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The Biomechanics of Cycling with a Transtibial Amputation:

Recommendations for Prosthetic Design and Direction for Future Research

Article  in  Prosthetics & Orthotics International · October 2009

DOI: 10.1080/03093640903067234 · Source: PubMed

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Prosthetics and Orthotics International
September 2009; 33(3): 256–271

The biomechanics of cycling with a transtibial amputation:

Recommendations for prosthetic design and direction for
future research

W. LEE CHILDERS, ROBERT S. KISTENBERG, & ROBERT J. GREGOR

School of Applied Physiology, Georgia Institute of Technology, Atlanta, Georgia, USA

Abstract
People with amputations may find cycling advantageous for exercise, transportation and rehabilitation.
The reciprocal nature of stationary cycling also makes it a viable model for research in motor control
because the body is supported by the saddle allowing the researcher to focus on the cyclic movement
of the legs without the confounding variable of balance. The purpose of this article is to provide an
overview of the cycling task in intact cyclists and relate this information to understanding the
challenges faced by cyclists with transtibial amputations (CTA). Ongoing research into the
biomechanics of CTAs will be summarized to expose the differences between intact and CTA cycling
mechanics, asymmetries between limbs of CTAs as well as neuromuscular adaptation following
amputation. The article will include recommendations for prosthetic design and modification of the
bicycle to improve cycling performance for CTA at all experience levels.

Keywords: Prosthetic design, biomechanics of prosthetic/orthotic devices, prosthetic feet,

rehabilitation of amputees, amputation, motor control, cycling

Introduction
People with amputations may find cycling advantageous for exercise, transportation and
rehabilitation. The cycling task provides an opportunity to maintain cardiovascular health
and overall fitness1 without exposing either limb to the large impact loads associated with
walking or running.2 The reciprocal nature of stationary cycling, for example, makes it a
viable method for use in neuromuscular and orthopedic rehabilitation because the body is
supported by the saddle allowing the researcher/clinician to focus on the cyclic movement of
the legs without the confounding variable of balance. The ability to reduce and control
important variables during the cycling task also allows the researcher/clinician to investigate
several aspects of how the motion is controlled (motor control).
Control of the cycling task involves integration of both the neuromuscular and
musculoskeletal systems. This includes the appropriate timing of muscle activation in order
to manage loads imposed on each joint,3 the transfer of energy between joints4 and
imparting energy to the cranks5 for propulsion. The strategy utilized then, must take into
account each muscle’s functional role6–8 in controlling this task. To better visualize the

Correspondence: Walter L. Childers, MS Prosthetics and Orthotics, Applied Physiology, Georgia Institute of Technology, 281 Ferst
Drive, Atlanta 30332-0356, USA. E-mail: lee@gatech.edu

ISSN 0309-3646 print/ISSN 1746-1553 online Ó 2009 ISPO

DOI: 10.1080/03093640903067234
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 Special Sports Edition Biomechanics of transtibial amputee cycling 257

various stages of this task many investigators have broken up the pedal stroke into four
quadrants (Figure 1). While each cycle is part of a continuum of demands, understanding
the different control requirements during each quadrant and how those requirements are
met by coordinated activation of key muscles (Table I) is crucial. However, before one can
understand the challenges faced by a cyclist with a transtibial amputation (CTA), one must
understand these aspects of an intact cyclist and how that cyclist meets those challenges.
The purpose of this article is to provide a foundation of knowledge regarding the
challenges faced within the pedal cycle, to have the reader better understand the task of
cycling (Figure 2) and finally to better relate this information to understanding the challenges
faced by a CTA. Recent ongoing research into the biomechanics of CTAs is summarized to
expose the differences between intact and CTA cycling mechanics, asymmetries between
limbs of unilateral CTAs as well as neuromuscular adaptation following amputation. The text
includes recommendations for prosthetic design and modification of the bicycle to improve
cycling performance for CTA at all experience levels. These recommendations are derived
from experimental data from multiple studies, computer simulations, and personal
experiences of the authors. The article concludes with possible directions for future
research into the biomechanics of CTAs. All human subjects who participated in studies
associated with this article provided a separate written informed consent and participated in
protocols approved by the Institutional Review Board.

Review of the biomechanics of intact cycling

The top of the pedal stroke
The top of the pedal stroke is a transition area and occurs from approximately 315–458
relative to 08 or top dead center of the crank (TDC) (Figure 1). The pedal is traveling from
posterior to anterior while transitioning from moving superiorly to inferiorly. To get through
the top of the stroke the leg must direct force forward while preparing for the power phase
(Figure 2). Effective application of force to the pedal during this phase is difficult but critical
to the transition and development of an effective power phase. The Rectus Femoris (RF), for
example, is active trying to flex the hip and extend the knee to direct forces anteriorly. To
prepare for the power phase, the Gluteus maximus (GM) and Vasti (VAS) start to activate
just before TDC while the hamstring group (HAM) begins activity to aid in hip extension.

Figure 1. Pedal stroke quadrants. Zero is defined as when the crank is vertical or at top dead center (TDC). The top
of the stroke is from 315–458. The power phase is from 45–1358. The bottom of the stroke is defined as 135–2258.
The recovery phase is defined as 225–3158.

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258 Special Sports Edition W.L. Childers et al.
Table I. Major lower limb muscles involved in cycling, the motions they produce and their major functions to
performance of the cycling task.

Corresponding
abbreviation Motion the muscle
Muscle in Figure 2 produces Major function in cycling

Tibialis anterior TA Single joint ankle flexor Stabilize ankle during bottom
(dorsiflexor) and recovery phases
Soleus SOL Single joint ankle extensor Stabilize ankle during power phase
(plantarflexor)
Gastrocnemius GAS Two joint knee flexor and Stabilize ankle and direct pedal
ankle extensor forces during power and bottom phases
Quadriceps (Vasti) VAS Single joint knee extensor Major power producing muscle group
Rectus femoris RF Two joint hip flexor and Direct force at the top of the stroke
knee extensor and produce power during power phase
Hamstring group HAM Two joint hip extensor Direct forces during power and bottom
and knee flexor phases
Iliopsoas IL Single joint hip flexor Possibly aids to lift leg during recovery
Gluteus maximus GM Single joint hip extensor Major power producer

Figure 2. Schematic of the lower limb showing representative muscle activity of the lower limb, direction and
magnitude of the force at the pedal, and limb positions in the four different quadrants of the pedal stroke. Muscle
activity within each quadrant is indicated by the thickness and shade of the lines. Muscles may be very active (thick
black), moderately active (thin black) or not active (thin grey). Numbers around the pedal arch denote the start and
stop of the respective quadrant in crank degrees relative to TDC. Magnitude of the force vector corresponds to its
length defined by the schematic key. Values for limb orientation, muscle activation and force production are derived
from experimental data on an intact cyclist operating at 200 watts and 90 rpm. Refer to Table I for a summary of
each major muscle group and their function during cycling.

The power phase

The power phase is where the body must produce enough force to overcome the
resistance at the pedal as well as to help lift the opposite leg during its recovery phase.
During this phase about 90% of the total power is imparted to the bicycle. The GM and
VAS are generating most of the force seen at the pedal during this time. The ankle

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 Special Sports Edition Biomechanics of transtibial amputee cycling 259

extensors (plantarflexors) activate to stabilize the ankle and allow the energy generated by
the larger more proximal muscles to be transferred to the pedal and ultimately rotate the
crank.

The bottom of the pedal stroke

The bottom of the pedal stroke is another transitional region of the pedal cycle. The HAM,
Gastrocnemius (GAS) and Tibialis anterior (TA) are all active in this phase. The TA is active
to stabilize the ankle so that tension developed in the GAS may be transferred to the knee
joint to assist the HAM with knee flexion.9 In CTA, the ankle is either absent or prosthetically
simulated and thus cannot be stabilized by active muscular contraction. Furthermore, the
GAS has been surgically changed to a single-joint knee flexor and can only act upon the
knee joint concentrically (if at all) to aid in directing forces during this portion of the pedal
cycle. Note: The large downward forces during this phase (Figure 2) are due to the inertia of
the heavy limb being redirected from moving inferiorly to a superior direction and are not
derived directly from muscular activation. Muscle activation during this phase is needed to
direct as much of this force posteriorly.7

The recovery phase

This phase occurs when the pedal has cleared the bottom and is now ascending back
toward TDC. As the name implies, this phase of the crank cycle is intended for recovery of
several extensor muscle groups. During this phase, the Vastii show no appreciable activity.
The TA and the Iliopsoas (IL) are most active3,10 with the TA assuming two functions: (i) To
stabilize the ankle for force transfer from hip flexor muscles, and (ii) to start dorsiflexing the
ankle thereby allowing more clearance for the limb during the top of the stroke. This cannot
be accomplished in CTA. Their prosthetic ankle cannot actively dorsiflex through TDC for
limb clearance thus creating the need for accommodation through increased hip and knee
flexion for these cyclists. The RF will begin activity during the end of this phase aiding in hip
flexion, while preparing for the top of the pedal cycle.
The power during this phase is negative, i.e., power is being absorbed (Figure 3) because
the forces during this phase are directed inferiorly (Figure 2). From the standpoint of
mechanical effectiveness, this phase of power absorption may seem inefficient to the casual
observer. However, there is a difference between mechanical effectiveness and metabolic
efficiency. Mechanical effectiveness is the ratio between the total force seen at the pedal
and the force directed to turn the cranks. In cycling, inertial and gravitational forces of a
heavy (*18 kg) spinning leg are large and generally directed inferiorly (impeding rotation)
during the recovery phase.11 The two limbs are coupled by the cranks so that while one limb
is in recovery, the other is in its power output phase. In order to generate the same baseline
power, the flexor groups of the ascending limb must increase muscular activity 1.1 to 3.4
beyond baseline performance and increase the whole body metabolic demand by 9%12 to
overcome these gravitational and inertial forces to pull the foot up faster than it is being
‘pushed’ up by the opposite limb. Attempting to ‘pull up’ and generate positive power during
this phase will increase mechanical effectiveness but at a high metabolic cost13 regardless
of cycling experience and pedal type.12 Korff et al. (2007) studied the energy requirements
of different pedaling techniques and reported that the cyclist’s ‘preferred technique’ was the
one most metabolically efficient, and that consciously altering this technique, e.g., ‘pulling
up’, resulted in a decrease in metabolic efficiency. This was the case even when the cyclists
were ‘pulling up’ as they remained unable to generate positive power during this phase.

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Figure 3. Exemplar Mean Power (dark line) of five continuous crank cycles + 1 standard deviation (thin line)
developed about the crank spindle during the pedal stroke. Data derived from one limb of an elite cyclist pedaling at
200 watts and 90 rpm. Note the large positive impulse during the power phase (45–1358) and the negative impulse
during the recovery phase (226–3158).

Attempting to ‘pull up’ will certainly reduce the demand on the opposite limb but the costs
appear to outweigh any possible benefits available at least to intact cyclists.12

Biomechanics of cyclists with transtibial amputation

Cycling with transtibial amputation poses significant challenges resulting from the loss of the
ankle joint structure, the muscles that control that joint, and the sensory input from the joint
and surrounding musculature followed by alteration of muscle properties within the remaining,
more proximal muscles.14 These challenges are further compounded because CTAs must
interact with their environment through a prosthetic limb on one side and an intact limb on the
other. The geometric asymmetry between limbs contributes to asymmetric work (torque)
production seen in cyclists with a uni-lateral CTA.15,16 In one report, in eight CTAs work
asymmetry was seven times greater than in a control group of nine intact cyclists.15 Work
asymmetry occurs when one limb has difficulty producing and/or directing forces
appropriately.17 This asymmetry could be related to multiple factors beyond a strength or
mass difference between limbs15 and may even represent a change in the motor control
strategy used by the body to accomplish this task. Further research is needed to clarify what
strategy CTAs utilize for propulsion, the underlying causes of this different strategy, and what
affects that strategy. Increasing our understanding of how the body changes its strategy for
locomotion following amputation is crucial for the design of improved rehabilitation programs.

EMG patterns in CTAs

Muscle activation patterns in one- and two- joint muscles generally reflect their
biomechanical role in movement control.7 Lower limb loss will affect the role played by
individual muscles in limb control. The GAS muscle is altered following transtibial
amputation, i.e., relegated to a one-joint knee flexor, while the more proximal, non-

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 Special Sports Edition Biomechanics of transtibial amputee cycling 261

amputated, muscles retain their anatomical attachments. Analysis of muscle activation

patterns collected using surface electromyography (sEMG) in six CTAs revealed that the
neuromuscular system shifted activation in three amputated GAS muscles to later in the
pedal cycle (Figure 4). This shift in timing appears to be more appropriate for the muscles’
new role as a single joint knee flexor. The other three subjects showed almost no activation.
Reasons for this lack of activation could be related to the surgical procedure, signal artifact
of the electrode rubbing the socket, nerve damage and/or excessive scaring of the residual
limb. When the remaining GAS was utilized by the CTA and those signals were collected,
the neuromuscular system adapted to the change in muscle function to utilize the muscle in
its new role as a single joint knee flexor.18
Other changes observed in CTA include: (i) Increased variability in the activity patterns of
two-joint muscles in the sound and amputated limb compared to intact cyclists, and (ii) the
GAS in the sound limb increased its duration of activity.18 These results help explain the
asymmetries observed between the two limbs as prolonged activation of the GAS will help
apply more force effectively during the bottom of the pedal stroke, thereby helping the
ineffective amputated side through the top of the pedal stroke. The increases in muscle
activation variability observed in the two joint muscles in CTAs18 may also reflect difficulty in
energy management across multiple joints4 and/or failure of the neuromuscular system to
integrate sensorimotor information into the modified neural control system.19,20 Additional
research is necessary before these issues can be fully understood.

Recommendations for adaptation of the bicycle and cycling prosthesis design

Bicycle positioning
How the body interacts with the bicycle is affected by changes in body position.21–23 The
location of the saddle in relation to the crank spindle, the handlebar and the pedals defines
the constraints imposed on the neuromuscular system to energize the bicycle. For example,

Figure 4. Average sEMG of the Gastrocnemius (GAS) muscle from the sound (dashed) and amputated (solid) limbs
showing a shift in activation to later in the crank cycle for the amputated GAS. sEMG signals were pre-amplified and
bandpass filtered (3 db at 8 and 550 Hz), RMS was taken, averaged across 15 cycles and normalized to the
maximum value. The sound limb data was derived from six CTA while the amputated limb data was derived from
three CTAs.

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262 Special Sports Edition W.L. Childers et al.

alterations in saddle height will partially determine the functional joint range of motion
(ROM), and thereby determine the range of muscle lengths and available contraction
velocities.24 Saddle height alterations also affect the location of the center of mass and thus
the bicycle handling characteristics.23 These interactions between multiple body segments
and the bicycle however, are complex and beyond the scope of this article. The reader is
encouraged investigate this topic further through textbooks24 and lay publications23,25 to
better understand clinically acceptable practices for bicycle fitting.
Experience gained with CTA athletes suggests that following published guidelines for
intact cyclists25 is appropriate when no comorbitities exist. However, comorbitities and
limitations in joint ROM are common following an amputation.26 These will affect the position
of the body thereby making the cycling task more complicated. It is recognized that the
prosthetist’s expertise lies with the alignment of the prosthesis for walking but the alignment
of the prosthesis in conjunction with the alignment of the body on the bicycle incurs different
and more complex challenges. When a person with a trans-tibial amputation desires to
cycle, it is recommended that the clinician pair with someone trained and skilled in bicycle
fitting25,27 to produce the best clinical outcome. The interactions of the body and its position
on the bicycle are very complex even in intact, non-symptomatic patients and overuse
injuries have been associated with poor positioning.24,25 These interactions are implicitly
more complicated by the introduction of a prosthesis so the clinician should proceed with
caution when fitting someone that wishes to cycle.

The effect of crank shortening

Shortening the crank on the amputated side will help reduce the geometric asymmetries
between the two lower limbs of a CTA. The intact ankle in the sound limb actively
plantarflexes at the bottom of the pedal stroke and dorsiflexes at the top.5 Prosthetic ankles
lack the ability to actively move and thus the amputated side can either compensate by
increasing knee range of motion (ROM) and/or by greater movement at the hip joint. An
increase in knee ROM would be accomplished by over extending at the bottom and being
more flexed at the top of the cycle.28 Inferior translation of the hip joint could prevent
increased extension of the knee joint at the bottom of the crank cycle but may create
irritation between the saddle and soft tissues of the cyclist. Shortening the crank on
the amputated side brings the pedal closer at the bottom and further away at the top of the
stroke making demands on the affected side knee ROM similar to the intact side while
reducing the need for hip joint movement. A computer program has been calibrated with
experimental data collected on an intact cyclist to simulate the kinematics of a CTA cycling
with and without a shortened crank (Table II). Preliminary work completed in three CTAs to
evaluate the effects of shortened cranks showed a reduction in work asymmetry in two
CTAs while one CTA showed no change (Table III). Work asymmetry is the difference in
work or torque production between the two limbs. Work asymmetry is calculated using
instrumented pedals that measured the magnitude and direction of force produced at the
foot/pedal interface of each limb.17 A reduction in work asymmetry indicates the sound limb
had to contribute less work to turn the pedals. Despite the reduction of work asymmetry with
the shorter crank in two out of three subjects, no experimental data was taken on limb
kinematics thus no conclusions can be drawn as to whether a reduction in knee ROM or hip
joint translation occurred as predicted by the computer simulation. Furthermore, experience
gained working with CTA cyclists showed that most inexperienced CTAs report an increase
in comfort while more experienced CTAs (þ10 years’ experience) report initially use of a
shortened crank arm but later converting back to symmetrical crank arms as they better

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 Special Sports Edition Biomechanics of transtibial amputee cycling 263
Table II. Hip and knee angles derived from a computer simulation showing changes in limb kinematics by shortening
the crank arm 15 mm. Hip angle defined as the included angle between the thigh and horizontal. Knee angle
defined as the included angle between thigh and shank segments. The model was calibrated to experimental data
of an intact cyclist pedaling at 200 watts and 90 rpm. The amputated limb was simulated by eliminating ankle
motion. Hip joint translation was assumed to be similar in all conditions.

Hip angle (degrees) Knee angle (degrees)

Condition Minimum Maximum ROM Minimum Maximum ROM

Sound limb 14 57 43 65 133 68

Amputated limb with symmetrical crank arms 10 56 46 64 135 71
Amputated limb with 15 mm shorter crank arm 12 53 41 67 129 63

Table III. Results of unpublished pilot work performed on CTA comparing work asymmetry (defined as a percent
difference between the contributions of each limb to total work output) with symmetric crank arms and a 15 mm
shorter crank arm on the amputated side. Two of the three CTA showed a reduction of asymmetry while the third
showed no change.

Subject Work asymmetry with symmetrical Work asymmetry with 15 mm

number crank arms (%) shorter crank arm on the amputated side (%)

1 15.0 7.0
2 30.0 20.8
3 20.8 20.8

adapt to cycling. Again, more research is necessary before a clear clinical recommendation
can be made. Adaptation of the bicycle to a shorter crank can be achieved by obtaining a
crank shortening adapter29 available through local bike shops (Figure 5).

The role of the prosthetic foot in cycling

The stiffness of the prosthetic foot influences cycling performance at high intensities (90%
max heart rate) but not at low intensities, i.e., more recreational level intensities (70% max
heart rate).30 Cycling with an intact lower limb requires activation of the triceps surae and
tibialis anterior muscles to stabilize the ankle so that energy generated by the knee and hip
extensors may be transferred to the pedal.3 While triceps surae and tibialis anterior muscle
activation is necessary in walking, for example, for ankle stability, braking and propulsion,31
these prosthetic feet are designed to mimic the ankle/foot complex during walking, i.e.,
allowing it to compress and store energy at initial contact then decompress and release that
energy at toe-off. Forces and the timing of those forces are different between walking and
cycling however, requiring a prosthetic foot be designed to meet the specific demands of
cycling.
In cycling, the compressive forces used to store energy in a prosthetic foot are derived
from muscular sources being used to turn the crank during the power phase. Then at the
bottom of the stroke, these vertical forces are removed to allow the foot to decompress and
release energy. The problem with a flexible prosthetic foot is that it requires muscular forces
to compress it during the power phase thus removing energy that should be transferred to
the cranks. The foot decompresses during the bottom of the pedal stroke. The forces during
this phase are directed ineffectively to produce torque. Figure 2 shows limb orientation as
well as the scaled magnitude and direction of typical forces at the foot/pedal interface during

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Figure 5. Example of a commercially available adapter to shorten the crank arm on the prosthetic side while moving
pedal out laterally to increase clearance between the prosthetic heel and the crank. Photograph shows a frontal
view of the installed bracket on a crank arm with a pedal (bottom left) as well as the bracket uninstalled (top right).
This bracket allows for four different crank arm lengths and may be easily removed and installed on many different
bicycles.

the power phase (when the foot is being compressed) and the bottom of the pedal stroke.
The use of a flexible prosthetic foot results in energy removed from the crank cycle and not
returned in an effective manner.
The energy removed from the crank by the flexible prosthetic foot requires compensation
from the sound limb to increase its output in order to meet task demands. The result is an
increase in pedaling asymmetry.15 Furthermore, we have found that the increases in torque
asymmetry are only apparent at higher cycling intensities. Cycling at lower intensity requires
lower normal forces which in turn may not be sufficient to compress the prosthetic foot to
create a noticeable asymmetry. Thus, for a cyclist in a rehabilitation setting or cycling for
recreation, the stiffness of the prosthetic foot has little effect. It is not until the cyclist is
operating at higher; more competitive intensities that an energy storage and return (or
dynamic response) type prosthetic foot will begin to have a negative impact on their
performance.

Combination of a shortened crank arm and a stiff prosthetic foot

Pilot work to optimize cycling performance in a Para Olympian cyclist was performed to
minimize work asymmetry. The flexible prosthetic foot was removed and the cycling cleat
was placed at the end of the pylon via a custom aluminum bracket. The anterior-posterior
position of the cleat was maintained between both limbs at the 1st metatarsal head. The
crank arm on the amputated side was shortened 15 mm. Work asymmetry was initially at a
30% difference between limbs meaning that the sound limb contributed 65% of the work
while the amputated limb contributed 35% of the work. Work asymmetry was reduced with

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 Special Sports Edition Biomechanics of transtibial amputee cycling 265

the stiff foot and the shorter crank to a 7% difference between limbs. There was also a
corresponding reduction in HAM and GAS activity within the sound limb. The combination of
a stiff foot interface along with a shorter crank arm reduced the work asymmetry to a level
similar to intact cyclists15,17,30 for this elite level athlete. It is not known however, if these
results can be generalized to more recreational cyclists.

Foot/pedal interface for cyclists with amputations

Attaching the prosthetic foot to the pedal is necessary in order to keep the prosthetic foot in
contact with the pedal throughout the pedal cycle. Several methods could be used to secure
the foot to the pedal and pedal selection is a balance between the levels of security vs. the
cyclist’s ability to remove the foot in an emergency. The easiest, yet least secure, method is
to use a studded BMX pedal with a soft soled shoe (Figure 6). Other methods include using
Velcro1 between the pedal and shoe, a neoprene strap or commercially available clipless
pedal systems (Figure 6). Although all clipless pedal systems have been used successfully
by CTAs, some are better than others. Using a double-sided mountain bike system allows
the use of a cycling shoe with a recessed cleat that will ease walking off the bicycle. It also
allows the cyclist to clip into either side of the pedal whereas most road pedal systems only
allow access on one side. The pedal system should require 208 or less of axial rotation
(known as float) to ease cleat disengagement.
The cylindrical shape of the residual limb allows for poor rotational control and thus may
limit the cyclist’s ability to axially rotate the limb for disengagement of the pedal. When using

Figure 6. Four examples of different bicycle pedals suitable for CTA. A studded BMX pedal (top left) provides the
least foot/pedal security while being the easiest to dismount the bicycle. A LOOK brand road pedal (top right)
provides a more secure method to attach the foot to the pedal but only allows entry on one side. The bottom two
clipless pedal systems from Shimano (bottom left) and Crank Brothers (bottom right) are designed for mountain
biking and allow entry on either side. A pedal designed for mountain biking also us a smaller cleat that may be
recessed in the cycling shoe to ease walking off of the bicycle.

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a clipless pedal system, it is recommended that the cyclist clip in their amputated limb first,
push off with that limb and then clip in the sound limb once they are moving. To unclip, it is
recommended that the sound limb unclip first, the cyclist stops, moves their body toward the
front of the bike, fully extending their still ‘clipped in’ amputated limb and use internal/
external hip rotation to unclip (Figure 7). This technique has also been successful for people
cycling with AFOs or limited ankle motion.

Prosthetic foot to crank clearance

The prosthetic foot should be aligned with no toe out as it creates a clearance problem
between the prosthetic heel and the crank arm. If the individual utilizes their walking
prosthesis for cycling that has been aligned with a toed out prosthetic foot, it is suggested
they outset the pedal laterally using a pedal spacer32 available at local bike shops
(Figure 8). The use of these spacers may also be used to alter medial-lateral tracking of
the knee in the frontal plane during cycling. Medial-Lateral alignment should consider
individual comfort and allow the knee to track vertically over the pedal.25 Medial-lateral
deviation during the pedal stroke may increase varus/valgus knee moments24 and
predispose the cyclists to knee pain.24,25 Increasing varus/valgus knee moments may also
result in irritation of the residual limb on the medial or lateral condyle of the knee and the
distal tibia.

Figure 7. Diagram demonstrating a technique to disengage clipless pedals for cyclists with amputation. As the
cyclist comes to a stop, they should disengage their sound limb and place on the ground for stability (left panel). The
cyclist should then move their trunk toward the front of the bicycle while fully extending their amputated limb (right
panel). Finally, to disengage, the cyclist may use internal or external rotation of their hip (arrows in left panel). There
are other techniques to disengage clipless pedal systems the cyclist may adopt later but this is an example of a
technique the cyclist may use initially. This technique works well for any cyclist with limited ankle mobility.

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 Special Sports Edition Biomechanics of transtibial amputee cycling 267

Anterior-posterior cleat placement and effective prosthetic length

Anterior-posterior (A-P) placement of the cleat does not affect metabolic efficiency in
intact cyclists33 or CTA34 but will affect muscle activation of the GAS, SOL and TA in
intact cyclists.35 Minimization of muscle activation of these muscles occurred at or
just posterior to the 1st metatarsal head and reflect established guidelines for intact
cyclists.25

Figure 8. An example of a commercially available spacer to outset the pedal laterally and increase clearance
between the prosthetic heel and the crank arm when a walking prosthesis is being used for cycling and heel/crank
clearance is a problem. The crank arm shortening adapter (Figure 5) will also outset the pedal. Spacer pictured with
a Shimano SPD mountain bike pedal (Figure 6).

Figure 9. Diagram describing the difference in effective prosthetic length for cycling and walking. Effective
prosthetic length in cycling is from the knee center to the cycling cleat. Effective prosthetic length should be
matched to the sound limb. For example, if the cleat on the sound limb is positioned at the 1st metatarsal head
yet the cleat on the prosthesis is positioned posteriorly then the prosthesis should be lengthened to minimize
geometric asymmetries.

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Figure 10. Exemplar data for effective leg length during the crank cycle of the sound limb (dashed line) and a
prosthesis (solid line) using a flexible dynamic response type prosthetic foot. The horizontal line at 550 mm
represents the effective leg length of the sound limb when the ankle is in the neutral position for this particular
CTA. Cleat location for both limbs is approximately the 1st metatarsal head. Effective leg length in cycling is
measured from knee joint center to the center of the cycling cleat. Increases in effective leg length indicate the
ankle is extending. Note: Although the prosthetic foot allows movement, is not similar to the sound limb in both
amplitude and phase. Therefore allowing ankle motion in the prosthetic foot will not replicate the motion of the
sound limb during cycling. Data derived from a CTA subject operating a 350 watts and 125 rpm during a
simulated time trial.

In CTA the A-P location of the cleat will determine the overall socket flexion/extension
angle as well as determine the effective prosthetic length. The effective prosthetic length in
cycling is different than walking. In walking, the effective length is the distance from the knee
center to the bottom of the heel while in cycling, the end point is the pedal spindle and not
the heel. Therefore, effective prosthetic length for cycling should be measured from the knee
center to the centerline of the cycling cleat (Figure 9). Furthermore, the effective prosthetic
length should be set similar to the sound limb to minimize geometric asymmetries. However,
the sound limb ankle can actively move thus constantly changing this length throughout the
pedal cycle (Figure 10). The same computer model used to analyze crank arm lengths28
was used to analyze the kinematics of effective prosthetic length changes. A compromise
was made so that if the effective prosthetic length was similar to the sound limb when the
ankle was in the neutral position, kinematic asymmetries were minimized. These results
however, should be used with caution as there is currently no experimental data to help
determine optimal A-P placement of the cycling cleat or the complex interaction between A-
P placement and effective prosthetic length. It is therefore left to the clinician and cyclist to
make the best clinical judgment.

Suspension selection for cycling

Suspension selection for cycling varies according to cyclist preference and experience and
generally reflects what is utilized for the walking prosthesis. Although suction suspensions
have been used successfully, the increased bulk of the system needs to be considered. The

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 Special Sports Edition Biomechanics of transtibial amputee cycling 269

prosthetic liner plus suspension sleeve will reduce knee ROM and create potential problems
between the posterior aspect of the knee and the posterior trimline of the prosthesis.
However, there has been no systematic evaluation of different suspensions and the
problems (if any) associated with their use in cycling.

Cycling with bilateral transtibial amputations

A cyclist with bi-lateral transtibial amputations allows for alteration of the femur to shank
ratio. Pilot work on a bi-lateral transtibial cyclist for triathlon competition was completed to
optimize this relationship. Increasing the overall limb length requires raising the saddle
thereby raising the center of gravity of the cyclist. This may create problems with bicycle fit
and stability. Shortening the limb length increased stability but creates more knee flexion
and ROM. An effective prosthetic length of 0.93 times the thigh length provided the best
compromise between kinetic and kinematic variables. This ratio is similar to the average
intact population.36

Conclusion
The cycling task provides a method for rehabilitation, exercise and investigations into motor
control for people with amputation. This article provides a background in how intact persons
cycle, the challenges faced by cyclists with amputation and how those challenges result in
pedaling asymmetries. A change in motor control strategy is suggested as a cause of the
asymmetries yet more research is warranted before a complete understanding of how this
strategy differs from the sound limb or intact cyclists. This article provides recommendations
on how the bicycle and the prosthesis may be adapted to improve cycling performance.
These adaptations may be different for competitive and recreational cyclists. For
competitive cyclists, a stiff prosthetic foot is recommended. Recreational cyclists may
utilize their walking prosthesis if the pedal is moved laterally to allow clearance between the
heel and the crank arm. Both groups may benefit from using a shorter crank arm on the
amputated side as well as a commercially available clipless pedal system. It is
recommended that the prosthetist team up with an experienced bicycle fitter to help with
the complex problems of body positioning. Many questions still remain regarding the affect
of different prosthetic alignment on cycling performance and will require additional research.
Continuing efforts will help provide solutions to optimize prosthetic wearer outcomes for both
recreation and rehabilitation.

Acknowledgments
The authors gratefully acknowledge Warren Mays, CPO, for his review of the manuscript,
Peter Harsch, CP, and Bob Gailey, PhD PT, for their advice and support during the writing of
this manuscript, Laura Clark Jones, Rob MacDonald, and Chris Hovorka for their help in
data collection. The authors also acknowledge the incredible support from the students,
faculty and staff of the School of Applied Physiology as well as the patience of all the
subjects that participated in these research studies. We would also like to thank Ossur,
Prosthetic Design Inc., Outback Bicycles and Serotta Bicycles for their donation of
prosthetic components and bicycle equipment.

Declaration of interest: The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.

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270 Special Sports Edition W.L. Childers et al.

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