431625

2012
POI36110.1177/0309364611431625Eshraghi et al.Prosthetics and Orthotics International

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Review
Prosthetics and Orthotics International

Pistoning assessment in lower 36(1) 15–24

© The International Society for
Prosthetics and Orthotics 2012
limb prosthetic sockets Reprints and permission:
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DOI: 10.1177/0309364611431625
poi.sagepub.com

Arezoo Eshraghi1, Noor Azuan Abu Osman1, Hossein

Gholizadeh1, Mohammad Karimi2 and Sadeeq Ali1

Abstract
Background: One of the main indicators of the suspension system efficiency in lower limb prostheses is vertical displacement
or pistoning within the socket. Decreasing pistoning and introducing an effective system for evaluating pistoning could
contribute to the amputees’ rehabilitation process.
Objectives: The main objective of this study was to review existing research studies that examine the occurrence of piston-
ing in lower limb prosthesis with different techniques in static (standing) and dynamic (walking and jumping) positions.
Study Design: Literature review.
Methods: Keywords related to slippage, suspension, pistoning and vertical movement in lower limb prosthetics were used
to search the literature available in PubMed, ScienceDirect,Web of Science and Google Scholar databases. Sixteen articles
were selected for further analysis according to the selection criteria.
Results: The following methods have been used to measure the occurrence of pistoning in prosthetic limbs: radiological
methods, photographic technique, motion analysis system, sensor and spiral computerized tomography (CT). Pistoning
was measured both in standing and walking.
Conclusions: The results of this review reveal that further research is needed to develop and evaluate easy, accurate and
safe methods of measuring pistoning. Future studies should provide a gold standard for the acceptable range of pistoning
in a prosthetic socket.

Clinical relevance
This literature review contributes to a further understanding of lower limb prosthetic biomechanics by highlighting the
strengths and weaknesses of the techniques that are currently available for evaluating the occurrence of pistoning in a
prosthetic socket. It provides a useful overview of the current methods of measuring residual limb movements relative to
the socket and liner, and will be of use for both practitioners and researchers in prosthetics and orthotics fields.

Keywords
Prosthetic design, prosthetics, rehabilitation of prostheses users
Date received: 17 May 2011; accepted: 8 November 2011

Background The suspension system and socket fit utilized in prosthetic

Suspension systems are utilized as a means of attaching
upper and lower prosthetic limbs to the body.1–3 There are
several different systems available for lower limb prosthe-
ses, which include cuff, supracondylar/suprapatellar socket
(SC/SP), rubber sleeve, elastomeric liners, suction socket
and elevated vacuum. In addition, recent developments in
osseointegration allow the direct attachment of prosthetic
components to the residual limb,4–10 which will not be con-
sidered in this review study. Prosthetists are required to
determine the suitability of a suspension system by consid-
ering the level of amputation, the residual limb condition
and the amputee’s average activity levels.
devices play significant roles in the prosthetic function, the
patient’s mobility and the amputee’s overall satisfaction with
a device.11–14 According to research findings and amputees’
statements, prosthetic fit and suspension are closely interre-
lated in terms of both the levels of comfort experienced by
1University of Malaya, Kuala Lumpur, Malaysia
2Isfahan University of Medical Sciences, Isfahan, Iran
Corresponding author:
Arezoo Eshraghi, Department of Biomedical Engineering, Faculty of
Engineering, University of Malaya, Kuala Lumpur, Malaysia
Email: arezoo@um.edu.my
16
the patient, and the functional efficiency of the prosthesis.15–17
For instance, many studies have revealed that silicone liners
are the preferred suspension systems for many lower limb
amputees because they provide good suspension, improved
function and a robust fit within the socket. Patients’ comfort
and satisfaction were also higher with this system than they
were with conventional suspension systems, such as the belt
used with the patellar tendon bearing (PTB) socket.5,17–18
The forces (e.g. ground reaction force and torque)
exerted on the lower limb during standing and walking can
displace the prosthetic limb on the stump. This displace-
ment often occurs during the swing phase of gait and is
reversed when the limb is bearing weight during stance.3
The occurrence of pistoning or vertical movement inside
the socket is often considered to be one of the most effec-
tive indications of whether a suspension system has been
successful or unsuccessful to retain the lower limb prosthe-
sis.3,19 Poor suspension has negative effects on the residual
limb skin, amputee’s gait and comfort levels.20–27
Researchers have been working on the development of
new suspension systems that can increase the options avail-
able to clinicians.4,28–29 The ability to measure pistoning
helps when evaluating the quality of a suspension system in
a lower limb prosthesis.30–33 Many different methods have
been utilized for measuring pistoning movement of the
stump or the position of the bone. These include radiogra-
phy,21,34–35 photographic method,29,36–37 motion analysis
technique,38 and spiral computerized tomography (CT).32
Photoelectric sensor has been also deployed.33
Despite its importance and impact on the performance
and patient’s satisfaction with a prosthetic device, pistoning
in lower limb prosthesis has not been widely studied. At
present, the available literature on the socket fitting and
suspension is mainly focused on pressure distribution,39–45
shear force46–49 and friction.34,50–52
The objective of this study was to summarize the litera-
ture that addresses the occurrence of pistoning in lower limb
prosthesis. The objective data were evaluated with regard to
the methods that have been used for assessing pistoning dur-
ing static (standing) and dynamic (walking and jumping)
conditions with different prosthetic suspension systems.
Methods
Search
The following keywords were used in the PubMed,
ScienceDirect, Web of Science and Google Scholar data-
base search to find suitable research papers: prosthetic pis-
toning, stump vertical movement, residual limb slippage,
and prosthetic suspension.
Selection criteria
Peer-reviewed papers were selected. Only experimental
studies were of interest for this paper and, as
Prosthetics and Orthotics International 36(1)
such, subjective studies that were completed via the use of
questionnaires and finite element study designs were
excluded. The study design, method of subject selection,
research tools, protocol and outcome parameters were
reviewed.
Results
Search results
A total of 285 research papers were identified via the above-
mentioned search engines. An additional 10 papers were
also found by checking the references of the search results.
The title and abstract of each individual study were
assessed. Some of these 295 papers were computational
models, were conducted on the upper limb prosthetics, den-
tal prosthetics and implants, or were common between the
databases; these were subsequently excluded. After refine-
ment based on the above-mentioned selection criteria, 21
related papers remained, from which three articles were
subjective studies. These were disregarded and 18 experi-
mental papers were selected for the purposes of this review
according to the inclusion criteria.
The study population, prosthetic specifications and data
presentation of each paper are summarized in Tables 1, 2, and 3.
The number of subjects that participated in the studies,
except from those involved in case studies, ranged from
five29 to 22.53 The age of participants varied widely from
1553 to 81.54 Six papers were case studies.31,33–36,55 Time
since amputation was between one month56 and 46 years34;
however, not all studies provided details of the time since
amputation. While both unilateral and bilateral amputees
were included, the subjects were mostly unilateral transtib-
ial amputees. Only one study was conducted on a transfemo-
ral subject.57 The cause of amputation was mostly trauma,
but also included diabetes, infection, arteriosclerosis, tumor,
burn, Berger’s disease and congenital limb defects (Table 1).
Prosthesis specifications
Transtibial prostheses were mainly total surface bearing
(TSB) and PTB. The only transfemoral prosthetic socket
was a quadrilateral suction socket, with single axis foot and
mechanical knee joint.57
The various suspension systems that were the subject of
the research in SC/SP,4 SC,4 cuff,4,34 waistband with cuff,4
elastic sleeve4,34,55 and supracondylar wedge.4 On the whole,
the type of liners utilized was unclear; however, some studies
did mention that they had employed Pelite,4,31,54 silicone
liner21,34–38 and urethane liners58. Söderberg et al.34 (2003)
used four different suspension systems (cuff, SC, pin and
lock, and vacuum) with the same soft liner (TEC liner) and
same socket, for one 69-year-old transtibial amputee.
Gholizadeh et al.36,38 fabricated TSB sockets with Talux feet
and two different suspension systems (pin and lock system
and suction system).
Eshraghi et al. 17

Table 1. Characteristics of subjects in the studied literature.

Study (n = 18) Age (year) Cause of amputation (%) Stump length (cm)
Grevsten & Erikson (1975)56 28–66 Unknown 5–22.5
Newton et.al. (1988)19 Unknown Unknown Unknown
Wirta et al. (1990)4 23–76 Trauma, Infection, diabetes, Disease, 8–19
Congenital
Lilja et al. (1993)60 61–79 Diabetes mellitus (5), 10–20
arteriosclerosis (2)
Commean et al. (1997)31 56 Unknown Unknown
Narita et al. (1997)21 19–74 Traumatic injuries (6), tumors (2), 13–29
burns (1)
Bocobo et al. (1998)54 39–81 Vascular disease, trauma Unknown
Convery & Murray (2000)57 39 Industrial accident 18
Madsen et al. (2000)32 Unknown Unknown Unknown
Board et al. (2001)58 32–64 Trauma Unknown
Tanner & Berke (2001)55 37 Trauma Short stump
Yigiter et al. (2002)53 15–37 Traumatic injuries 12.5–17.5
Soderberg et al. (2003)34 69 Trauma 10
Sanders et al. (2006)33 60 Traumatic injury Unknown
Papaioannou et al. (2010)35 Unknown Unknown 14.8
Gholizadeh et al. (2011)38 22–71 Diabetic-Trauma 13–17
Gholizadeh et al. (2011)29 38–54 Diabetic-Trauma 13–16
Gholizadeh et al. (2011)36 51* Vascular disease 14–15

*Bilateral transtibial patient

Table 2. Study population.

Study (n = 18) Sample size Study design Data presentation

per patient
Grevsten & Erikson (1975)56 22 CSS Yes
Newton et al. (1988)19 8 CSS No
Wirta et al. (1990)4 20 CSS No
Lilja et al. (1993)60 7 CSS Yes
Commean et al. (1997)31 1 CS Yes
Narita et al. (1997)21 9 CSS No
Bocobo et al. (1998)54 12 CSS No
Convery & Murray (2000)57 1 CS Yes
Madsen et al. (2000)32 19 CSS Yes
Board et al. (2001)58 11 CSS Yes
Tanner & Berke (2001)55 1 CS Yes
Yigiter et al. (2002)53 20 CSS No
Soderberg et al. (2003)34 1 CS Yes
Sanders et al. (2006)32 1 CS Yes
Papaioannou et al. (2010)35 10 CSS No
Gholizadeh et al. (2011)38 6 CSS No
Gholizadeh et al. (2011)29 5 CSS yes
Gholizadeh et al. (2011)36 1* CS yes

CS= Case Study; CSS= Case Series; *Bilateral transtibial

Data presentation Outcome parameters

Except from the case studies, data for each patient were The following outcome parameters were considered in the
provided individually in four studies. Yigiter et al.53 and study: static pistoning, dynamic pistoning and amount of
Wirta et al.4 presented only group data (Table 2). residual limb, bone or skin slippage within the socket.
Table 3. Distribution of articles based on the methodology and prosthetic components.
18

Study Year of Method Instrument Level of Socket type Soft liner type Measurement Interface
publication amputation (range of pistoning) (mm)

Static Dynamic Skin/soft Bone-soft Liner-

tissue-liner/ tissue/ socket
socket socket
Grevsten & Erikson56 1975 # Roentgenology TT* SS None No Yes (20–74) No
Newton et.al.19 1988 # X-ray TT PTB Soft liner Yes (10–20) No No
Wirta et al.4 1990 # (W) Plunger and potenti- TT PTB Polyethylene Yes (6–31) No No
ometer foam liner
Lilja et al.60 1993 # X-ray TT PTB None No Yes (20–81) No
Commean et al.31 1997 # Spiral x-ray CT (SXCT) TT PTB Sponge insert Yes (6.5)* Yes (10.5)* No
Narita et al.21 1997 # # (W) X-ray Cineradiography TT PTB TSB Silicon liner No Yes (25–36) No
(ICEROSS)
Bocobo et al.54 1998 # (W) Videofluoroscopic TT PTB Polyethylene Yes (NA) No No
foam liner Kem-
blo insert
Convery & Murray57 2000 # X-ray TF† Quadrilateral None No Yes (39.5– No
SS 40.5)
Madsen et al.32 2000 # CT Scanner TT Unknown Unknown Yes (0–32) No No
Board et al.58 2001 # X-ray (plain radiogra- TT SS VS Urethane liner Yes (42–45) Yes (33–40) Yes (1–5)
phy) Sleeve
Tanner & Berke55 2001 # X-ray (plain radiogra- TT TSB Neoprene Silicon Yes (2–20) Yes (31–33) No
phy) liner
Yigiter et al.53 2002 # Marker and measuring TT PTB TSB Soft liner No No Yes (4–16)
tape
Söderberg et al.34 2003 # Roentgen stereophoto- TT TSB KBM Silicon liner No Yes (7–35) No
grammetry (TEC)
Sanders et al.33 2006 # (W) Photoelectric sensor TT PTB None Yes (39.8– No No
43.5)
Papaioannou et al.35 2010 # Dynamic roentgen ste- TT PTB VS Silicon liner Yes (19–151) Yes (3–11) No
reophotogrammetry
Gholizadeh et al.38 2011 # Vicon motion system TT TSB Silicon liner No No Yes (0–5)
(Seal-In® X5 &
Dermo®)
Gholizadeh et al.29 2011 # Camera and markers TT TSB Silicon liner No No Yes (0–9)
(Dermo®)
Gholizadeh et al.36 2011 # Camera and markers TT TSB Silicon liner No No Yes (0–4)
(Seal-In® X5 &
Dermo®)

*TT=transtibial; †TF=transfemoral; KBM=kondylen betting munster; NA=the amount of pistoning was not reported; PTB=patellar tendon bearing; SS=suction socket; TSB=total surface bearing;VS=vacuum
Prosthetics and Orthotics International 36(1)

socket; W=walking; the pistoning was measured during gait; * Only the mean pistoning value was reported.
Eshraghi et al.
Pistoning measurement methods
Various imaging methods have been successfully used to
evaluate the position of bones inside the prosthetic socket.59
Mostly radiological methods have been used.19–21,34–35,54
Spiral or helical CT also provides a high resolution, 3-D
image of the stump and prosthesis.32 Recently, a simple
photographic method has been reported29,36–37 and finally,
Gholizadeh et al.38 used Vicon motion analysis system to
evaluate pistoning in transtibial amputees.
The literature review revealed that the majority of
researchers measured the displacement between the bone and
the socket, the liner and socket or the soft tissue, by using
different techniques in static position19,29,32,34–38,53,55 or during
dynamic tasks33,35,54,60–61 to check pistoning inside the socket.
Therefore, the methods available were classified according to
whether they utilized static or dynamic pistoning. These are
presented in Table 3. By static pistoning, authors mean the
pistoning due to loading during standing and dynamic piston-
ing happened in activities such as walking or jumping.
Static pistoning
In 1975, Grevsten and Erikson,56 and then later in 1980s,
Newton et al.19 were among the first to study PTB prosthe-
sis by roentgenology, during which the pistoning motion
was evaluated in four and two weight bearing positions,
respectively.
Some researchers tried to mimic the gait by adding loads
to the prosthesis when it was in a static position.21,31,38 In
one study, pistoning of the tibial end was assessed in four
simulated phases of the gait cycle. The researchers achieved
that through the utilization of a board that was tilted 15
degrees in order to position the limb in arrangements that
mimicked heel strike and toe off. When attempting to imi-
tate the swing phase, they positioned the prosthetic limb at
45 degrees relative to the floor.60 The same levels were used
in a study by roentgen stereophotogrammetry to measure
four types of suspension (supracondylar, PTB strap, distal
pin suspension and vacuum suspension with expulsion
valve), during which a 1-kg load was applied to the pros-
thetic foot as a means of replicating the centrifugal force.34
In another study, a 5-kg load was applied to the foot of
the prosthesis to simulate the swing phase, and an x-ray
was taken with the prosthesis suspended at a knee flexion
angle of 30°. On the radiograph, the tibial bone displace-
ment relative to the socket bottom was measured by calcu-
lating the value difference between the weight-bearing and
non-weight-bearing positions.21
An x-ray study determined the amount of pistoning
between residual femur and socket both while bearing the
weight over the transfemoral prosthetic limb and during the
non-weight-bearing condition. The sagittal and coronal
planes of the residual femur were x-rayed. The axial dis-
tance from a reference point at the lateral distal socket wall
to the distal end of the femur was measured.34
19
The effect of the neoprene sleeve on the vertical tibia and
stump displacement was compared with a shuttle lock sus-
pension system in a study by Tanner et al.55 The pistoning
motion was assessed via a total of six radiographs for two
suspension systems in three weight bearing positions (full,
partial and none). The distance between each of the end of
tibia and the distal residual limb soft tissue to proximal lock
was measured on the x-ray films. One prosthesis with shuttle
lock was fabricated, but in order to evaluate the neoprene
sleeve, the pin was removed.55
Yigiter et al.53 assessed suspension systems in PTB and
TSB sockets by marking the anterosuperior edge of the
socket as it appeared while standing and during the swing
phase. However, no data was produced that indicated
exactly how the measurement was performed.
Loads of 44.5 N and 88.9 N were used to simulate the
swing phase during walking and running respectively in a
study of pistoning by x-ray. The x-rays were taken while
the subject was lying supine and the data produced during
loaded and unloaded positions was compared.58
Some researchers attempted to measure suspension sys-
tems by applying weight to the prosthetic limb. Commean
et al.31 used a harness in order to apply the force to the
prosthesis by the shoulders. In a further study, Madsen et al.32
designed a loading device for the spiral CT method that
provided a means by which large loads could be applied.
The loads were determined according to the subject's
weight (full and half body mass). In both studies, the
patients were evaluated in supine position.
Photographic method by the use of a camera and mark-
ers was recently introduced as a new approach for the pis-
toning measurement.29,36–37 Photos were taken in five
loading conditions. Then the images were analyzed on the
computer to measure the pistoning. The reproducibility of
measurements was reported to be good.
In a recent study,38 researchers used a Vicon motion sys-
tem to evaluate the pistoning in transtibial amputees while
in static positions. They attempted to simulate ambulation
by adding three different loads (3, 6 and 9 kg) to the pros-
thetic foot. The authors claimed that the Vicon motion sys-
tem was capable of quick and easy determination of the
occurrence of pistoning between the liner and socket.
Furthermore, they presented the motion system as a prefer-
able alternative to exposing amputees to x-ray.
Dynamic pistoning
We found only a few studies that focused on the occurrence
of pistoning during gait. Sanders et al.33 (2006) used a non-
radiological tool to measure the position of the distal end of
the residual limb surface in relation to the socket when
walking on an 18.5 meter walkway. Measurements were
provided by means of a photoelectric sensor, which was
placed in a holder and mounted on the inside distal socket
wall.
20
In another study, the prosthetic pistoning that occurred
when an amputee walked on a treadmill during one gait
cycle was measured using cineradiography. The distance
between the socket and the distal tibia was measured and
the movement of the stump was calculated by subtracting
the distance value in the weight-bearing position from the
value in the suspension position.21
Wirta et al.,4 in a study of the effect of below-knee sus-
pension systems, placed a potentiometer as an axial move-
ment detector at the distal end of the socket. The subjects
were asked to walk a 7.5-meter distance at three different
speeds: normal walking speed, fast and slow. The following
seven suspension systems were compared: cuff (PTB/C),
supracondylar (SC), figure-of-eight SC strap, waistband
with cuff, (SC/SP, rubber sleeve and SC wedge.
In a videofluoroscopic research study, the participants
were asked to walk at a comfortable speed on a treadmill.
The researchers raised the treadmill so that the knee and
stump were fully visible. Leaded elastic markers were
attached to some of the prosthetic components both outside
and inside the socket. Three exposure rates of 50, 80 and
110 KV were selected and the results were compared.
Anteroposterior and mediolateral views were taken. A
video camera was used to record the treadmill gait during
the mean trial time of 40 s.54 Two researchers evaluated the
recorded videos and their agreement over the detection of a
particular component (stump or prosthesis) was taken as
the reference.
Finally, Papaioannou et al.35 presented a new method of
3-D) socket–stump telescopic movement evaluation that
was executed while the subject performed sudden fast stops
and descended the stairs. They measured the piston motion
between the skin and socket through the use of a roentgen
stereogrammetric system that measured pistoning via tanta-
lum pigments, which were fixed to the bone, skin and
socket. Imaging could only be conducted within a confined
region between the orthogonal x-ray systems. The tech-
nique did not allow evaluation during walking. The authors
claimed that their method produced results of high accu-
racy when measuring pistoning between the stump, socket
and bone.35
Amount of pistoning
Grevesten and Erikson found an 11.3-mm bone displace-
ment in relation to the socket when a suction-based PTB
prosthesis was utilized.56 In another study with a PTB pros-
thesis, the average distal tibia vertical movement during a
gait cycle was 57 mm.60
Wirta et al.4 compared the vertical movement of conical
and cylindrical residual limb shapes and reported a mean
pistoning movement at the end of the residual limb of 19.1
mm. In both conical and cylindrical stumps, the rubber
sleeve produced the least pistoning of the seven evaluated
systems.4
Prosthetics and Orthotics International 36(1)
In 1997, a research study by Commean et al.31 moni-
tored the slippage between the skin and socket as well as
tibia movement in order to evaluate the prosthetic fit in a
transtibial subject. For simulating the gait, the researchers
used two axial loadings of 44.5N and 178N. They identified
a 10-mm tibial slippage and a movement of approximately
7 mm for the distal end of skin relative to the socket.31 It is
not clear what suspension system was used.
In an x-ray study that was completed by Narita et al.,21
the tibial displacement between the stance and swing phase
was identified as 25.3 ± 9 mm for the TSB prosthesis and
36 ± 5.6 mm for the PTB prosthesis. The translation for the
TSB prosthesis was significantly lower (p < 0.05) and the
suspension effect of the TSB prosthesis was consequently
superior to that of the PTB prosthesis.21 Similarly, another
study on the pistoning effects of PTB and TSB sockets,
within which marker was placed on the sock over the
stump,53 revealed less displacement with TSB (40 mm).
Bocobo and colleagues54 described two case reports
that focused on 12 subjects. Of the amputees that were the
subjects of the research, only one case was reported to
have a PTB socket. It was stated that significant piston
action was observed in one subject, possibly by compari-
son between two phases of gait; however, they did not
mention in which phase the pistoning was the most severe.
They also did not provide the value of the pistoning. The
pistoning movement was measured by subtracting the
position of patellar tendon bar marker from the knee joint
during two gait phases.54
A spiral CT study completed by Madsen et al.32 did not
represent any specific value for the pistoning that was
observed, and was limited to the provision of a figure leg-
end that provided details of differences in displacement
between full body weight and non-loading conditions. The
displacements ranged from 0 to 32 mm.
In a study by Board et al.,58 the observed amounts of
liner and tibia bone displacement relative to the end of
socket marker were 40 mm and 70 mm for the socket with
electric vacuum pump (Harmony® system) and the normal
valve transtibial socket, respectively. The amount of piston-
ing with normal suction was reported to be 50 mm. Although
the pistoning was measured statically under loads, the
majority of subjects stated that they felt less pistoning with
the vacuum socket than they did with the normal suction
during walking activities.58
When the shuttle lock system was evaluated versus the
no lock condition, the value of tibial end displacement from
the proximal edge of the lock was almost equal in both sus-
pension conditions across three different loading positions.
However, there was less soft tissue displacement noted
with the shuttle lock system. The patient also preferred the
shuttle lock as a result of lower pistoning. The researchers
concluded that the amputee’s opinion about the pistoning
was more related to the soft tissue movement than the
tibia.55
Eshraghi et al.
In Söderberg’s et al.34 study, the pistoning of the tibia
within the Kondylen Betting Munster (KBM) socket with
SC strap was revealed to be about 35 mm, while the pin and
sleeve resulted in approximately 17 mm of displacement.
Sanders et al.33 studied distal residual-limb position dur-
ing gait. In their findings they mentioned that after toe off,
the residual limb came 30 mm out of the socket. They also
identified an overall 40-mm stump displacement in proximal
direction at the end of the swing phase. Additionally, they
stated that pistoning in the PTB without strap was 0.8 mm
larger than it was when the strap was used. Furthermore, after
a five minute rest, 3.7 mm more pistoning was found (before
rest: 39.8 mm, after rest 43.5 mm for PTB with SC strap).
A roentgen stereogrammetric study on transtibial ampu-
tees that was completed by Papaioannou et al., surprisingly
revealed 151 mm pistoning movement in the fast stop task
and 19 mm pistoning movement for the step down between
the markers on the skin and socket.35,62 However, they
could not measure the pistoning during walking. Except
from one case that used a customized vacuum socket with
silicone liner, the type of suspension systems was not spe-
cifically indicated.35
In the only study on transfemoral prosthesis, Convery
and Murray34 measured the vertical movement of the femur.
After the subject changed his position from full weight to
non-weight-bearing, the femur displacement was measured
at 1 mm.
Photographic method showed about 9 mm of pistoning
between the Dermo® liner and socket in non-weight bear-
ing compared with full weight bearing position.36 Another
study using same photographic methodology revealed that
adding loads to the prosthesis caused less pistoning between
Seal-In® X5 liner and the socket (2 mm) compared with
Dermo® liner (4 mm).29
Gholizadeh et al.38 compared the pistoning between two
different transtibial liners (Seal-In® X5 and Dermo® liner)
and the socket through the use of a motion analysis system.
The analysis of the data showed the maximum amount of
pistoning within the socket occurred after 90 N was added
to the prosthetic limb. On average, 2 mm (SD 1) pistoning
occurred with the Seal-In®X5 (60% less than Dermo®
Liner) and 5 mm (SD 1.5) with the Dermo® Liner (p <
0.02), after the 90 N load was added.38
Discussion
Suspension systems should help to establish a firm prosthetic
attachment to the limb. It is claimed that suspension systems
that are based on the suction concept reduce the displacement
of the skeletal anatomy by 50%, which will in turn result in
increased stability between the stump and socket and a reduc-
tion in skin sores.56Above all, less pistoning may indicate a
more natural gait and the amputee is more likely to feel like
the prosthesis is a part of their body.19,63,38 Different methods
have been used to evaluate pistoning in lower limb
21
prosthesis, both in static and dynamic positions (Table 3). To
date, radiological methods have constituted the more popular
methods of measuring the pistoning. However, such methods
are rarely available to prosthetists due to the cost of the
equipment involved and the complex, time consuming data
collection required. In addition to that, such methods involve
exposing the patient to radiation via the x-ray process which
is not desirable.64 Although some of these studies tried to pro-
duce precise x-ray examinations, measurement inaccuracy
still exits.56 The measurements may vary a little owing to dis-
tortion following the minor changes in distances between the
extremity and the film. In order to get higher resolution
images some studies tried different exposures rates.
Using CT scanners as a means of measuring pistoning
does have some advantages. These include the ability to pro-
duce high spatial resolution that provides 3-D visualization
of the prosthesis and the internal tissues of the stump.
However, such measurement methods require the subjects to
be positioned supine. Madsen et al.32 stated that evolution in
CT imaging systems may entail that these devices could eas-
ily be adapted to perform more sophisticated loading proto-
cols. The harness that Commean et al.31 used to apply load to
subjects had several limitations because it took a long time
to set up and the subject needed to be fully cooperative.
The evaluation of pistoning by photoelectric sensor was
also reported to have some drawbacks because it was not
wireless and a cable was required to connect the sensor to
the data acquisition system. This problem could be over-
come with radio-frequency telemetry systems. A further
problem with this measurement method was that it did not
allow the use of a liner with shuttle lock and pin as it was
impossible to make a hole at the end of the liner.33
The researchers were able to measure piston motion
between the socket and liner by a photographic
method.29,36,37 They claimed easy and fast determination of
pistoning; however, the reliability and repeatability of the
method needs to be further investigated.
The use of a Vicon motion system38 has been recently
reported for the purposes of static pistoning measurement.
The technique was said to be accurate. However, one of the
main problems with this measurement system is the fact
that it requires a motion laboratory that may not be acces-
sible to every rehabilitation or prosthetic center.
Additionally, it cannot be employed to monitor the tibial
movement within the soft tissue.
Only five studies indicated that the trials were repeated
three to five times21,29,33,36,38; therefore the reliability of the
data in most of the reviewed papers is questionable.
However, it can be justified to some extent by ethics related
to the x-ray exposure. Finally, as far as the current research
established, no one has set a limit for the acceptable amount
of pistoning. Only Newton et al.19 stated that vertical dis-
placement of 10 mm or less is considered ideal and com-
fortable. Nevertheless, they did not provide any evidence to
support their statement.
22
Conclusions
The focus of this paper was on the available methods for
measuring pistoning in lower limb amputees. Some 70% of
the available studies measured pistoning by simulating the
gait through applying static loads. The loads were meant to
mimic the centrifugal or inertial forces that acted on the limb
during walking (mostly swing). Some say that the pendulum
dynamic applies to the swinging lower limb65 and, as such,
this inertial force is influenced by the segment weight (here
the prosthesis mass). Nevertheless, similar loads were used
for different subjects which is somewhat controversial.
Overall, some important points can be inferred from the
evaluation of the available literature. With regard to the
complicated equipment and techniques that are available
for the purpose of measuring pistoning, existing methods
seem to be far from practical in a clinical setting and, as
such, many of them are only suitable for manufacturers
who wish to evaluate their suspension system products,
including the liners. Since a reduction in pistoning signifi-
cantly contributes to optimal prosthetic fit, further research
with larger sample sizes seems necessary in order to invent
and evaluate accurate, safe and simple methods of piston-
ing measurement that can be made more widely available
to every prosthetist.
Displacement of the residual limb relative to the socket
or ‘pistoning’ causes frictional loads.66 The present study
revealed that the majority of the studies focused on slip-
page or vertical movement of the residual limb inside the
socket. However, as friction has two components of slip-
page and shear force, both should be taken into account.66
While low pistoning might be an indicator of proper cou-
pling between the skeleton and prosthesis, it might, in turn,
result in skin breakdown.52
Pistoning is mainly a phenomenon that occurs during
the gait and functional activities. Today, with technological
advances that have resulted in more choices of kinematic
gait analysis, static techniques seem to be of no use and
research studies should employ methods of dynamic evalu-
ation. Moreover, there are many different liners available
and there is a distinct lack of published research that
addresses how these liners influence pistoning.
It is also worth noting that, consistent assessment is of
importance. Fabrication and fitting by one single prosthetist
would be one possible solution. Future research should also
examine the occurrence of pistoning during activities of
daily living. The effect of body mass index (BMI) is another
area that has not been fully addressed within the existing lit-
erature. Walking causes sweating which, in turn, changes the
biomechanics of the liner-skin interface and might influence
the prosthetic attachment to the stump. Therefore, research
studies should be conducted to determine the effect of walk-
ing time and distance. Little is known about the bone-stump-
socket interface kinematics in transfemoral prostheses.
Hence, investigation of socket suspension in transfemoral
prostheses is also recommended.
Prosthetics and Orthotics International 36(1)
Acknowledgements
We appreciate the help and support of Össur (Reykjavik,
Iceland), especially Ms Ása Lúðvíksdóttir and Mr Scott Elliott.
The authors would also like to thank Dr Steven A Gard at
Northwestern University Prosthetics-Orthotics Center, and
Dr Anthony McGarry at the National Centre for Prosthetics
and Orthotics, University of Strathclyde for their invaluable
advices.
Conflict of interest
The authors report no conflict of interest.
Funding
This work was supported by the Malaysia UM/MOHE/HIR grant
(Project Number: D000014-16001).
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