When it comes to sports, the playing field is not always equal for a child with a limb difference, and participation might feel intimidating. That is why parents, coaches, and health care workers need to pay special attention to the child’s potential limitations and help to figure out ways of making participation more inclusive. Participation in sports has shown to have a positive influence on the individuals with disabilities in quality of life as well as physical and psychosocial realms.¹ This applies to team sports as well as to individual sports. Challenges might come up during different developmental stages in a child’s life or as interests change, so it is good to be ready to assist when needed.

A caretaker should inspire confidence in a child’s introduction to a new sport. The question should not be if it is possible, but how. It is also important to be cognizant of any difficulty that a child might have, so that helpful intervention can be achieved. Intervention can come in the form of adapting technique, adapting the piece of equipment, or provision of an activity-specific prosthesis. A child with limb difference often figures out ways of adapting technique on their own but may also benefit from some instruction. Adaptive equipment can involve simply modifying existing equipment to fit or function better or it might involve different or specialized equipment altogether. An activity-specific prosthesis may be ideal for performance for an avid athlete, but may be unnecessary, especially for someone just starting out.²

Adapting equipment should be made with safety and performance in mind. It is important to prevent entrapment, the connection of the child to the piece of equipment if something such as a fall were to occur. For certain sports in which the prosthesis is being used, an auxiliary form of suspension, such as a sleeve or belt, is advised to prevent the prosthesis from falling off, which could cause injury to the child or others. Following these considerations, the child may often participate in sports not specifically organized for individuals with disabilities.³

For a child with limb difference, team sports are commonly integrated with nondisabled peers. Padding over the prosthesis is sometimes mandatory for sports with potential contact with other players. If the prosthesis is just getting in the way or is painful to wear, adapting technique is sometimes necessary. Examples include competing on the swim team without a prosthetic leg, or throwing the ball from the sidelines using one hand instead of two. When a prosthesis is not being worn, a residual limb protector may be devised to protect against impact or joint injuries.

For larger groups of children with disabilities, team sports could be played in a seated position. Such examples of events that may be modified in this way and are often included in the Paralympic games include seated volleyball, sled hockey, wheelchair basketball, and wheelchair rugby. Team sports could also be played standing, but with modified rules and equipment. One such example is amputee football or soccer. This is a sport played using Lofstrand crutches for lower extremity amputees and upper extremity amputees playing goalkeeper positions.

Strength and conditioning are part of many team sports. Adaptive needs can be unique to the level of amputation as well as the specific exercise. For those with upper limb differences,
strengthening the affected side can be particularly challenging, and alternative tools should be considered, including resistive bands, cables, and cuffs. Exercises can be performed with or without the use of a prosthesis. For lower limb differences, a common problem is that the heel of the prosthetic foot comes off the ground when squatting during certain leg exercises. A good solution is to position a weight underneath the heel to bring it into a more natural athletic stance position.

Innovations in prosthetic design have opened up possibilities in performance that were previously limited. One such example is running blades. When Van Phillips first invented and personally used the Flex-Foot in 1984, it opened up doors for many amputees to run more efficiently and with less impact to the residual limb.^4,5,6,7 Since then, various manufacturers have created increasingly improved designs.

The biomechanical requirements for running differ compared with walking for lower extremity amputees.⁸ The primary difference between walking-specific and running-specific feet is the presence of a heel.⁷ Although running on a foot prosthesis designed for walking is possible, and some newer foot designs intend to satisfy both requirements, a foot prosthesis that includes a heel is not optimal for running.⁸ Some prosthetic feet such as the Össur Cheetah Xplore JR and Fillauer Pediatric formula (Figure 1) offer a good transitional prosthetic foot that can walk well for day-to-day use and provide adequate energy storage for running in short bursts for field sports. Running prosthetic feet designs incorporate C-shaped (distal mount) or J-shaped (posterior mount) carbon blades with excellent spring-like properties.⁵ Although distally mounted prosthetic feet have more adjustability for height and alignment, they do require a larger amount of space available between the ground and socket. Height of the running prosthesis should be slightly higher than the sound side to factor in compression of the carbon fiber spring.⁵ Alignment of the toe of the blade should fall in line with the bisection of the socket in the sagittal plane (Figure 2).

For transfemoral designs, the inclusion of a knee is optional. Without a knee joint, circumduction is required to clear the foot during swing phase. For a transfemoral running prosthesis, which includes a prosthetic knee, the prosthetist must ensure stable knee alignment and optimal swing-resistant settings for safety and efficiency. Also, with a prosthetic knee, more learning is required on behalf of the patient, and training with a skilled physical therapist is advised.

Access to prosthetic running legs is a challenge with the expense and lack of coverage by most insurance providers. Fortunately, some nonprofit organizations exist in the United States, such as the Challenged Athletes Foundation, Amputee Blade Runners, Never Say Never Foundation, and High Fives Foundation.² These organizations award grants for prosthetic running feet and sometimes other adaptive equipment. Those children fortunate enough to have a dedicated prosthetic running leg may find it useful for team sports, gymnastics, dance, or simply keeping up with peers on the playground.