 ± 0.06 0.67 ± 0.05 0.70 ± 0.07 Not significant 

Step length prosthetic side [m] 0.74 ± 0.08 0.74 ± 0.08 0.66 ± 0.08 0.73 ± 0.05 0.74 ± 0.09 Not significant 

Asymmetry step length sound side - 
Prosthetic side [m] 

-0.05 ± 0.05 -0.04 ± 0.06 +0.05 ±0.07 -0.06 ± 0.05 -0.03 ± 0.07 

HD vs. TT 
HD vs. TF 

HD vs. TF without vaulting 
HD vs. TF with vaulting 

 

 

 

 

Figure 1: Top: Mean course of contralateral vertical ground reaction force (time normalized) for all three amputation levels (upper left) and 

the two subgroups, “TF with vaulting” and “TF without vaulting” (upper right). Bottom: Relevant peak values with statistical data. 

0

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TF without vaulting
contralateral

TF with vaulting
contralateral

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1.Max GRF v

TT

sound side

TF

sound side

HD

sound side

Series4

TF

sound side

without vaulting

TF

sound side

with vaulting

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GRF v: Force-rate in the first 5% gait cycle

Not significant n.s.*
**

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* *

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2.Max GRF v

C

Not significant

TT sound side TF sound side HD sound side TF sound side 

without vaulting 

TF sound side 

with vaulting 

https://doi.org/10.33137/cpoj.v8i1.44416


 

5 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X IMPACT OF AMPUTATION LEVEL AND VAULTING ON GAIT LOADING PARAMETERS 

Pröbsting et al., 2025 

In contrast, the force rate during the first 5% gait cycle 

differed significantly between all amputation levels. The 

higher the amputation level, the steeper the force rate (HDs: 

98 ± 14% BW, TFs: 79 ± 14% BW and TTs: 67 ± 15% BW). 

In conclusion, the first peak was reached earlier with higher 

amputation levels. 

Contralateral sagittal knee moments 

In the HDs group, there was a general trend towards 

increased extension moments on the contralateral knee 

compared to TTs and TFs. As the amputation level 

increased, the peak flexion moments tend to decrease, 

(TTs: -0.50 ± 0.28 Nm/kg, TFs: -0.46 ± 0.30 Nm/kg, HDs: 

0.27 ± 0.38 Nm/kg), whereas the peak extension moment 

increased (TTs: 0.51 ± 0.19 Nm/kg, TFs: 0.60 ± 0.29 Nm/kg, 

HDs: 0.76 ± 0.20 Nm/kg). The TFs without vaulting showed 

a reduced peak flexion moment (-0.28 ± 0.24 Nm/kg vs. -

0.56 ± 0.29 Nm/kg) and a reduced peak extension moment 

(0.46 ± 0.32 Nm/kg vs. 0.68 ± 0.24 Nm/kg). All differences 

are statistically not significant (Figure 2).  

Contralateral frontal knee moments 

Generally, the peak adduction moment (first peak for all 

subjects) increases with a more proximal amputation level 

(TTs: 0.51 ± 0.19 Nm/kg, TFs: 0.55 ± 0.20 Nm/kg, HDs: 0.57 

± 0.14 Nm/kg). The TFs with vaulting also show an 

increased peak compared to those without vaulting (0.57 ± 

0.22 Nm/kg vs. 0.53 ± 0.16 Nm/kg). Nevertheless, none of 

these differences show statistical significance (Figure 3). 

DISCUSSION 

The objectives of this study were to analyze the 

biomechanical impact of different lower limb amputation 

levels and vaulting on the load applied to the locomotor 

system. The higher the amputation level, the curve of the 

vertical ground reaction force becomes significantly steeper 

during the first 5% GC. The first peak of vertical ground 

reaction forces, the peak knee adduction and extension 

moments tend to be higher both in individuals with higher 

amputation level and in TF individuals with vaulting.  

 

 

 

 

Figure 2: Top: Mean course of external contralateral sagittal knee moments (time normalized) for all three amputation levels (upper left) and 

the two subgroups, “TF with vaulting” and “TF without vaulting” (upper right); Bottom: Selected peak values with statistical data. 

-0.6

-0.4

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t [% stance phase]

TF without vaulting
sound side

TF with vaulting
sound side

- External Knee Flexion Moment

+ External Knee Extension Moment

-0.6

-0.4

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+ External Knee Extension Moment

- External Knee Flexion Moment

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Max. Knee Extension Moment                                                                                

B

Not significantNot significant

TF sound side 

with vaulting 

TF sound side 

without vaulting 

HD sound side TF sound side TT sound side 

https://doi.org/10.33137/cpoj.v8i1.44416


 

6 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X IMPACT OF AMPUTATION LEVEL AND VAULTING ON GAIT LOADING PARAMETERS 

Pröbsting et al., 2025 

Peak knee flexion moments decreased with higher 

amputation levels and tended to be higher in TF individuals 

with vaulting. Individuals with lower limb amputation have 

an increased risk of developing knee joint degeneration.13 

Therefore, any increase in knee joint loading forces and 

moments is clinically relevant. For this reason, the non-

significant increases in forces and moments observed in 

this study, are still clinically important. 

Primary hypothesis: Load on the contralateral side 

increases with higher amputation level. 

During the first 5% gait cycle, the vertical ground reaction 

force increased significantly faster with a more proximal 

amputation level, although the walking speed decreased 

accordingly. This interrelation between force rate and 

walking speed is untypical. Typically, the increase in vertical 

ground reaction force becomes steeper as walking speed 

increases.30 

The prosthetic limb exhibited a reduced stance and 

prolonged swing duration. As noted by Ding et al.,31 this may 

contribute to a more abrupt “landing” on the contralateral 

limb, evidenced by a significantly greater peak knee loading 

rate and a significant increased force rate observed in this 

study. Subsequently, the first peak of vertical ground 

reaction force was increased with higher amputation level. 

This, in turn, impacted the first peak knee adduction 

moment, which was also slightly increased with higher 

amputation level, but more pronouncedly.  Based on these 

effects, it can be concluded that knee compression forces 

were also increased.32 Thus, the shortened prosthetic 

stance phase contributed to an increased load on the 

contralateral side. This should be avoided by an optimally 

aligned prosthesis, adequate prosthetic components and 

appropriate gait training. Increased knee extension, or 

rather less knee flexion moments, were identified for higher 

amputation levels, both at the beginning and at the end of 

stance. Although these peaks are not significantly different, 

a clear and systematical tendency can be observed with a 

higher amputation level. The missing significance might be 

in relation to the speed differences within each group.  

All individuals in this study, independent of their level of 

amputation, showed a prolonged stance phase duration on 

the contralateral side compared to the prosthetic side. This 

leaded to an asymmetric stance phase duration, as 

confirmed by other studies comparing TTs and TFs with 

able-bodied individuals1 and with each other.7  

 

 

 

 

 

Figure 3: Top: Mean course of external contralateral frontal knee moments (time normalised) for all three amputation levels (upper left) and the 

two subgroups, TF with vaulting” and “TF without vaulting” (upper right). Bottom: Selected peak values with statistical data. 

 

-0.2

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t [% stance phase]

TT sound side TF sound side HD sound side

A

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sound side

TF with vaulting
sound side

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Max. Knee Adduction Moment

A

Not significant

TF sound side 

with vaulting 

TF sound side 

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HD sound side TF sound side TT sound side 

https://doi.org/10.33137/cpoj.v8i1.44416


 

7 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X IMPACT OF AMPUTATION LEVEL AND VAULTING ON GAIT LOADING PARAMETERS 

Pröbsting et al., 2025 

The results of the present study confirmed the results of 

Heitzmann et al.2 and showed that asymmetric stance 

phase duration significantly differed across all amputation 

level, with TTs showing the smallest and HDs showing the 

greatest asymmetry. Therefore, the contralateral limb 

experienced comparatively higher loading over a 

significantly longer time with a higher amputation level. 

Thus, it can be assumed that the significantly longer loading 

duration, combined with the significant faster load 

transmission and higher ground reaction forces, as well as 

sagittal and frontal moments, explain the higher prevalence 

of knee osteoarthritis13 with higher amputation level. 

Consequently, the primary hypothesis of the present study 

stating that a more proximal amputation level increases the 

load on the contralateral side is confirmed by the results. 

Secondary Hypothesis: Vaulting increased the load on the 

contralateral side. 

In comparison with able-bodied individuals, prosthesis 

users experience a reduced ability to actively control the 

prosthesis with the residual limb as the level of amputation 

increases (from TT to HD), and their strategies for achieving 

ground clearance become more limited. As a result, the 

contralateral side is used more intensively for compensation 

with vaulting being the most obvious and specific strategy. 

This strategy was observed in all HDs, 63% of the TFs and 

only 12% of the TTs in the present study.  Increased vaulting 

with higher amputation level is a logical and sometimes 

necessary consequence and was already observed by 

Heitzmann et al.2  

Some highly functional and safe prosthetic components, 

e.g. more functional hip joints,6 microprocessor knee joints33 

and hydraulic ankle joints,3 support the generation of more 

ground clearance. But one of the main influencing factors is 

prosthetic alignment, specifically the anterior-posterior 

position of the knee joint axis of rotation and the foot.33 

Furthermore, people with lower limb amputation rely on the 

ground clearance provided by the prosthesis without any 

sensory feedback. The prosthesis may not perform 

optimally especially in unpredictable situations and 

therefore patient-initiated vaulting is understandable. 

Besides contralateral forefoot pain, this compensation 

strategy could lead to biomechanical consequences, such 

as higher energy consumption than able-bodied individuals 

and an asymmetric loading distribution, with increased 

ground reaction forces on the contralateral limb.21 

Furthermore, vaulting can also lead to increased ankle, 

knee and hip moments on the contralateral limb at the end 

of stance phase.7  

For a more detailed analysis of the impact of vaulting on the 

loading of the locomotor system, the TF patient group was 

divided into two groups with and without vaulting. A similar 

separation was not useful for the other amputation levels. In 

the HD group, all individuals performed vaulting. In the TTs, 

the group with vaulting was too small compared to the “non-

vaulting” group.  

The following analyzed peak values were increased for the 

TFs with vaulting: first and second peak ground reaction 

forces, first peak knee adduction moment, max. knee flexion 

and max. knee extension moment. The most obvious 

difference between the two groups was found in the sagittal 

plane. On the one hand, TFs with vaulting showed more 

stance flexion,21 which could explain the higher knee flexion 

moments in the first part of stance. On the other hand, the 

faster anterior movement of the Center of Pressure (COP)21 

and the prominent extension of the knee joint at the end of 

stance21 could explain the increased extension 

moments.7,21  

Generally, walking speed influences the magnitude of joint 

moment peaks,34 and the TF group with vaulting walked 

0.06m/s faster than non-vaulting group. According to Lelas 

et al.,34 this speed difference could explain an increase in 

the peak knee flexion moment by 0.02 Nm/kg and the peak 

knee extension moments by 0.003 Nm/kg.  However, the 

difference in the peak knee flexion moment between the two 

groups of TFs was 0.20 Nm/kg and the difference in the 

peak knee extension moment was 0.22 Nm/kg, both of 

which were more pronounced.  Therefore, the increase of 

knee joint moments for TFs with vaulting can be clearly 

attributed to this compensatory motion. Nevertheless, the 

secondary hypothesis that vaulting influences the load on 

the contralateral side can be confirmed to a certain extent 

as the results were not statistically significant, but were 

clinically relevant for patients showing unusually high loads.  

Limitation 

The limitations of this study were, on the one hand, the 

different number of subjects with the respective amputation 

levels. The small number of people with HD amputation was 

a particular limitation in this study. On the other hand, 

determining the effect of vaulting was challenging when 

comparing two different cohorts of people with TF 

amputation, as individual knee moment heights were highly 

subject-specific. In order to reduce the latter limitation, an 

analysis of able-bodied individuals walking with and without 

vaulting should be conducted in future studies. This could 

provide a more detailed understanding of the specific effect 

of vaulting on knee joint moments. 

CONCLUSION 

In summary, the loading of the contralateral limb increases 

with higher amputation level. The increase of knee loading 

is caused by the reduced stance duration of the amputated 

side with a fast force transmission onto the contralateral 

side in the first phase of stance. The effect of vaulting as a 

compensation pattern leads to an additional increase of 

https://doi.org/10.33137/cpoj.v8i1.44416


 

8 

Pröbsting E, Schmalz T, Bellmann M. Impact of amputation level and vaulting on loading parameters during level ground walking. Canadian Prosthetics & Orthotics 
Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X IMPACT OF AMPUTATION LEVEL AND VAULTING ON GAIT LOADING PARAMETERS 

Pröbsting et al., 2025 

contralateral limb loading. As the level of amputation 

increases, the ratio of vaulting in amputees increases, 

which means that the contralateral load also increases with 

the level of amputation. Therefore, the aim of gait training, 

prosthetic alignment and the selection of prosthetic 

components should support a more symmetric gait without 

or with only moderate compensatory vaulting patterns. 

ACKNOWLEDGEMENTS 

The authors thank the participants whose data were retrospectively 

analyzed for their valuable contribution. 

DECLARATION OF CONFLICTING INTERESTS 

Eva Pröbsting, Thomas Schmalz and Malte Bellmann are 

employees of Ottobock, the manufacturer of prosthetic 

components. The authors alone are responsible for the content and 

writing of the paper. 
 

AUTHORS CONTRIBUTION 

• Eva Pröbsting: Investigated, analyzed the data and wrote the 

manuscript. 

• Thomas Schmalz: Investigated, analyzed the data and 

reviewed   

• Malte Bellmann: Investigated, analyzed the data and 

reviewed. 

 

All  authors  have  read  and  approved  the  final  version  of the 

manuscript.  

 

SOURCES OF SUPPORT 

The authors received no support. 

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Journal. 2025; Volume 8, Issue 1, No. 2. Https://doi.org/10.33137/cpoj.v8i1.44416  

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

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Pröbsting et al., 2025 

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