Appendix B

Appendix B: Evaluation of Law Enforcement Officers with Amputations

Examination of the law enforcement officer (LEO) with an amputation involves addressing several aspects of the health of the affected limb(s) as well as the general health of the individual. The following list highlights some specific issues that should be addressed:

1: Physical health of the affected limb.
2: Residual Limb Length
Length is a marker of ability to achieve acceptable fit. Long residual limbs present a problem with achieving symmetry in length with the opposite limb. Short residual limbs present a problem with having enough tissue for the socket of a prosthesis to achieve adequate stability.

Common problem residual limb lengths include:

• Below the knee in the distal 2/5 of the tibia
• Below the knee less than 3 cm from tibial tubercle
• Above the knee less than 5 cm from the ischial tuberosity

This is an issue more relevant to the rehabilitation team and likely to be resolved prior to any evaluation for law enforcement duties. However, as a factor in understanding potential failure points in the human/device interface, the concept should be understood and addressed in the examination.

3: Skin Health
Residual limb skin problems have been shown to be present in up to 70% of young, active amputees.13

• Non-weight-bearing surfaces represent potential areas for skin breakdown, often tied to poor prosthesis fit. Common sites include the anterior surface of midfoot, malleoli, distal tibia, fibular head, tibial crest, distal femur.
• Evidence of active or healed pressure ulcers suggests problems with prosthesis fit. Active pressure ulcers may preclude regular use of the prosthesis and require frequent periods of no prosthesis use. The skin overlying healed pressure ulcers is more prone to repeat breakdown than skin that has never had an ulcer.
• Verrucous hyperplasia, wart-like lesions on the end of a residual limb due to proximal “choking” of the residual limb, indicates an ill-fitting prosthesis.
• Chronic cellulitis, folliculitis, and/or fungal infections may preclude daily or longer duration (e.g., overtime) prosthesis use. The skin of the residual limb as well as the padding in the prosthesis socket should be examined for evidence of staining from skin wound drainage.
• Epidermoid cysts, noted as deep subcutaneous round or oval, initially non-tender lesions, more commonly along the point of contact of the prosthesis brim of transfemoral prostheses, these cysts may enlarge and eventually become tender and/or erupt leaving an open sore.13
• Scar adhesion to deeper tissues at the surgical site, which may create shear points and symptomatic neuromas, should be documented.

4: Range of Motion in Remaining Joints
Any contracture at the next proximal joint will adversely affect prosthesis fit and prosthesis/patient function and energy expenditure and will require job task functional assessment. A flexion contracture of greater than 20° generally makes fitting of the prosthesis difficult. A contracture of less than 20° may allow prosthesis fitting, although it may still adversely affect function to the point of the LEO being unable to safely and effectively perform necessary law enforcement job functions.

5: Pain
Poorly controlled residual limb pain and/or presence of symptomatic neuromas may adversely affect fit and wear time of the prosthesis as well as introduce mental distraction from mission objectives. Additionally, medications used to treat phantom pain may have performance implications (see Medications chapter). At the time of this writing, gabapentin, amitriptyline, venlafaxine, topiramate, levetiracetam, and carbamazepine are commonly used to treat residual limb pain.

NOTE: Since a number of the phantom pain medications are also anti-epileptic drugs and many amputations are associated with multiple trauma events, it should be verified that the medications have not been prescribed for treatment of a concomitant seizure disorder.

6: Gait
Gait reflects proper fit and alignment of prosthetic components. Many gait deviations can be addressed by adjustments to the prosthesis. Once all prosthetic mechanical and fit issues have been addressed, persistent gait abnormalities are likely to be associated with contractures or muscle weakness in the residual limb.

7: On-going Reassessment
An amputation is the beginning of a life-long relationship between a person and their rehabilitation team. The LEO should be required to have regular follow-up with the police physician, to supply either medical records or summary notes from any medical care related to the residual limb or associated conditions and to notify the police physician of any adverse developments in personal health, residual limb health or prosthesis function. Prosthesis service records for the last year or since fitting of the current prosthesis should be submitted as well.