Prosthetic Devices for Adaptative Sport in Pediatrics: A Narrative Review

Abstract

(1) Background: Pediatric activity-specific prosthetic adaptations—such as running blades or cycling attachments—enable children’s participation in recreational activities, otherwise limited with daily use prostheses (DUPs). However, there is little information regarding their design, manufacturing process, and biomechanical performance. This review addresses this gap by systematically analyzing the current literature on upper and lower limb amputations, and offers a novel synthesis to inform future research. (2) Methods: A review of the literature published in English between 2005 and 2025 was conducted using databases such as PubMed, Scopus, Web of Science, and Google Scholar. We included studies focusing on amputation, prosthetics, and 3D printing. (3) Results: Running and cycling prostheses are among the most extensively studied in recent years. Comfort is reported as a key aspect for achieving an optimal outcome, and innovations in sockets align with biomechanical principles of amputation. However, high costs remain a significant barrier. (4) Conclusions: Advancements in design, material choices, and techniques, such as 3D printing (3DP), have been central to the development of novel activity-specific prostheses for children. However, the current literature focuses mainly on track sports and cycling. This, as well as the lack of accessible key information behind the development of these devices, showcases the present gap between the pediatric and adult research fields.

1. Introduction

Limb deficiency in children presents significant challenges to both psychosocial well-being and physical functioning, particularly when navigating varied daily environments. Unlike adults—whose amputations are often acquired due to trauma, peripheral vascular disease, or infections [1,2]—pediatric limb loss is frequently congenital, resulting from developmental anomalies during limb formation. Pediatric patients also differ significantly from adults in their physical characteristics, as they are still undergoing rapid skeletal growth, with continuous changes in limb length, girth, and motor development, along with a greater likelihood of terminal bone overgrowth. These factors necessitate a specialized approach to care and rehabilitation in the pediatric population.

Limb absence or deficiency can translate into difficulties when performing both sportive and daily living activities (ADLs). In fact, prosthetic care is essential throughout the lifespan of children with limb deficiencies, regardless of whether the cause is congenital or acquired, and the use of prosthetic devices in treatment aims to offer children the possibility of developing age-appropriate capabilities such as walking, grasping, or lifting, as well as promoting participation in physical and recreational activities such as sport.

Sport activities have long been reported to contribute positively to physical and mental health [3,4], and pediatric-adapted prosthetic devices aim to approach the aforementioned barriers and enhance children to perform sport-specific skills by allowing for them to regain large parts of their lost functions [5]. Participation in recreational activity is important for their growth and physical development, as well as improvements in fitness, motor coordination, self-esteem, quality of life (QoL), and social integration.

This review aims to carry out an in-depth analysis of state-of-the-art prosthetic devices in a pediatric population and their use in recreational activities and adaptative sport for both lower- and upper-limb deficiencies.

2. Methods

2.1. Search Strategy

An extensive literature search was conducted across the following electronic databases: PubMed/MEDLINE, Scopus, Web of Science, and Science Direct. The search covered all publications available from January 2005 to January 2025. Keywords and MeSH terms (and combination of thee) were used and included the following: “pediatric prosthesis”, “congenital limb deficiency”, “acquired amputation”, “sports participation”, “recreational activities”, “3D printing”, “additive manufacturing”, “upper limb”, and “lower limb”. Boolean operators (AND, OR, NOT) were used to refine search outputs. The combination of these keywords has been gathered in

Table 1. Full search strategy.

Search Strings	Last Search Date
(prosthes* OR device) AND children AND sports	20 March 2025
(“pediatric prostheses”) AND sports	20 March 2025
“Prostheses AND (“recreational activities”) AND children”	20 March 2025
“Prostheses AND sports AND children”	20 March 2025
“Auxiliary AND sports AND children”	20 March 2025
(“acquired amputation” OR congenital amputation” OR “congenital limb deficiency”) AND (“sports participation”)	20 May 2025
Prostheses AND sports AND children AND “3D printing” AND “additive manufacturing”)	20 May 2025
Prosthetic AND (hand OR leg OR foot OR feet OR limb) AND children AND (sports OR “recreational activities” OR running OR swimming OR bicycle OR “table tennis”)	22 May 2025
(Prostheses OR prosthetics) AND (children OR pediatric) AND limb AND (sports OR “recreational activities” OR running OR swimming OR bicycle OR)	22 May 2025
(prosthesis OR prostheses OR device) AND amputation AND deficiency AND (sports OR “recreational activities” OR running) AND (children OR pediatric) AND limb	22 May 2025
“Artificial Limbs” [MAJR] AND children	22 May 2025

* truncation opertor.

. In addition, gray literature sources (e.g., Google Scholar, WHO reports, ResearchGate) were also examined to capture non-indexed but still relevant documents.

2.2. Inclusion and Exclusion Criteria

Studies were included in this review if they met the following criteria: First, the study population had to consist of children or adolescents aged between 0 and 18 years, with either congenital or acquired limb amputation. Second, the intervention of interest was the use of prosthetic devices—whether upper- or lower-limb prostheses—specifically for participation in sport or recreational activities. Third, the type of prosthetic devices considered included both commercially available solutions and those designed using 3D-printing technologies. Fourth, the studies were required to report descriptive or evaluative data on aspects such as device use, design, usability, physical performance, quality of life, or psychosocial impacts in the context of sport or recreational activity. Fifth, eligible study designs included original research articles employing quantitative, qualitative, or mixed-methods approaches, as well as case reports, technical reports, and clinical studies. Finally, only studies published in English or those that provided an English abstract were included.

Studies were excluded if they did not meet the above criteria. Specifically, studies were excluded if they focused on adult populations or included mixed-age populations that did not present a separate analysis for the pediatric subgroup. Additionally, studies were excluded if they only addressed the daily functional use of prosthetic devices without any reference to sport or recreational participation. Studies focusing exclusively on surgical procedures or pre-prosthetic interventions were also not considered eligible. Non-peer-reviewed materials were excluded, except for gray literature produced by international agencies that demonstrated clear methodological rigor. Lastly, editorials, commentaries, and conference abstracts without accessible full-text versions were excluded from this review.

Although this study is a narrative review, to ensure the inclusion of high-quality and relevant published studies, we adopted the following screening process: All potential pa-pers were subjected to the screening process by two independent reviewers. We first screened titles, keywords, and abstracts independently. After the first screening, Reviewer 1 selected relevant documents, according to the aforementioned inclusion and exclusion criteria. Then, a second reviewer crosschecked the studies. A final list of relevant and high-quality studies that were eligible for inclusion was compiled, and any disagreements were resolved by a third reviewer or by consensus. The studies that met the criteria were reviewed in the full text to determine whether they should be included in this review.

2.3. Study Selection Process

The study screening and selection process was conducted in four distinct steps in order to ensure methodological rigor and minimize potential bias. Studies that were deemed irrelevant were excluded from further consideration. In the second step, the abstracts of the remaining records were to assess their relevance to the topic and their adherence to the predefined inclusion criteria. Studies that met the criteria or that were judged to be potentially eligible were advanced to the full-text review phase. In the third step, full-text articles of all eligible or potentially relevant studies were obtained and examined in detail, applying the inclusion and exclusion criteria rigorously. In instances of ambiguity or disagreement regarding eligibility, the full author team discussed the study until a consensus was reached. Finally, to ensure comprehensive coverage of the available literature and reduce the risk of omitting relevant studies, the fourth step involved a manual screening of the reference lists of all included studies, as well as recent review articles published within the last twenty years, to identify any additional eligible records.

2.4. Data Extraction Synthesis

Data from each included study were extracted using a structured form developed to align with the review’s objectives. Extracted elements included study citation, publication type, design or scope, population characteristics (age, number of participants, amputation type), type of sport or recreational activity, level and location of limb loss, and type of prosthetic device used. Prostheses were classified by function (daily use vs. activity-specific), manufacturing method (commercial vs. 3D printed), and mechanical features (passive, dynamic, or myoelectric). Outcome measures were recorded when available and included functional performance, usability, user satisfaction, psychosocial dimensions, and participation outcomes. Data extraction was conducted as a narrative summary of the results reported in the literature over the past 20 years. It did not follow a meta-analytical or quantitative approach. Relevant information from the selected studies is presented in a comparative table (

Table 2. Data extraction table of the selected studies.

Type of Prostheses	Study (Author, Year)	Type of Article	Study Design/Scope	Population (N, Age) or Method	Sport(s)	Type of Amputation			Prosthetic Device	Outcome Measures Covered	Key Findings/Conclusions	Exposed Limitations/Gaps
						Etiology	Laterality	Level of Amputation
Lower limb	Hadj-Moussa et al., 2022 [6]	O.R.A	Qualitative cross-sectional study	Children and youth (8 participants [8–20 y.o.]).	Running (track, field, cross-country), basketball, gym	Congenital, acquired	Unilateral (n = 5), bilateral (n = 3)	Knee (n = 1), transtibial (n = 6), ankle (n = 1)	RSPs	Impact of RSP in sport and physical activity participation. Benefits and limitations of their use compared to DUPs.	Advantages of RSPs include jumping. Limitations involve running and jogging at different speeds and long periods of time.	Financial barriers. Limited studies that approach RSPs.
	Agnew et al., 2020 [7]	O.A	Innovative Study	Mechanical testing methods for simulation.	NR	NR	NR	NR	College Park: Truper, Ossur: Cheetah Junior, Flex-Foot Junior, Vari-Flex Junior.	Simulation of single-leg drop-landing with four pediatric prosthetic feet from two heights and two contact orientations.	All prosthetic feet were stiffer for flatfoot. The Ceetah was the least sensitive to foot angle, while the Flex-Foot Junior and Truper showed the greatest values of stiffness for flatfoot. Individual feet showed different stiffness, but differences were not significant of height changes.	The four prosthetic feet had different intrinsic functionalities when applied in sports contexts. Prosthetic feet are often the result of re-dimensioned adult prostheses.
	McQuerry et al., 2019 [8]	O.A	Qualitative cross-sectional study	Infants, children, and adolescents [96 participants (0–21 y.o.)].	NR	Congenital (n = 78), acquired (n = 18)	Unilateral (n = 84), bilateral (n = 12)	Transfemoral (n = 9) Knee (n = 27), Transtibial (n = 21), Ankle (n = 39)	Defined as low-end or high-end, based on L-code.	Subjective perception of function based on amputation level using PODCI scores.	Better sport/physical functioning scores for ankle-level compared to knee-level amputation. Congenital and acquired amputees showed similar outcomes. Bilateral knee amputees had significantly worse outcomes in transfers of sport/physical functioning compared to ULA.	Limited data comparing functionality for different levels of amputation, specially for causes other than osteosarcoma.
	Westberry 2017 [9]	N.R	State of the art (1983–2015)	Children.	Running and swimming mentioned	NR	NR	_ †	_†	Residual limb deformities and prosthetic management. Fabrication and performance of these devices.	Importance of an adequate residual limb. Fitting of initiates with a simple device and follows a gradual transition.	Financial demands during lifespan suppose a limit. Molding and manufacturing should use CAD/CAM systems.
	Griffet, 2016 [10]	N.R	Literature Overview (1998–2011)	Infants, children, and adolescents.	Multi-sport	Congenital, acquired	NR	Hip, femur, tibia, foot	C-leg Ottobock, Genium leg Ottobock, commercially available sport-specific TDs.	Amputation surgery, fitting of prosthetic devices, performance, and rehabilitation.	Adaptation of a prosthesis requires a disciplinary team, periodic evaluations, imaging, and GA. Specific evaluation for ASPs.	Lack of literature on the psychological impact of amputation. Fitting of prostheses in children adapts to their growth. Difference in performance between feet and below-knee prostheses.
Upper limb	Kopova’ et al., 2024 [11]	O.A	Innovative study	Children (3 participants [4–5 y.o.]).	Cycling	NR	NR	_ †	Innovative device.	Design and implementation of a low-cost upper-limb cycling adapter for young children with a 360º rotation around arm axis.	Use of FDM and MJF as the 3DP technique. Bicycle adapter consists of a rotational eight-tooth mechanism and a grasping end. Flexion and pronation enabled. Nanomaterials as a future proposal.	FDM presented quality limitations. Testing and evaluation performed without the wrist mechanism.
	Kanas et al., 2009 [4]	N.R	Literature Overview (1998–2009)	Children.	Multi-sport	NR	NR	_ †	TRS-manufactured ASPs.	Technical and functional aspects of activity-specific TDs for children in a variety of sports and activities.	TD choice must consider different aspects. Classification of ASPs. Prescription of these devices requires reaching certain milestones. Type of prosthetic components and their use.	Issues reported on the cost of the ASP, age and size of the user, and its use in certain activities. Reported lack of documentation of TDs and their designs.
	Walker et al., 2008 [12]	O.A	Qualitative cross-sectional study	Children (11 participants [4–16 y.o.]).	Multi-sport	Congenital (n = 10), Traumatic (n = 1)	Unilateral (n = 10), bilateral (n = 1). Unilateral prosthetization only.	Proximal third of the forearm (n = 4), middle third of the forearm (n = 3), wrist (n = 2), hand (n = 2)	Commercially available ASPs (TRS-manufactured and others).	Successful users evaluation through a chart review and patient survey.	TDs for weight-lifting and violin-playing adaptations were reported as being beneficial to the user’s performance. Age differences between successful and unsuccessful users. Effect of level of amputation on reported success. Relevance of the use of one or two limbs in bimanual activities on the outcome.	Lack of sensorial input and feedback in current ULPs can affect outcomes in certain activities.
Both upper and lower limbs	Louer et al., 2021 [2]	N.R	Literature Overview (1975–2020)	Children.	NR	Traumatic	Unilateral and bilateral	_ †	_ †	Surgical principles in pediatric amputation, recovery timeline. Pain/complaints of prosthetic fits and possible causes. Timing of prosthetic use in ULA and LLA in pediatric congenital deficiencies.	Importance of quality amputation in growing children. Factors impacting adaptation of the prostheses and timing of prosthetic introduction for DUPs and ASPs.	A prosthesis lasts a child 12–18 months. Surgical approaches and prosthetization are limited to the growing characteristics of the pediatric patient.
	Hall et al., 2020 [13]	N.R	Current Concept Review (1972–2020)	Infants, children, and adolescents.	NR	NR	Unilateral and bilateral	_ †	_ †	Timing and future function of prosthetic devices. Prosthetic options and terminology.	Requirements for proper prosthetic use and timing of its fitting. Characteristics of the residual limb needed for an adequate prosthetization.	ASPs are not considered “medically necessary” and are not covered by insurance.
	Ahmed et al., 2018 [5]	O.A	Qualitative study	Children and adolescents [11 participants (6–14 y.o.)] and parents.	Multi-sports	Congenital (n = 11)	NR	Upper deficiencies: elbow (n = 1), trans-radial (n = 3), Hand (n = 2) Lower deficiencies: transtibial (n = 4), transfemoral (n = 1)	_ †	Interviews with children with and without parents. Functionality, capabilities, stigma and social environment, interest for sport, and investment involved.	Variability in reported functionality of the prosthetic device.	Cost of ASPs. Sampling bias mentioned as a possible limitation. Lack of comparative studies between children who do not engage in sport activities and does who do.

O.A, original article; O.R.A, original research article; N.R, narrative review; DUP, daily use prosthesis; RSP, Running-Specific Prostheses; LLA; UL, upper limb; 3DP, 3D printing. NR, not reported; ^† Not specified.

).

3. Results

To provide a clear visual representation of the screening process and the number of studies retained or excluded at each stage, a flow diagram is used. As reported in Figure 1, a total of 675 papers were initially identified using the search strategy; after removing duplicates and screening abstracts based on inclusion criteria, 34 articles were selected for full-text review. Following further exclusions due to insufficient data or misalignment with the target population, 23 papers were excluded due to the following exclusion criteria: non- targeted population (n = 3); inadequate study design (n = 5), which included studies with incomplete or unclear methods and studies with insufficient follow-up or outcome measures; and irrelevance to the research question (n = 6), insufficient data (n = 3), which included papers with missing key outcome data. A total of 11 articles were retained for analysis, including two identified using a parallel search on Google Scholar.

3.1. Nature of Pediatric Limb Deficiencies and Impacts in Prosthetic Use: Congenital and Acquired Amputations

According to the International Organization for Standardization (ISO) [13,14], congenital limb differences can be categorized into two categories: transverse and longitudinal. The first refers to limb deficiencies where a distal segment of the limb is missing, whereas the latter occurs when bones along the longitudinal axis are shortened or missing. In the case of longitudinal deficiencies, the distal segments are present, either partially or fully. The incidence of upper-limb congenital deficiencies is between two and three times greater with respect to those of the lower limbs [13,15], and while congenital transverse deficiencies are more common among upper-limb malformations, it is longitudinal deficiency that prevails over transverse limb differences in the case of lower extremities.

In the case of congenital amputation (i.e., limb agenesis), surgery is not an adequate approach, but rather a highly specific management strategy [10]. Congenital deficiencies in young children can initially be accommodated in a prosthesis, but may pose complications and limitations for future prosthetic design, function, and cosmesis throughout the child’s growth. Alternatively, trauma-related limb loss is the leading cause of acquired amputations [9,16] and typically result in the transverse or complete amputation of a limb. In fact, finger amputations are the most common traumatic amputation in all age groups, with a peak incidence in the case of toddlers. Complications may occur due to severe soft tissue loss or trauma to other parts of the body. Additionally, acquired amputations might be a result from tumors or infection; terminal bone overgrowth in children exemplifies possible congenital abnormalities, and can also lead to amputation as the only solution.

In both cases of amputations (i.e., congenital and acquired amputations), pediatric patients may benefit from prosthetic devices. Consequently, high-quality amputation is essential for obtaining an adaptable residual limb suitable for prosthetic fitting that maximizes physical function and minimizes experience of pain or discomfort. To this purpose, limb amputation in pediatric care follows a strict set of surgical principles [2,10,17] aimed at ensuring recovery and restoration of a “normal” life, in such a way to ensure age-appropriate developmental milestones and the possibility of participating in recreational activities. These principles include the preservation of length and growth plates, favoring disarticulation over transosseous amputation, preservation of joint function (especially of the knee), and stabilization of the proximal portions of the limb. Disarticulation of the knee is very rarely performed in children, but can be required to treat tibial tumors or congenital deficiencies [2,10]. Nonetheless, possible complications in the fitting of a prosthetic device derived from or after amputation include bone overgrowth [2,9,10] at the transected end due to preservation of the growth plate in very short final stumps or formation of a sharp spur at the end of the bone after amputation in the case of transtibial amputation. These complications might involve a subsequent amputation.

The residual limb stump must thereby be of optimal length to correctly provide stability, comfort, and functionality to the prosthetic device. If too long (more commonly found in traumatic amputations of the foot, especially in older children), the use of sport-specific terminal devices might not be possible in high-demand activities such as those that require dynamic-response feet. In the majority of cases, a shorter residual limb is preferred over a long residual limb [9]. Stump length and shape must therefore fit the patient to accommodate the device properly, not only at the time of amputation, but also during the child’s growth.

The levels of upper limb loss can be classified as transcarpal and partial hand, styloid/wrist disarticulation, transradial, elbow disarticulation, transhumeral, glenohumeral (shoulder) disarticulation, and interscapulothoracic (or forequarter) [18,19,20]. Similarly, for the lower limb, classification follows as partial foot, transmetatarsal, lisfranc, chopart, ankle disarticulation (Syme’s amputation), transtibial, transfemoral, hip disarticulation, and hemipelvectomy. Each level of amputation requires a special adaptation of a prosthetic device, which will be discussed in this paper.

Additionally, it has been reported that the outcome of prosthetic use is notably influenced by the unilateral or bilateral loss [4,18]. While bilateral amputees find in prostheses a key resource to interact with their surroundings, unilateral amputees perceive these devices as a tool that serve as an aid for the sound limb.

3.2. Prosthetics in Children

3.2.1. Nomenclature of Prosthetic Devices

One of the main issues highlighted over the years related to the use of prostheses are their functional roles in the user’s ability to perform the different daily activities. Understanding the role of each component of a prosthesis is essential to ensuring its overall compatibility and functionality. The general structure of a prothesis (Figure 2) consists of a socket, interface, structure, and suspension, regardless of the type and level of amputation, and may include additional specific components based on the level of deficiency (i.e., feet, knees, terminal devices, or elbows).

The socket accommodates the user’s residual limb to the prosthesis by surrounding it, thereby serving as a point of attachment between the two. It is custom-made and seeks to adapt to the amputee’s morphology while compressing pressure-tolerant regions of the residual limb in order to securely suspend the prosthesis. The interface is a material placed between the skin and the socket, and it is almost always used, with the exception of cases where direct contact between the limb and the socket is appropriate. While gel liners are typically fabricated to accommodate cylindrical-shaped residual limbs, custom foam liners are often used for atypically shaped limbs. Most models also use prosthetic socks (with various thicknesses) to adjust for volumetric limb changes. Optionally, a socket liner can be additionally used to improve comfort and suspension. In the case of activity-specific prostheses for activities such as weight-lifting, fishing, and impact sports require a prosthesis with additional strength. Such additional strength can be achieved without necessarily compromising comfort by modifying the socket material, cable, and harnessing to ensure safe and successful outcomes, as well as a suspension system. The latter becomes a key aspect, especially in sports that produce a significant distal pull or draw on the terminal device, such as bowling. As a result, auxiliary harnessing, suspension sleeves, and the use of a pin-type locking liner could be proposed as an additional resource.

The Terminal Device (TD) is the most distal component of the device and can serve as a helping component for grasping functionality, or is otherwise limited to appearance purposes. Self-suspending devices exploit wider boney anatomical areas of the remaining limb, such as in the case of malleoli for the Syme amputation of the lower limb. Complementarily, sleeves are often used on cylindrical limbs, such as transtibial amputations, to attach the prosthetic socket to proximal limb segments. On the other hand, harnessing is often used to further assist in prosthetic suspension and/or to leverage body motion to actuate grasping functions in a TD in active upper-limb devices. Alternatively, suction and vacuum suspension require a consistent and intimate socket fit. Consequently, they are rarely used in pediatrics due to children outgrowing the fit.

Selection of an optimal prosthetic device derives from proper consideration of the level of amputation, residual limb condition, and patient’s development, as well as the intrinsic purpose of the prosthesis and family goals. The first consideration is considered to be the most fundamental principle when considering prosthetic options [19].

3.2.2. Current Barriers in the Field of Pediatric Prosthetics

Functionality of the Device

As outlined in Battraw et al. [21], pediatric prosthesis wearers may be content with no grasping function and opt for a passive device or choose not to wear a device at all in the absence of sufficient functional gain, due to the limited benefit of active prosthetics relative to no grasping function at all. In the case of children born with congenital ULDs, effective learning of one-handed compensatory strategies for most daily tasks happens early in life. Since there is no real sense of limb loss, the prosthesis is perceived as an aid and not so much as a limb replacement. Therefore, congenital deficiency supports a close-to-normal function in daily life, and evidence suggests that little improvement in physical functioning comes from using current prosthetic devices.

Similarly, Louer et al. [2] showcases the choice not to wear a prothesis due to the inability of the devices to enable sensation feedback, thereby impairing functionality. In Hall et al. [13], it is reported that children with congenital deficiency may suffer a block of limb sensory feedback due to the prosthetic socket, which is necessary to develop strategies to become functional, and is otherwise achievable without the prosthesis following adaptative compensatory mechanisms. This is especially evident for children with bilateral hand and/or arm absences. In Walker et al. [12], problems associated with upper-extremity prostheses, such as a lack of sensory feedback, are theorized to extend to activity-specific prostheses as well. In fact, it has been found that the use of recreational terminal devices is beneficial only in those activities where bimanual activity is required, such as lifting barbells or playing the violin. In the case of baseball or basketball, adaptation of TDs rarely helped. On the other hand, older children with acquired amputation from trauma or disease will tend to adapt well to prostheses, since function, sensation, and dexterity have been lost in the affected limb as a consequence of the intervention [13].

Prosthetic Comfort

Prosthetic comfort is a key factor that influences the user’s choice of use. Excessive sweat in socket liners can cause both discomfort and risk of slippage [6]. Socket design for lower-limb prosthetics is oriented to achieving an increase in the weight-bearing surface area of the socket, eliminate friction at the skin–socket interface, and eliminate all lever effects between the socket and suprajacent segment’s soft tissue envelope that may lead to significant mechanical and thermal stresses resulting in scarring and skin breakdown. To tackle these issues, application of new materials, such as silicone gels, co-polymers, and polyurethane, have contributed positively to advances in prosthetic devices.

Ill-fitting sockets can also lead to discomfort, and, in the case of the pediatric population, attention must be paid to morphological modifications associated with the child’s growth. In the case of a growing and developing child, designing a system that the child will not outgrow becomes the main challenge. In fact, there is evidence that child growth limits consistent device control. As the child grows, the morphology of the affected limb changes, and, with it, so does the fit of a prosthetic socket. As a result, the control of the prosthesis will be affected due to unprecise contact, and placement of sensing technology in the case of myoelectric prosthetic devices [21]. In addition to lack of comfort and fit, excessive weight and limited RoM have also been reported [5].

Economic Barriers

Prosthesis fitting in pediatric users involves several steps, and patients will require a new prosthesis about every 12–24 months until they are skeletally mature [2]. Comparably, in Griffet et al. [10], a change of prosthetic device is purported to be, typically, once a year. Modifications to the prosthesis, followed by a correct physical or occupational therapy that helps with adaptation or when a new major developmental stage is entered, can extend the device’s useful life as the child grows. Correspondingly, the economical limitations of prosthetization in children have been emphasized over the years. In fact, in Sayed et al. [5] and James et al. [22], particular focus has been given to activity-specific prosthetics being secondary “not medically necessary” devices that are, therefore, not covered by insurance.

3.3. Timing of Prosthetic Fit

Developmental milestones should be considered with respect to the timing of prosthetic fitting and component sophistication. The event that determines the appropriate timing for a child’s first upper-limb prosthetic device is the acquirement of sitting balance at around 5–7 months [13], and an active prosthesis can be introduced around the second year of age [2]. In fact, initial fitting prior to an age of three years has been linked to an improved functional outcome of prosthetic use for children with unilateral congenital below-elbow deficiency, although no relevant benefits were extracted for fitting before one year of age [23]. Additional evidence suggests that early prosthetization could be useful in ensuring the fast adaptation of the child to the prosthetic device in children with agenesis or amputation of the upper limb [24], and a trend of a lower rejection rates in children with congenital unilateral limb deficiency has been found. In fact, a higher rejection rate was found in prosthetic fitting performed after this age [25].

In the case of lower-limb prosthetics, the ideal time for the initial endorsement of a prosthetic device in congenital deficiency is when they can perform a pull-to-stand maneuver, usually between 10 and 12 months [2], or even up to 14 months, of age [13]. Evidence has shown that a functioning mechanical knee as a first prothesis encourages symmetry in patterns of movement such as crawling, tall kneeling, and pulling to stand in select patients [2,26]. Gradual transition from daily use prostheses (DUPs) into more customized devices as the child matures is underlined in several studies (Louer et al. [2], Westberry [9], Kanas et al. [4]). In fact, the incorporation of components must follow the development of age and the needs and requirements of the growing child. Usually, the implementation of these devices, such as activity-specific devices, occurs when the child can no longer profit from DUPs and physical requests overcome the functionality offered by these aforementioned devices [13].

3.4. Activity-Specific Prostheses

Recreational activities often require a separate or secondary prostheses with activity-specific components that can meet the child’s needs in order to perform such activities when they are otherwise (i.e., without the prosthesis) unable to do so.

3.4.1. Upper-Limb Prostheses

Upper-limb pediatric prosthetic adaptations have been studied in Walker et al. [12], Kanas et al. [4], and Kopova’ et al. [11]. In the first study, the usefulness of 15 commercially available recreational terminal devices for upper-extremity deficiencies were studied through chart reviews for 11 children (ages 14–16 years) with below-the-elbow amputations at four different levels: the proximal third of the forearm (n = 4), middle third of the forearm (n = 3), wrist (n = 2), and the hand (n = 2). All but one of the subjects were unilateral amputees, and prosthetic fitting was only evaluated unilaterally. Similarly, only one subject had an acquired amputation, and the rest presented congenital deficiencies. In Kanas et al. [4], a variety of commercially available activity-specific prostheses were also qualitatively analyzed, and a classification of activities was introduced for adapted prosthetic TDs. On the other hand, Kopova’ et al. [11] introduced the development of an innovative cycling adapter for upper-extremity amputees.

Commercially Available Prosthetic Terminal Devices

For children with upper-limb deficiencies, activity-specific terminal devices are available and can either be interchanged with a conventional terminal device or integrated into a secondary prosthesis. In Kanas et al. [4], the use of a quick disconnect wrist unit is highlighted as the more obvious and simplest way to adapt an existing prothesis, which facilitates the quick release of an existing terminal device in enabling a change to a terminal device more appropriate for the desired activity [4]. A variety of sport-, hobby-, and activity-specific terminal devices currently available on the market work with this mechanism. Some examples of these sports involve holding ski poles, oars for boating, or fishing poles. In fact, Hosmer Dorrance Corporation, TRS, Inc., and Texas Assistive devices are presented as three of the major manufacturers of adapted TDs. Examples are shown for TRS products, such as the Grip Prehensor with locking pins for weight-lifting, the Hi-Fly fielder for baseball, the Violin Bow Adapter, the Amputee Golf Grip for golf, the Slap Shot Hockey, and the Rubber-Covered Hook TD for the trumpet. Walker et al. also presented the Mill Re-Bound Pro Basketball Hand, the Shroom Tumbler, the Free Flex, the Super Sport, the Freestyle Fin Kit, and the SKI 2 for skiing.

Classification of Activities

Kanas et al. [4] classifies the prosthetic adaptations and options for use in specific activities into three groups: water/snow sports, team/individual sports, and fine arts/hobbies [4], some of which can be found in Figure 3. The first category faces potentially harsh environments, and the socket may need to be sealed to prevent water from entering or alternatively be modified to allow for water to easily drain out of the socket. Non-corrosive materials in the socket have been proposed as an appropriate approach. Although performance in swimming can be accomplished with standard devices, custom-made devices for this sport better enhance propulsion in water [9].

Team and individual sports present the highest diversity due to the use of different types of balls and the intrinsic differences between sports. Consequently, among others, different custom-made TDs for sports such as lacrosse, basketball, baseball, golf, or ice hockey have been commercialized. The Super Sport hand is an example of a multisport terminal device that can be used in basketball, soccer, gymnastics, and sports requiring catching skills. Recently, Kopová et al. [11] have recently developed, tested, and validated a novel upper-limb adapter for young children that can lead to enhancements in physical activities such as cycling. The prototype allows for 360º rotation around the arm axis and allows for natural duction movement, unlike traditional models that address static or limited-mobility prostheses. This activity-specific device has been developed for children between 1 and 3 years old and has been tested on three children from ages 4 to 5, and aims to provide natural-like rotation of the body during cycling. Two prototypes were developed before reaching the third and final product design. The final product consists of a three-part mechanisms with a gripping end, designed with a narrower central part and a shape-expanding flexible clamp that allows for connection/disconnection while stationary. Flexion is partly enabled by the rotation of the prosthetic’s clamping part, which, in turn, also permits a duction movement (enabling radial and ulnar deviation). The mechanism consists of eight teeth that correspond to unique positions and can be fixed using the interaction between a nut and two interlocking parts with complementary shape projections. This product, however, does not include movements associated with breaking.

The last category of fine arts and hobbies includes participation in music, photography, weight-lifting, wood chopping, painting, hunting, archery, and table pool. These activities generally require precise intrinsic muscular control of the hand, wrist, and fingers, which is very hard to replicate in prostheses. However, one solution might be choosing from the different dynamic wrist units available. An example that can be taken into consideration is the use of a violin terminal device, where a flexion wrist unit may be modified by removing the tension and resistance and used in conjunction with the terminal device. This modification would tackle the problematic of creating a smooth intricate movement.

3.4.2. Lower-Limb Prostheses

Other examples of sport-specific activities are studied in Griffet et al. [10], Agnew et al. [7], and Hadj-Moussa et al. [6] for lower-limb pediatric amputees. In the first study, amputation at the different levels of the lower limb were examined, and prosthetic potential is discussed. The study identifies three levels of amputation: the hip, the femur, the tibia, and the foot. Special focus is given to feet prosthetics in Agnew et al. [7], where the characteristics of foot prostheses’ performance is evaluated in a simulated test under different conditions. Additionally, in Hadj-Moussa et al. [6], particular exploration of the use of Running-Specific Prostheses (RSPs) in sports was conducted using a qualitative cross-sectional study for eight individuals (ages 8–20 years) with three levels of amputation: knee disarticulation (n = 1), transtibial (n = 6), and ankle disarticulation (n = 1), as well as both unilateral (n = 5) and bilateral (n = 3) amputation.

Amputation Levels and Prosthetic Implications

As exposed in Griffet et al. [10], prostheses that use lightweight material for the hip and knee perform poorly in children, especially for uphill and downhill walking. Conversely, children who have reached their final height can make use of high-performance prosthetic materials, which can create a more dynamic flow of the gait on unlevelled ground. Although high-performance prosthetic material devices (e.g., the C-leg microprocessor-controlled knee together with carbon-fiber foot and Helix 3D hip joint) make running possible, it is not easy for the user.

Above Knee Amputation 

Above knee amputation (or amputation at the level of the femur) is the limb loss level that benefits most from technological advances. Innovative solutions leave behind the quadrilateral socket to integrate the ischium in a socket that cups the medial aspect of the ischial tuberosity. This allows better control of the prosthesis and returns the femur to its physiological natural abduction position. In fact, its better tolerance to sump size and comfort in long-distance walks adapts well to pediatric patients. The authors highlight equipment of the prosthesis with a shock absorber to improve comfort, a torque absorber for playing golf, or even a rotator at the knee to enable cross-legged sitting. For sport-specific activities, different prosthetic devices have been developed with the integration of different components, such as the aforementioned running blade for running, and a specific knee-foot combination for alpine skiing and snowboarding.

Below Knee (or Transtibial) Amputation 

Below the knee amputation allows for accommodation of total-contact sockets (Total Contact Bearing—TCB). These sockets are modeled over a thin adhesive or 6 mm gel sleeve and combined with a ratchet or vacuum suspension system. Uniformly distributed pressures in the socket allows for complete elimination of friction, while maintaining its holding capacity intact due to its physiological and uniform tightening. Similarly, as in the case of femoral prosthetics, total-contact sockets are always used over an adhesive sleeve that is rolled onto the stump. In order to participate in sports and recreational activities, activity-specific components are also available for pediatric population: broad range of dynamic carbon-fiber feet, shock absorbers, torque absorbers, and feet specifically designed for skiing or water sports. Below-knee prosthetic devices are consistently more versatile than above-knee prostheses. This supports the conclusions of McQuerry et al. [8], in which sports/physical functioning subscale of the PODCI reported higher scores for the ankle-level of amputation, with respect to the knee-level amputations.

Foot Amputation 

The last level of amputation corresponds to the foot. In order to participate in sports and recreational activities, activity-specific components are also available for pediatric population: broad range of dynamic carbon-fiber feet, shock absorbers, torque absorbers, and feet specifically designed for skiing or water sports. Below-knee prosthetic devices are consistently more versatile than above-knee prostheses. In Agnew et al. [7], the stiffness characteristics of four commonly prescribed pediatric prosthetic feet (College Park: Truper; Ossur: Cheetah Junior, Flex-Foot Junior, Vari-Flex Junior) is evaluated through simulation of a single-leg drop-landing representative of the average 8–9 male child, and that may occur during sports or play.

The article underlines the uniqueness of pediatric population in that their lifestyle comprehends higher levels of activity with respect to adults, characterized by high-impact activities, such as running or jumping. Performance of prosthetic devices during such high-impact activities can be understood through force and kinetic loading. In fact, stiffness can describe performance, as it quantifies the relationship between elastic energy storage and return [7]; and is therefore closely related to GRFs and kinetic loading. For example, a less stiff prosthesis (i.e., a less rigid device) will store a higher amount of energy during the initial stance phase and return a higher amount of energy in the latter half of stance. However, a greater muscle activation in the residual limb will be needed in order to stabilize a more compliant device, and will result in a higher metabolic demand.

Performance and stiffness of the aforementioned prosthetic during a representative high-impact activity was quantified by studying simulated landing execution in two rapid loading conditions (i.e., landing from two different heights, 5 and 10 cm), while applying two different contact orientations (flatfoot and plantarflexed). Although different stiffness values were gathered across different prosthetic feet, differences in values between different heights were not significant. Overall, all feet exhibited a large range of vertical GRF, deformation, and stiffness results, for which validity was considered for activity-specific prescription purposes. The Cheetah Junior and the Vari-Flex prosthetic feet were found to be better suited for high-impact activities, due to the recorded higher deformation response to higher drop height, in comparison to the Flex-Foot Junior and the Truper, which presented a greater viscoelastic component. Accordingly, the study attributes a greater capability of mitigating forces transmitted through the residual limb to higher deformation results. In addition, the paper associates stiffness to a structural property, and not a material property; and validates it with stiffness results being affected by limb orientation. The article also emphasizes the importance of testing a broad range of functionalities in prostheses, beyond their intended or intrinsic functions, since children are likely to use their prosthetic feet in alternative ways that do not necessarily correspond to the specified activity levels.

In McQuerry et al. [8], different levels of amputation for LLAs with prostheses are evaluated. The paper reported better sports and physical functioning for children with more distal amputations, compared to those with more proximal amputations. These findings align with previous research that have associated proximal amputations to a greater functional limitation, and support the notion that preserving limb length, when possible, can lead to better functional outcomes and QoL for pediatric amputees.

Running-Specific Prostheses (RSPs) and Alternative Solutions

Limitations found in DUPs, prescribed as primary use, are correlated to rigidity in the shank, ankle, and heel components, which leads to insufficient energy absorption/generation capacity. As a result, movements, such as those of a healthy ankle joint, cannot be performed with DUPs. Conversely, RSPs feature curved carbon-fiber blades, the deformation of which allows for impact absorption and energy storage required in high-impact activities such as running, sprinting and jumping (Figure 4). In addition, the lack of a heel component and lighter weight grants a greater energy return, and, consequently, a major explosive moment. In fact, during submaximal running, energy expenditure is reduced significantly when using RSPs compared to DUPs. These design features also differentiate the RSPs from other prostheses, such as dynamic elastic response prostheses (DERPs) or crossover feet. Running-specific prostheses were originally developed for use in competitive sports by athletes, especially for events like track and field competitions in the Paralympics and other elite sports settings. However, the authors mention the significant growth in the use of RSPs in recreational activities within adult and pediatric populations.

While RSPs may have a positive impact on children’s participation in sports, especially in those that involve jumping (i.e., basketball, gymnastics), various issues can appear when over long periods of time that might lead to switching the prosthetic device back to a DUP. The main intrinsic limitations of RSPs are related to the difficulties faced with maintaining balance when standing still or trying to stop. An explanation for this could be the curved shape, small base, and inertial properties of the device. The limited versatility of RSPs, outside of running, can be exemplified by issues with performing quick start–stop motions or navigating uneven terrain. As a result, both court-based sports or physical activity performed outdoors may present limitations to lower-limb amputees. In addition to this, RSPs have a fixed stiffness that make their use difficult over different running and jogging speeds. In the particular case of bilateral amputees, subjects reported a preference for using RSPs for non-running activities, such as walking or playing in the park. In some cases, children preferred not to use their prosthetic devices when participating in sports, opting instead for alternative methods that offered greater stability or adaptability, such as performing gymnastics without a prosthesis for improved balance, playing seated volleyball, wheelchair kin-ball, or sledge hockey [27].

Alternatively, dynamic elastic response prostheses (DERPs) are also made from carbon fiber and provide energy return capabilities. The presence of a heel component can help the user maintain balance, especially during standing. Complementary to RSPs, DERPs also demonstrate potential for use in sports, particularly in the evaluation of start–stop motions.

Our comparative analysis of these studies gathers common perspectives on the use of commercially available activity-specific devices and their current limitations. In Walker et al. [12], a higher ratio of successful users was found for wrist and partial hand-level amputees in relation to participants with amputation at the level of the proximal or middle forearm. Similarly, adapted devices for children with limb loss at the level of the tibia (below-knee) presented better performance than those who suffer from more proximal amputation deficiencies, according to Griffet et al. [10]. The authors in Walker et al. [12] also found evidence of the current limitations of these devices in the lack of sensorial feedback: as a result of not being able to mimic normal hand function, functional TDs become of little use in those activities where the use of both limbs is not required, such as baseball or basketball. Conversely, in Ahmed et al. [5], it was found that some users presented positive feedback on account of perceived benefits in posture, strength stability, balance, and weight distribution that prevented them from overusing the sound limb.

In addition, cost has been repeatedly outlined as a barrier to access commercially available prostheses for recreational activities. Being a secondary prosthesis, families often face economic challenges [4,5,6,13].

3.5. Current Role of Myoelectric Devices and Innovative Methods

Children born with congenital limb deficiencies present consistent and distinguishable biological control over the affected muscles of the residual limb, the signals of which can be extracted through electromyographic recording at the level of the skin, otherwise known as surface electromyography (sEMG). Motor control of advanced dexterous prostheses is derived from the electrical activity of residual limb muscles, recorded using surface electrodes. These signals are processed by a control system, the output of which activates electromechanical actuators to drive grasping movements. This principle extends to individuals with traumatic amputations, where surgical approaches aim to preserve muscle integrity to the greatest extent possible. By maintaining viable muscle groups, the residual limb can provide robust myoelectric signals for prosthetic control, following the same sEMG-based mechanisms observed in congenital cases. However, children born never having actuated a hand, with underdeveloped muscles and limbs, present particularities that differ from adults and children with later-acquired amputations. In fact, distinct patterns of muscle deformation when attempting to move the missing hand have surfaced with ultrasound-based prosthetic control [21].

These electrically controlled devices face aforementioned barriers such as signal noise and artifacts (such as sweat, movement, skin impedance, or muscle crosstalk), electrode placement sensitivity, limited control channels, fatigue, and lack of feedback. In addition, smaller muscles, in the case of children, generate decreased amplitude signals. Current sEMG have a heavy weight, and their fragility and their elevated cost [28,29] make their use in sports and recreational activities challenging.

On the other hand, small size, constant growth, and psychological development in children have an impact on the complexity of their prosthetic needs [29]. Consequently, little effective translation of currently available sEMG prosthetic technology has been adapted to pediatric population, and innovative solutions, such as ultrasound-based prosthetics or a Brain–Computer Interface (BCI), remain solutions that await further advancement.

Furthermore, 3DP is a growing field in the production of prosthetic devices that comprehends different possibilities. In fact, different types of 3D printers (i.e., additive, subtractive), methods (such as CAD), materials (i.e., metal, ceramics, polymers, composites), and techniques for 3DP (i.e., FDM, SLS, SLA, LOM, MJF, EBM, CLIP) exist [30]. This new approach reduces cost, production time, and production waste in respect to traditional methods that use the assembly of small quantities instead of a single-unit print, and could represent a breakthrough for transitional prostheses.

In addition to the aforementioned benefits of 3DP, additive manufacturing (AM) represents a breakthrough in adaptive sports and sports medicine, since it also allows for the customization of prosthetics, as well as face masks, bike helmets, football helmets, jockey helmets, mouth guards, or cycles. However, mechanical properties depend on the printing orientation, and exact values are difficult to predict [11]. In fact, durability, sufficient grip strength, reproducibility, and shrinkage of the printed product would benefit from further research. Additionally, research on 3D-printed prosthetics seldom addresses functional devices that allow for children to engage in recreational activities, but rather focus on production of prostheses that may replace missing limb parts, help enhance the child in bimanual tasks, increase the muscle strength and RoM of the sound limb, and support myoelectric prostheses.

Conversely, Kopová et al. [11] tested and validated a novel upper-limb adapter for young children to aid cycling using two 3DP techniques: FDM and MJF. The first technique was implemented to produce the first two prototypes, while MJF was used in the final product, having obtained problematic supports of the model and poor surface quality in the prototype production.

4. Discussion

The present article seeks to overview state-of-the art prostheses for lower limbs and upper limbs, designed to support sporting and leisure performance in pediatrics. The intention of the present study is to outline the devices reported as functional to this purpose and that may have a positive outcome, and to serve as a reference for future studies that intend to develop and design innovative technologies that may benefit the inclusion of children with deficiencies in sport and leisure activities. To this end, the present paper has retained relevant 11 articles in a 20-year span. The limited number of papers included reflects the current gap in the literature regarding the use of pediatric activity-specific prosthesis in sports, as well as the lack of quantitative and meaningful data to support this area of research.

4.1. Activity-Specific Prostheses: Current Landscape and Conflict Findings

An activity-specific prosthesis is designed based on the impairment of the user and the activity to perform. In fact, commercially available activity-specific prostheses range from water/snow sports and individual and team sports to hobbies such as music, as reported in Kanas et al. [4]. While water and snow sports require an appropriate mechanism for water management, individual and team sports face the challenges of a vast diversity of demands that respond to the differences of equipment between sports; hobbies, on the other hand, require a fine coordination of the hand, wrist, and finger musculature to properly execute the task. Among currently available manufacturers, TRS has been found to be of the most frequently cited in the literature in recent years.

• Multifactorial Determinants of Prosthetic Use

Development, acceptance, and use of pediatric prostheses is a complex issue and comprehends a vast list of possible determining factors, among others, including the following: congenital (e.g., phocomelia) and acquired (e.g., traumatic) amputations, unilateral or bilateral amputations, functional aid, comfort, and the context of the individual. Nonetheless, the present paper demonstrates the lack of literature on the use of prosthetic devices in upper-limb bilateral amputations and their performance during participation in recreational activities. In fact, Hadj-Moussa et al. [6] reports a higher challenge for pediatric BLA to accommodate the prosthesis and a preference for using RSPs in non-running physical activities such as walking or playing in the park, or even the removal of prostheses during gymnastics, volleyball, kin-ball, and hockey [6]. Similarly, McQuerry et al. [8] disclose worse outcomes in those sports or physical activities that require weight transfer, compared to ULA [8]. On the other hand, Walker et al. performed a qualitative cross-sectional study that included subjects with both unilateral and bilateral amputations. However, prosthetization was performed unilaterally, even for those with bilateral deficiencies.

The level of amputation has been consistently reported as another significant factor influencing prosthetic performance [4,8,12], with more proximal amputations leading to better performance results; and surgical technique developments and improved robustness of principles underlying amputation surgery are considered essential to create a stump capable of accepting a function-restoring prosthesis. In addition, innovative material prospects have been introduced, and new prosthetic designs are still being explored. Correspondingly, notable advances have been made in the field of limb prostheses in children. Nonetheless, the use of state-of-the-art prosthetic devices in sports is reported in the literature as being controversial, especially for children. While these devices can offer increased mobility and balance in the case of lower-limb amputees (LLAs) and increased reach function in the case of upper-limb amputees (ULAs), prosthetic devices still have limitations, representing an obstacle to achieving near-normal performance in limb deficient individuals, especially in childhood. The excessive weight of the device, limited range of motion (RoM), and lack of comfort and fit have been reported in the case of sport-specific devices for children. In fact, in Walker et al. report that inadequate functionality of the Terminal Device, as well as loss of sensory input, are limitations on its use in sports for unilateral amputees.

On the other hand, physical functional limitations found in advanced myoelectric devices extend to noisy control signals, sensitivity to electrode displacement and arm posture, and muscle fatigue. Moreover, economic challenges have been vastly reported as a current barrier for the use of prostheses in the field of recreational activities.

• Capacity vs. Performance: Real-World Use

An important consideration that has emerged in recent years, but remains unrepresented in pediatric prosthetic research, is the distinction between what a child can do under ideal conditions and what they actually do in everyday life. These conceptual separations—referred to, respectively, as capacity and performance—are embedded in the International Classification of Functioning, Disability and Health [31]. While capacity reflects the potential ability of an individual to carry out a task in a standardized environment, performance considers the effective execution of that task in the context of the child’s real-life environment, shaped by facilitators and barriers. As highlighted in a recent systematic review [32], understanding functioning in children with disabilities requires a multi-dimensional approach that goes beyond clinical or biomechanical parameters.

This distinction is especially relevant in the context of sports and recreational participation, where factors such as device usability, motivation, family support, and peer inclusion heavily influence the actual use of prosthetic devices. Recent studies offer valuable insights in this regard. Della Bella and colleagues [33] employed the ABILHAND-Kids questionnaire to assess perceived manual ability in children with congenital and acquired upper-limb deficiencies, showing that prosthetic fitting alone does not necessarily correlate with improved functional autonomy. Similarly, Manocchio and colleagues [24] pointed out that early prosthetic intervention—although important—needs to be matched by follow-up that includes the assessment of real-life participation outcomes. Moreover, the validation of the Child Amputee Prosthetics Project—Prosthesis Satisfaction Inventory (CAPP-PSI) [34] adds further depth by examining dimensions such as comfort, esthetics, usability, and psychosocial impact. These factors, which align closely with the environmental and personal domains of the ICF, are particularly relevant when considering prosthetic use in social and dynamic contexts like sports. These tools, therefore, provide a structured framework to evaluate not only the functional outcomes, but also the subjective and contextual experience of prosthetic use.

4.2. Gaps in Pediatric Activity-Specific Prosthetic Design

4.2.1. Adult-to-Pediatric Design Limitation

Particular attention has also been given to the lack of translation from adult to pediatric designs. In Agnew et al. [7], it is specifically noted that the biological and biomechanical differences between pediatric and adult populations are often overlooked in the design of activity-specific prosthetic devices. Pediatric prostheses are frequently scaled-down versions of adult models, rather than being tailored to the distinct anatomical, physiological, and loading characteristics of children. This approach neglects the fact that reducing the size of a prosthesis without adjusting its material properties or structure results in higher stresses, as forces are distributed across a smaller cross-sectional area. As such, pediatric prosthetic devices must be engineered according to child-specific biomechanics. Similarly, Tiele et al. [35] designed a prototype of an 800 g transradial device for cycling that consists of a slider block with a quick-release mechanism and spring plungers. The prosthesis incorporates two safety mechanisms: a sliding mechanism, designed for minor falls and collisions; and a clamping mechanism, intended for more severe, head-on collisions. However, these release techniques require a 200 N and a 700 N force exertion, respectively; applicable for young adults, but not children of young age. Analogously, innovation in sports is often centered around high-performance prosthetic limbs tailored for sports in adults, such as running [36,37,38,39], cycling [40,41,42], and swimming [43].

4.2.2. Gaps in Pediatric-Specific Biomechanical Research

The mechanical properties of these devices have also been studied for recreational use in adult athletes for running [44,45], cycling [42,46], swimming [47,48], and other adaptive sports such as rock-climbing, golfing, skiing, cross-country skiing, or kayaking, as examined in De Luigi et al. [49]. In fact, in Hadj-Moussa et al. [6], the biomechanical factors that affect running with an RSP and the biomechanical compensatory strategies of users wearing RSPs have been gathered for subjects that ranged in age from 17 to 67 years, with an average of 31.4 years across all studies. The paper takes into consideration different amputation levels (lateral/bilateral foot, transtibial, knee, and transfemoral disarticulation), and attributes force production imbalances and joint kinetics differences between the prosthetic and intact limbs to the loss of the ankle joint in ULA. Accordingly, adult runners employ a series of compensatory strategies, such as altering the spatiotemporal and kinetics parameters. In fact, several important spatiotemporal aspects of running gait are influenced by kinetics, including the GRFs of both the prosthetic and intact limbs. In its turn, kinetics play an important role in leg stiffness (i.e., ratio of the peak vertical GRF and peak leg compression) and the regulation of lower limbs during running. Numerous studies on adult populations demonstrate that prosthetic limbs exhibit reduced vertical GRFs and impulses compared to intact limbs across all running speeds [6], which could be a result of alterations to the musculoskeletal system [50] and/or limitations to the RSP’s design [51,52]. In the pediatric population, GRFs of prosthetic feet have been evaluated during high-impact performance during landing [7], but no research was found on the quantitative effect of stiffness gradient in pediatric RSPs on energy return and GRFs at different speeds.

The biomechanical aspects of gait have been researched for pediatric lower-limb amputees [53,54]. However, there is a lack of comparative biomechanical research focusing on pediatric limb mechanics or motor development in sports, such as in the case of RSPs [53], all of which are critical to designing prostheses that are not only effective, but also safe and supportive of normal physical development. In fact, while cycling and swimming have also been studied for transtibial amputation in adults, adaptation to pediatric care currently presents little or no evidence of lower-limb activity-specific prostheses for these sports. Agnew et al. studied the stiffness of four different pediatric prosthetic feet during single-leg drop-landing at different heights and orientations, but no tests on children were reported. Also, the effect of shoe-drop on kinematics and kinetics for tennis specifically has been studied for able-bodied children [55], but there is little or no evidence of its application to pediatric amputees.

5. Limitations

This review has some methodological limitations that should be acknowledged. First, although the literature search was comprehensive, only articles published in English were included, which may have led to the exclusion of relevant studies published in other languages. Second, this review focuses exclusively on studies that explicitly addressed the use of prosthetic devices in sport or recreational contexts, potentially overlooking broader insights from general rehabilitation research that could be relevant to activity-specific applications. Finally, there was considerable heterogeneity across the included studies in terms of study design, participant characteristics, types of prosthetic devices, and outcomes. This variability made it difficult to compare findings or to draw generalizable conclusions across different clinical and cultural contexts. As a result, the synthesis was limited to qualitative thematic analysis, and findings should be interpreted with caution, particularly when considering their applicability to specific subgroups of the pediatric population or to healthcare systems with differing prosthetic provision frameworks.

6. Conclusions

Despite growing interest in activity-specific prostheses and their potential to improve inclusion and participation in sport and leisure for children with limb deficiencies, current evidence suggests that the field remains underdeveloped in several key areas. While there are notable mentions of such prostheses—especially in adult populations—there is a marked scarcity of detailed studies or systematic approaches to their design and implementation for pediatric users. Moreover, the process of developing pediatric prostheses—from conception and design to testing and user feedback—has not been extensively documented in the current literature. There is little insight into engineering design decisions, material selection, or usability testing with children, which are essential to ensuring both functionality and safety. For example, the forces required to activate safety mechanisms in existing devices are often too high for young users, underscoring a lack of pediatric-centered considerations during development. In addition, while some studies investigate the mechanical properties of sport-specific prostheses (e.g., stiffness, damping, energy return), these analyses are almost exclusively performed on adult devices. Hence, there is a lack of comparative biomechanical research focusing on pediatric limb mechanics, gait patterns, or motor development, all of which are critical to designing prostheses that are not only effective, but also safe and supportive of normal physical development.

Finally, although activity-specific prostheses are increasingly acknowledged in the literature, they are often described without sufficient detail regarding the design rationale, customization for individual needs, or impact on functional outcomes. This leaves a significant gap in understanding of how such devices can be optimized for pediatric users in recreational and competitive settings.