Musculoskeletal & Integumentary · Topic 6 of 11

Amputation Care

Musculoskeletal · amputation and rehabilitation

Amputation Care

Keep the hip and knee straight, shape the limb with a shrinker, and sort phantom pain from a painful residual limb.

Key numbers

Residual limb pain: check the socket first≈ 60% residual limb pain

Above-knee walking costs 60–100% more energyAKA +60–100% energy

01 · Don't confusePhantom pain: felt in the missing limb

Phantom limb sensation (the nonpainful feeling that the limb is still there) affects most new amputees and can aid proprioception; phantom limb pain is real pain felt in the removed part, usually starting within days.

02 · DoPrevent hip and knee flexion contractures

Hip and knee flexion contractures form quickly and block prosthetic use: keep the hip and knee extended, never prop the limb on pillows, have the patient lie prone 15–20 minutes several times daily, and use extension splints.

03 · Watch forResidual limb pain: check the socket first

About 60% of amputees have residual limb pain; a poorly fitting prosthetic socket is the most common cause, followed by neuroma, bone spur, skin breakdown, infection and ischemia.

Causes & risk factors

Why it happens

Phantom sensation causes night-time fallsWith phantom sensation, patients often try to stand on both legs — especially getting up at night for the bathroom — and fall or injure the residual limb; warn them.

Control perioperative pain to reduce phantom painPhantom limb pain is more likely with painful conditions before amputation or poorly controlled perioperative pain; combining spinal and general anesthesia lowers the risk.

Diagnosis & monitoring

Work-up

Above-knee walking costs 60–100% more energyWalking with a prosthesis raises energy expenditure 10–40% after below-knee amputation and 60–100% after above-knee amputation, so endurance training is part of rehabilitation.

Management

Orders

Shrinker or elastic wrap 24 hours a day must knowShape the residual limb and control edema with an elastic shrinker or elastic bandage worn 24 hours a day (rewrap when loose); a permanent prosthesis waits until the limb stops shrinking, usually a few weeks.

Treat phantom pain: desensitization, mirror therapy, gabapentin must knowTreat phantom limb pain with desensitization (tapping, contrast baths, massage, vibration), mirror therapy, simultaneous exercise of both limbs, gabapentin, and TENS, acupuncture or spinal cord stimulation if needed.

Start rehabilitation once medically stableBegin rehabilitation as soon as the patient is medically stable — standing and balance work at parallel bars, hip and knee stretching, strengthening of all limbs — and early walking with a temporary prosthesis.

Red flags & don'ts

Avoid harm

Neuroma: shooting pain with prosthesis use complicationA neuroma causes electric, shooting pain in the residual limb with prosthesis use that eases on removal; a local anesthetic block is diagnostic, ultrasound or MRI confirms, and refractory cases need neurectomy.

Bone spur needs surgical resection complicationA spur at the cut end of the bone is found by palpation and radiograph; surgical resection is the only effective treatment.

Skin breakdown: stop the prosthesis, refit complicationErythema is the first sign of skin breakdown from socket pressure, friction or moisture; stop wearing the prosthesis until the skin heals and have the prosthetist adjust the fit.

Constant pain with fever: deep infection complicationConstant pain without skin changes, pain on compression or fever and tachycardia suggest deep infection (osteomyelitis, graft infection); in PAD amputees consider recurrent ischemia (transcutaneous oxygen < 20 mmHg).

The rules

Know these

Surgical pain beyond 3–6 months needs work-upPostoperative wound pain usually settles over 3–6 months; pain beyond that suggests infection, dehiscence, arterial insufficiency, hematoma, poor padding over bone or a poorly fitting prosthesis.

Phantom limb pain or residual limb pain?

Commonly confused

Where it is felt	In the part that was removed
How common	Most patients at some time
Usual causes	Peripheral and central nerve changes; worse with poorly controlled perioperative pain
Treatment	Desensitization, mirror therapy, gabapentin, TENS

Teach & follow up

Patient education

Inspect and wash the residual limb nightlyRemove the leg prosthesis at bedtime, inspect the residual limb (with a mirror), wash with mild soap and warm water, dry thoroughly and change the limb sock daily.

More detail

Reference

Show 5 reference facts

Transcutaneous osseointegration anchors the prosthesis directly to bone for patients who fail a socket (pain, recurrent infection, short limb); contraindications include osteoporosis, osteomyelitis, severe PAD, uncontrolled diabetes and smoking.

Most older below-knee amputees do best with a patellar tendon–bearing prosthesis with a solid-ankle cushion-heel foot; microprocessor knees and ankles are options after above-knee amputation.

Phantom limb pain involves peripheral and central nerve changes; it is worst soon after amputation, fades over time and is often worse when the prosthesis is off, such as at night.

After above-knee amputation keep the residual limb close to the other leg rather than drifting outward, and support it when sitting so it does not dangle.

Neuropathic residual limb pain (burning, shooting) typically starts within 7 days of amputation and may become chronic; it is treated with multimodal therapy including antidepressants and antiseizure drugs.

Pearl

Phantom pain lives in the limb that is gone; residual limb pain lives in the stump — and the socket is the usual culprit.

Sources · Merck Manual Professional — Leg Amputation Rehabilitation (updated Dec 2025) · Merck Manual Professional — Pain Following Amputation (updated May 2026) · UMass Memorial Health library — Preparing Your Residual Limb for a Prosthesis (positioning to prevent contracture) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).