The Juvenile Amputee In Athletics
Robert C. Hamilton, M.D.
During the past year we have become increasingly concerned with what appear to be unduly rigid restrictions placed upon the participation of juvenile amputees in athletics.
Experience at the University of Illinois Amputee Clinic does not support such restrictions. Since its inception in 1952, the clinic has treated more than 700 juvenile amputees (under 21 years of age). These patients have been almost equally divided between those with congenital and those with acquired amputations. Among the children with congenital limb deficiencies, there have been an equal number of boys and girls; among patients with acquired amputations, boys have outnumbered girls 3:2.
In treating these children over a period of years, we have had an opportunity to observe some of their athletic activities and to draw some rather firm conclusions as to the juvenile amputees' role in competitive sports and the influence of athletics in their total rehabilitation program.
Definition of Terms
First, our use of some key terms should be clarified:
In this discussion the term "amputees" is used to refer primarily to children with unimembral losses, although our remarks will also apply to some children with less severe types of bilateral amputations, such as bilateral Syme's or Syme's/below-knee amputations. It is considered that children who have other (multiple) handicaps are restricted to physical activities of a recreational nature and do not come within the scope of this paper.
The term "athletics" is used to refer to competitive sports, either team or individual, both with and without contact, on the secondary school, college, or organized sand-lot level. By organized sandlot level is meant Little League or merchant-sponsored community competition and not purely recreational sports.
The terms "amputee" and "athletics" may appear on first thought to be mutually exclusive. Our experience, however, has shown that this is not so.
Unimembral Amputee Not a Cripple
At the University of Illinois Clinic there is a strong belief that children with uncomplicated unimembral losses and some with bimembral amputations should be considered as mildly handicapped but definitely not crippled. Consequently, it is believed that there is almost no area of competitive organized athletics in which this type of amputee cannot participate. Further, it is felt that he should be encouraged to participate, naturally within the limits of his capacity. Athletics can play a vital role in the total rehabilitation of the juvenile amputee. Physicians should encourage the child to participate in sports, and his parents should permit such participation. Physicians should also make such modifications in the prostheses as are necessary for this participation-in general, strengthening or padding them-to help these children compete with their peers on a relatively equal basis.
Our experience at the clinic suggests that in contact sports-football, soccer, basketball, wrestling-and upper-limb prosthesis should never be worn. On the other hand, in many competitive sports with little or no contact, such as baseball and golf, the active use of a prosthetic terminal device is almost essential. In other activities-e.g. tennis, badminton, track and field events such as shot-putting, discus and javelin throwing-wearing an upper-limb prosthesis may be of utmost importance in maintaining balance and timing.
Although we were aware at the clinic that many of our juvenile amputees were competing in sports, it was not until a year ago, at our Student Athletic Trainers Clinic at the University of Illinois in Urbana, that one particular student-patient came specifically to our attention. This was Jimmy, a congenital left, very short below-elbow amputee (partial hemimelia), fitted with a standard below-elbow prosthesis, who is a second-string freshman-sophomore wrestler at Lincoln High School. He has begun to take up golf and also plays baseball (Fig. 1-4 ). In the latter sport, he simply dons his glove over the terminal device. Seven other very short below-elbow amputees have been fitted with a special baseball-glove attachment to their prostheses (which Jimmy did not care for); this is a matter of individual preference.
Another male patient with an acquired medium below-knee amputation secondary to a massive lymphangioma is a varsity wrestler. He does not wear his prosthesis for competition, and consequently his balance is adversely affected. He shrugs this off with the comment, "I may lose two points on the take-down, but I can usually make up for it on the mats."
* Carl, whose congenital anomaly (bifid distal femur and partial aphalangia) was surgically converted at the below-knee level, was a regular pitcher in his community Little League program (Fig. 5 ). Asked if fielding his opponents' bunts was not a problem, he said, "I just try to strike them all out." In three seasons he had four no-hit games to his credit.
*This young man, now a high school graduate, is a member of the first class in the course leading to an Associate in Arts degree in prosthetics, offered by the combined Northwestern University Prosthetics-Orthotics Education-Chicago City Junior College Program.
One exceptional child with bilateral lower-extremity acquired amputations-right below knee and left Syme's, resulting from a railroad accident at the age of 10 years-achieved exceptional honors in high school football. After playing the difficult position of middle linebacker for two years, he was honored by the National Football Foundation at its Hall of Fame dinner (Fig. 6 ).
Our final patient-athlete is a young man who in 1961, at the age of 11 years, sustained a left below-knee amputation secondary to a vascular injury. He has been an outstanding center in high school football (Fig. 7 ). He missed the All Conference Selection last season by one vote and, together with his parents and coaches, was looking forward to this season's competition.
With this background of experience, particularly that involving our two football players, we were amazed to learn recently that under a ruling of the National Federation of State High School Athletic Associations, these two boys could not legally participate in the sport:
"The 1966 Official Football Rules for the National Federation of State High School Athletic Associations (Rule 1, Section 5-Player Equipment -Article 3) states as follows: 'Illegal equipment shall not be worn by any player.... types of equipment which shall always be declared illegal include: (1) artificial hand, arm or leg.'"*
Report of AMA Committee
In taking issue with this ruling, as we do, we must also take issue with portions of the report of the American Medical Association Committee on the Medical Aspects of Sports upon which this ruling is apparently based. This report, entitled "Report on the Advisability of Amputees with Artificial Limbs Participating in Interscholastic Football," was drafted at the November 1965 meeting of the committee. Excerpts from this report with our comments follow:
"To consider an amputee a bonafide candidate for interscholastic sports in general, certain assumptions must be satisfied:
"1. The amputee is otherwise acceptable as a varsity candidate at the high school or college level-that is, the only question as to his
Personal communication from Clifford B. Fagan, Executive Secretary, May 27, 1966.
eligibility for participation is the loss of limb and the prosthesis ;
"2. The integrity of the affected limb is medically affirmed-that is, there is no known underlying bone disease, skin ulceration, or other medical contraindication to activity;
"3. The decision to play the candidate in competition would not be done for sympathetic or sensational reasons-that is, he would be judged only on his merit compared to his teammates on the basis of training, performance, and sportsmanship;
"4. The nature of the specific sport does not impose undue risk for the amputee or to the teammates and opponents of the amputee-that is, an inherent risk of a sport does not become a significant hazard.
"The first three assumptions (eligibility, personal health, objectivity) must be relegated to individual situations, and are the responsibility of the direct sport leadership in each community. With these assumptions stipulated, however, the Committee will confine its comments to the fourth assumption (the nature of risk) for the consideration of the National Alliance as regards interscholastic football."
Comment : We agree. The prime and perhaps the only factors to be weighed in considering the participation of an amputee in football (or any other sport) are his ability relative to his peers and the risk of injury to all concerned.
"The Committee appreciates and shares the concern of the National Alliance regarding unduly restricting the opportunity of a worthwhile sports experience for the atypical but aspiring student. Yet, football is a rigorous sport, and sentiment must yield to reasonable restrictions essential to the protection of the player, his teammates, and opponents.
"With the amount of external armor already imposed on the interscholästic football athlete, it is extremely difficult if not superficial to assess whether the additional armor in the form of a lower leg prosthesis constitutes increased risk to bearer or others. The composition of the shank is either wood or rigid foam which is covered by rawhide or plastic resin impregnated into a nylon stockinette. In any combination of shank and cover, if breakage occurs (and this would not be infrequent), the problem of the prosthesis is primarily economic, not safety."
Comment : We agree on both counts and point out that four below-knee amputees (one bilateral) from our own clinic group have competed successfully in high school football without prosthesis-related injury to the patient, his teammates, or opponents. The foam-rubber-padded, plastic-laminate shell of the below-knee prosthesis is scarcely harder than the subcutaneous portion of the normal tibia.
"There is an absence of substantial experience from which to draw or verify judgment on the advisability of amputees playing interscholastic football."
Comment : We agree and recommend that steps be taken to acquire the "substantial experience" necessary to form valid judgments.
"(The below-knee amputee) is not so readily evaluated as 'able' or 'unable' to participate in interscholastic sports. The Committee feels that the ability to perform skillfully over a period of time is basic to safe, effective, and satisfying participation in sports, and that the B-K amputee is not sufficiently agile to learn and perform proficiently the play-to-play skills required of an interior lineman in modern football (a ball-carrying position being an obvious contraindication)."
Comment : Experience at our clinic already cited indicates that the below-knee amputee can "perform proficiently the play-to-play skills required of an interior lineman."
"The B-K amputee would thus have to adapt and compensate in order to play. Because of the...aggressive contact inherent in line play, the stump would be constantly vulnerable to reinjury. The necessary alignment and fitting of the prosthesis (having thigh corset and metal knee hinge, or a patellar-tendon-bearing type without thigh corset) would be difficult to maintain. Other body segments are vulnerable because of the adaptation to the mobility skills. Moreover, the necessary adaptation of the individual assignments for team play may interfere with the suitable management of the rest of the squad."
Comment : In our experience, the stumps of below-knee amputee football players have been no more vulnerable to injury than other areas of the body, nor has there been interference with "the suitable management of the rest of the squad." We believe that the condylar strap is insufficient for suspension and that a thigh corset with heavy-duty single-axis hinges is necessary to maintain the alignment and integrity of the prosthesis. Breakage problems have been restricted to the single-axis hinges, and these have been repaired on a local basis.
"The (Syme's ankle disarticulation amputee) or one with partial foot amputation would have minimal impairment of the skills required of an interior lineman and would have little difficulty with prosthesis stability. Two panels of lower leg length are attached to the artificial foot and secured above the calf."
Comment : We agree, but believe that the distinction made between the below-knee and the Syme's level amputation is invalid, the difference being a matter of suspension only and not of agility, as both levels necessarily lack ankle mobility.
The Committee's Conclusions
Relative to interscholastic football, the AMA Committee on the Medical Aspects of Sports concluded:
"1. The participation of the arm amputee without prosthesis presents no problem;
"2. The participation of the arm amputee with prosthesis or of the A-K or B-K amputee cannot be justified;
"3. The participation of the foot amputee with prosthesis presents no problem if proper padding as provided in Rule 1-5-3-c is policeable;
"4. The aspiring amputee athlete who is prohibited from interscholastic football should be conscientiously guided to a more appropriate sport, preferably an individual sport."
As we have indicated, we are in disagreement with the portion of Conclusion 2 which states that "The participation of the....B.-K amputee cannot be justified" and the National Federation ruling arising from it. This ruling is binding on the greater majority of the high schools in 44 states and is contrary to our philosophy on the treatment of the unilateral juvenile amputee-that
he is a mildly handicapped but not a crippled child and may be equal to his peers in most aspects of life, including athletics. Obviously, not every amputee has either the ability or the desire to compete in contact sports such as football. We believe, however, that a blanket disqualification is unfair and unwarranted by the available facts; each case should be evaluated on its individual merits.
1. The participation of juvenile; with uncomplicated unilateral amputations in competitive interscholastic athletics is possible and desirable, and can be undertaken successfully. The same is true for children with some types of bilateral amputations.
2. Determination of the total capacity of an individual to participate should be the responsibility of the clinic team, his parents, and the coaches, guided by more flexible rules than now apply. Since subjective factors may enter into this evaluation, we believe that it would be in order to establish a committee consisting of cooperating clinic members who also have experience and interest in athletic medicine, a physical educator and/or coach, a member of the National Federation, and others, to set up objective guidelines for participation. In addition, these members should be available personally to act objectively in each case.
3. More specific information concerning amputee participation in sport and injuries resulting to the participant, his prosthesis, his teammates, and his opponents must be collected. We recommend that data of this type be obtained through the medium of a questionnaire directed to all the clinics cooperating in the child amputee research program.
4. Pending the findings of the proposed study, Table I presents suggested areas of athletic participation by unimembral and/or uncomplicated amputees based on our experiences.
Robert C. Hamilton, M.D. is the Associate Clinic Chief Juvenile Amputee Clinic University of Illinois College of Medicine Chicago, Illinois