Transtibial amputees are at increased risk of contralateral hip and knee joint osteoarthritis, likely due to abnormal biomechanics. Biomechanical challenges exist for transtibial amputees in gait and cycling;​ particularly, asymmetry in ground/pedal reaction forces and joint kinetics is well documented and state-of-the-art passive and powered prostheses do not fully restore natural biomechanics. Elliptical training has not been studied as a potential exercise for rehabilitation, nor have any studies been published that compare joint kinematics and kinetics and ground/pedal reaction forces for the same group of transtibial amputees in gait, cycling, and elliptical training.

The hypothesis was that hip and knee joint kinematics and kinetics and ground and pedal reaction forces would differ due to exercise (gait, cycling, elliptical) amputee status (amputated, control [non-amputated]), and leg (dominant [intact], non-dominant [amputated]). Ten unilateral transtibial amputees and ten control participants performed the three exercises while kinematic and kinetic data were collected. Hip and knee joint flexion angle, resultant forces, and resultant moments were calculated by inverse dynamics for the dominant and non-dominant legs of both participant groups. Joint biomechanics and measured ground/pedal reaction forces were then compared between exercises, between the dominant and non-dominant legs within each participant group, and across participant groups.

Significant differences in hip and knee joint flexion angles and timing, compressive forces, extension-flexion (EF) and adduction-abduction (AddAbd) moments, and anterior-posterior (AP) and lateral-medial (LM) reaction forces were found. Particularly, transtibial amputees showed maximum knee flexion angle asymmetry as compared to controls in all three exercises. Maximum hip and knee compressive forces, EF moments, and AddAbd moments were lowest in cycling and highest in gait. Asymmetry in amputee midstance knee flexion and timing in gait, coupled with low maximum EF moment for the non-dominant leg, suggests that amputees avoid contraction of the non-dominant quadriceps muscle. Knee flexion angle and EF moment asymmetry in elliptical training suggests that a similar phenomenon occurs.

Asymmetry in AP and LM reaction forces in gait, but not other exercises, suggests that exercises that constrain kinematics reduce loading imbalances. The results suggest that cycling and elliptical training should be recommended to transtibial amputees for rehabilitation due to reduced hip and knee joint forces and moments. Elliptical training may be preferred over gait due to decreased joint loading and loading asymmetry, but some asymmetry and differences from control participants still exist. Non-weight bearing exercises such as cycling may be best at reducing overall joint loading and joint load asymmetry but do not eliminate all kinematic and temporal asymmetries.

Current state-of-the-art prosthetic leg design is insufficient in restoring natural biomechanics not only in gait but also in cycling and elliptical training. Improved prosthesis kinematics that restore non-dominant knee flexion in amputees to normal levels could help reprogram quadriceps muscle patterns in gait and elliptical training and hip and knee joint biomechanical asymmetries. Further work in comparing contralateral and prosthesis ankle joint biomechanics would help to elucidate the relationship between prosthesis design and its impact on lower limb joint biomechanics.