Rehabilitation Protocol for Below-Knee Amputations

Introduction to Rehabilitation

The rehabilitation protocol after below-knee amputation should follow a comprehensive, progressive program to optimize outcomes and prevent complications, as recommended by the British Journal of Sports Medicine 1, 2

Isometric quadriceps exercises should begin in the first postoperative week for reactivating the quadriceps muscles when they provoke no pain, followed by progressive concentric and eccentric strengthening, as recommended by the British Journal of Sports Medicine 1, 2
Weight bearing should be implemented as tolerated if a correct gait pattern can be maintained, using crutches initially if needed, according to the British Journal of Sports Medicine 1, 3
Pain management should include cryotherapy in the first postoperative week to manage pain and swelling, as suggested by the British Journal of Sports Medicine 1
Immediate knee mobilization should begin within the first week to increase range of motion and prevent extension deficit, with the goal of achieving full extension and progressive flexion, as recommended by the British Journal of Sports Medicine 1, 2

Closed kinetic chain (CKC) exercises, such as partial weight-bearing squats and step-ups, should begin from week 2, as recommended by the British Journal of Sports Medicine 1, 3
Progressive strengthening should transition from isometric to concentric and eccentric exercises when the quadriceps is reactivated, provided there is no pain, effusion, or increase in temperature, according to the British Journal of Sports Medicine 1
Neuromuscular training should be added to strength training to optimize outcomes and prevent complications, as suggested by the British Journal of Sports Medicine 1
Balance and proprioception exercises should be added to strength training to improve neuromuscular control, as recommended by the British Journal of Sports Medicine 1, 3

Open kinetic chain (OKC) exercises should start from week 4 in a restricted ROM of 90°-45°, as recommended by the British Journal of Sports Medicine 1, 3
Progressive ROM should gradually increase in OKC exercises: 90°-30° in week 5, 90°-20° in week 6, 90°-10° in week 7, and full ROM in week 8, according to the British Journal of Sports Medicine 1
Eccentric training should be implemented for greater strength gains and muscle hypertrophy, as suggested by the British Journal of Sports Medicine 3
Core stability exercises should be included to improve gait and knee function, as recommended by the British Journal of Sports Medicine 1, 3

Quality of movement should be monitored during all exercises, and progression should only occur if exercises do not provoke pain, effusion, or increase in temperature, as recommended by the British Journal of Sports Medicine 1, 3
Functional assessment should use objective measures to evaluate progress, including strength testing and functional activities, although the specific guideline society is not mentioned in this context.

Comprehensive testing criteria should include:

Criteria	Target
No pain or swelling	-
Full knee range of motion	-
Limb Symmetry Index (LSI) >90% for strength and hop tests	>90%
Stable knee on clinical examination	-
Normalized patient-reported outcomes	-

Psychological readiness for return to sport should be assessed, with consideration of fear of reinjury and its impact on rehabilitation outcomes, as recommended by the British Journal of Sports Medicine 1, 3

Gradual sport reintegration should begin with skill drills before full competitive activities, with continued maintenance strength program and preventive neuromuscular training, as recommended by the British Journal of Sports Medicine 1, 3
Periodic assessments during rehabilitation to maintain motivation and track progress, according to the British Journal of Sports Medicine guidelines 3
Long-term strength maintenance program to support joint health, as recommended by the British Journal of Sports Medicine guidelines 3

Delaying mobilization can lead to complications, and immediate knee mobilization is critical to prevent extension deficit and osteoarthritis development, as recommended by the British Journal of Sports Medicine 1, 2
Neglecting quadriceps strengthening can result in significant negative consequences for long-term outcomes, with quadriceps strength deficits >20% having a major impact, as suggested by the British Journal of Sports Medicine 1
Focusing only on strength without neuromuscular control can lead to poor movement patterns and increased risk of reinjury, with both components being essential for successful rehabilitation, as recommended by the British Journal of Sports Medicine 1, 3
Functional bracing is not recommended for routine use after primary ACL reconstruction as it confers no clinical benefit, as suggested by the American Academy of Orthopaedic Surgeons 4