STEP 3: STRENGTH, CONDITIONING & AGILITY

For those who meet the minimum recommendations for running and have mastered the skill of walking on a prosthesis, running is an attainable feat. In order to become a runner and progress to becoming a good runner you need to focus your attention on strengthening your legs, especially your unaffected leg, and building your endurance levels in order to meet the energy demands of such a high level activity. Sure, you could just put on your running prosthesis and go out to see how you do, but it is imperative that you take the time to strengthen and condition your body in order to run well and prevent yourself from getting injured.

STRENGTH AND CONDITIONING

Some key concepts to keep in mind while running on a prosthesis:

Your unaffected leg is now going to be the main powerhouse so you need to really focus on strengthening all muscles in that leg.
On your residual limb, or both legs if you have bilateral amputations, your hip is now the main powerhouse for running and needs to generate all of the force in order to propel you forward (If you have a below knee amputation you will also have your hamstrings to help out). Therefore, you need to ensure that your hip musculature is sufficiently strong to meet the demands of the task.
Without proper strength, your body will compensate in various ways which can lead to injuries; therefore, it is crucial that you don't ignore the strengthening component of training.

Below are two squat progressions that you can use to strengthen numerous muscles in your legs at one time:

SQUAT PROGRESSION

Step 1: Small Squat to High Surface

Begin with your knees shoulder width apart with a high table or stable surface behind you.
You can hold your arms out to the side for balance if you want.
In a controlled manner, squat down to tap the high surface with your buttocks and then return to standing.
Make sure that your knees do not come forward over your toes as you squat down as this increases the stress at the knee and can cause pain. Instead focus on bringing your buttocks further back as you hinge forward at your hips.
Once you can perform 3 sets of 15-20 repetitions move on to step 2.
- Make sure that you are performing these with proper form before moving on to the next step. This will be determined on an individual basis and may take longer for some depending on initial level of strength.

Step 2: Equal weight through each leg

Using the same form as step one, now you want to focus on equally distributing your weight in between your two legs.
Place a scale under one leg and an equal sized book or a second scale under the other leg so that both legs are at an equal height.
Now when you squat, look at the weight that registers on the scale - it should be half of your body weight.
If you notice that the amount is either much greater than half your weight, you are favoring that leg. If you notice that the weight is much less than half of your weight, then you are likely not relying on that leg enough.
Practice until you feel that you can trust both of your legs to hold equal amounts of weight which will be evidenced by the reading on the scale. Then move on to deeper squats in step 3.

Step 3: Progressively Lower Squats

Once you are able to bear weight evenly between both legs. move on to progressively lower squats.
Squat in a slow and controlled manner, making sure that your knees do not come forward over your toes.
In order to strengthen, you want to perform an exercise to muscle fatigue - in other words you should perform as many squats as you can until you cannot squat any more. For some this might mean that you perform 3 sets x 10 repetitions. For others this number may be higher or lower. If you find that squatting your body weight has become too easy, you can squat with weight for an added challenge.

SINGLE LEG SQUAT PROGRESSION

The following progression is appropriate for strengthening the sound limb for individuals who have an amputation on one side. You can perform these with or without your prosthesis on.

step 1: standing on one leg

Begin by standing on your sound limb. If this is your first time working on balance you may want to hold on to a stable object initially to prevent falls.
Work up to 3 x 30 second holds.

Step 2: Bending the knee

Stand on your sound limb with your back against the wall.
In a slow and controlled manner, bend your knee a few inches, into a mini squat, and then straighten back up.
Try not to lean all of your weight against the wall - make sure that your leg is doing most of the work.
Once you can perform 3 sets of 30 repetitions, progress to step 3.

Step 3: squat to high surface

Stand on your sound leg with a tall, stable surface behind you.
Squat down, tap the table or surface and come back up - don't fully sit down.
Make sure that your knee points straight ahead from the front view and does not angle in towards you other leg as you squat down.
From the side, make sure that your knee does not come over your toes as you squat down. If you find this is happening, try to focus on bringing your buttocks further back and don't squat as low.
- When your knee comes over your toes, the forces on your knee increase and can result in knee pain.

step 4: squat to progressively lower heights

Now that you have mastered step 3 of the single leg squat, it is time to work on squatting progressively lower.
If you feel uncomfortable squatting without a surface behind you to tap or catch you if you lose balance, use a shorter table or surface than the one used in step 3.
- Additionally, there may be steps that are necessary for you between step 3 and step 4 in order to squat with proper form. For example, you may be able to squat down to a bench but then need to use your arms to push yourself back up.
- This progression may be different for everyone so gauge what you can do, look at your form in a mirror or on videotape and make sure that you don't progress too quickly. Proper form is more important than a greater amount of squats or a lower squat with poor form.
Tips for proper form
- Keep your knee behind your toes and focus on reaching your buttocks backwards in order to maximize the work of your gluteal muscles and minimize the stress on your knee.
- Make sure that from the front view, your knee does not angle in and that it stays pointing straight ahead. If you notice that you cannot control your knee as you squat down it is a sign of insufficient strength of the gluteus medius. Take a step back in the progression and work on control as this muscle is functionally strengthened with these exercises and with more repetitions using proper form it will strengthen enough to tolerate the next step with time.

ENDURANCE

For individuals with lower limb amputations, the energy expended to walk is significantly greater than for those who do not have amputations. This metabolic disadvantage becomes even more pronounced with running so it is critical to make sure that you have a high level of endurance prior to beginning your training as a runner so that you are able meet the energy requirements of a sport like running.

One study demonstrated that running with a SACH (Solid Ankle Cushion Heel) foot requires an energy cost that is 28-36% greater compared to individuals without amputations. A running specific prosthesis helps this disparity in energy costs however even then the energy cost is 9-32% greater compared to those without amputations. (Menglekoch 2014)

Below are three options for exercising at the gym that will help increase your endurance:

BIKE

ELLIPTICAL

WALKING

There are no established times or levels of resistance that have been determined to quantify if someone is ready for running. The key thing to keep in mind is that running is going to take a lot of energy and that in the process of learning to run, it will be very helpful to increase your endurance through other modalities in order to maximize the amount of time you can spend running.

Try to work on increasing your times on the bike, elliptical or treadmill to a half hour. Start out going as long as you can and try to add a couple of minutes every time you use them.
Increasing the resistance on the elliptical or bike as well as the incline on the treadmill will help to strengthen your legs while you work on building your time to increase your endurance.

AGILITY AND BALANCE

Agility drills are a great way to transition from walking to running - they help you learn to coordinate your limbs at a fast pace and you can perform them with your regular prosthesis. Agility exercises and balance exercises geared towards promoting stability in the socket will help you to become more stable with the quick movements required for running and can help to prevent balance related falls.

**Make sure that when you are working on balance you are in a safe environment - have something nearby to hold on to if you feel like you are going to lose your balance and make sure someone is nearby to help if you may need it.**

BALANCE DRILLS

The following drills should be performed with your walking prosthesis on.

Step 1: standing on one foot

Begin by standing on your prosthetic limb.
- If this is your first time working on balance, start by holding on to a stable surface nearby and work up to standing on that leg without support
Work up to 3 x 30 second holds

Step 2: eyes closed

Once you are comfortable with standing on one leg, the next step is to stand on your prosthetic limb with your eyes closed
This is an added challenge because when you take away vision, your limb must work that much harder to stabilize and know where it is in space.
Work up to 3 x 30 second holds
- You can also work on this drill with eyes open and/or eyes closed on an unstable surface such as foam or even a pillow if you are performing these drills at home.

step 3: single leg swing

step 4: cone taps

AGILITY DRILLS

High Knees

This drill is helpful as it requires you to activate your hip flexors in order to pick your knee up. During running a common problem some prosthesis users run into is difficulty picking up their knee on the prosthetic limb, especially for those with above knee amputations. They end up compensating with other means to swing that leg through in order to prevent their foot from catching which can result in falls.

Butt kicks

During this drill you want to bend your knees as much as you can in an effort to kick your butt.
For above knee amputees, work on performing this action on your sound limb only, as you stabilize on your prosthesis.

quick feet

For this drill you want to work on moving your feet as quickly as possible, placing each foot into each box as you move through the ladder.

Sideways quick feet

For this drill you are reaching with your front leg, and pushing with your back leg to quickly place each foot in each box as you move sideways down the ladder.
Make sure that you travel down the ladder on one side and then travel back on that same side to ensure that each leg gets a chance to be the back leg which pushes you forward.

In, In, out, out

In this drill place each foot into the box, and then step both feet out. Continue on in the same pattern of in, in, out, out for the rest of the ladder.
This drill requires you to move your feet quickly and push off of both legs when they are planted outside of the box.
Make sure you perform this drill twice, ensuring that if you led with your right foot the first time, you lead with your left foot the second time.

in, in, out

This drill is similar to the one above however this time instead of bringing both legs out of the box, you alternate bringing each leg out, planting it and then pushing off to place both feet in the next box.

carioca

Carioca, or braiding, requires good balance and is a higher level drill.
Moving laterally, step your left leg over your right leg, then step to the side with your right leg. Now bring your left leg behind your right leg, then step to the side with your right leg. Continue in this pattern.
After leading with you left leg, perform this drill again leading with your right leg.