Limb loss is a major life-altering event that is frequently accompanied by acute and chronic pain conditions (1, 2). Among these, two of the most common and distressing consequences reported by individuals with limb loss are phantom limb pain (PLP), referring to painful sensations perceived as originating from the amputated or missing limb, and residual limb pain (RLP), pain localized to the remaining portion of the limb (3, 4). The majority of individuals with an amputation will experience one or both types of pain, often at clinically significant levels and for years after their amputation (1). Pain interference, defined as the extent to which pain disrupts daily activities, social roles, sleep, and mood, is also elevated following limb loss (5). Both PLP and RLP have been associated with greater interference in everyday functioning (6, 7). Importantly, amputation has been identified as the surgical procedure with the highest incidence of chronic post-surgical pain in comparison to other surgeries including thoracotomy, mastectomy, inguinal hernia, caesarian section, etc. (8). This underscores the need for continued investigation into the mechanisms and predictors of pain following limb loss (9).

Some individuals with limb loss also report other phantom limb phenomena, including telescoping, a phenomenon in which the phantom limb is perceived to progressively shorten and even retract completely into the residual limb. It was first described by Guéniot (10) and has since been examined in greater detail by others (11, 12). Telescoping is estimated to occur in approximately 22% of individuals with limb loss (13) but estimates vary considerably, ranging from 14%–32% in large samples (14–16).

The extent to which telescoping is linked to variations in pain intensity or psychosocial outcomes is not well established (17). Several studies have examined the relationship between telescoping and PLP, but findings have been inconsistent, with some studies reporting positive associations with PLP intensity, others reporting negative associations, and still others finding no significant relationship. Larger-sample size investigations have reported that telescoping may be linked to the presence of PLP (13, 18), whereas several smaller studies (19, 20) and case reports (21, 22) described the absence of PLP to be associated with telescoping. Other research, including both longitudinal (23) and experimental studies (24), have indicated that telescoping may coincide with lower levels of PLP intensity or even remission of pain. Taken together, these mixed findings highlight the uncertainty regarding whether telescoping is a risk factor for PLP, a protective mechanism against PLP, or a causally-unrelated correlate of PLP. Clarifying the nature of this relationship is important, as it may determine whether telescoping is a process that facilitates adaptation after amputation or one that hinders it. Furthermore, if telescoping can be shaped through targeted interventions, it raises important questions about whether therapeutic strategies, such as immersive virtual reality experiences, could be designed to encourage adaptive forms of telescoping and support post-amputation adjustment.

Psychosocial factors such as pain catastrophizing, characterized by heightened negative thinking and worry about pain, as well as anxiety and depression have been consistently associated with poorer outcomes in the broader chronic pain literature, including conditions such as low back pain, fibromyalgia, and arthritis (25). In these conditions, the above psychosocial factors have been associated with increased pain intensity, greater disability, and diminished quality of life (26–32). Similarly, anxiety and depression have been linked to poor adjustment, greater pain, and less successful rehabilitation outcomes after limb loss (33, 34). These negative affective and cognitive processes may exacerbate pain perception and interfere with adaptive coping, highlighting the importance of examining psychological contributors to post-amputation pain experiences. In contrast, positive constructs such as optimism, resilience, and acceptance may serve as protective factors, potentially buffering individuals against pain-related distress and facilitating more effective coping strategies (35–37). Together, these constructs allow for a comprehensive investigation of both vulnerability and resilience factors in the context of chronic post-amputation pain.

While PLP and RLP have been extensively studied, the role of telescoping remains less understood in shaping these pain experiences and associated psychosocial outcomes. Very few investigations have directly compared individuals who report telescoping with those who do not, particularly in relation to pain intensity and psychosocial dimensions such as pain catastrophizing, anxiety, and resilience. This lack of direct comparison represents a critical gap in the literature. As such, the present study aims to examine how telescoping is associated with psychosocial aspects of post-amputation pain. Specifically, the goal was to establish whether pain intensity and interference, as well as psychosocial functioning, including pain catastrophizing, anxiety, depression, optimism, and resilience, differ between those who endorse telescoping and those who do not. Given the current lack of evidence regarding whether telescoping is a risk factor, a protective factor, or is causally unrelated to PLP, we did not make specific hypotheses about the direction of the relationships. Instead, our primary objective was to examine whether individuals with and without telescoping differ systematically in pain-related factors and psychosocial variables.

This study examined demographic, clinical, and psychosocial differences between individuals who reported telescoping of their phantom limb and those who did not, with the aim of clarifying the relationship between telescoping and phantom limb sensations, including pain. In this sample, 23 individuals (45.1%) reported experiencing telescoping of the phantom limb, while 28 (54.9%) did not. This rate is markedly higher than the 14%–33% estimate reported in large-scale studies (13–16). There are several plausible reasons for this discrepancy. First, the sample size is relatively small, which increases the likelihood of sampling variation and possibly overestimation of prevalence compared to those large-scale investigations. Second, the composition of our sample may differ in keyways. Most notably, a large proportion of participants had a traumatic amputation etiology, which prior work has suggested is associated with higher rates of phantom phenomena such as telescoping (17). Thus, the elevated rate of telescoping in our cohort may reflect greater risk factors (trauma etiology) in the sample, rather than indicating a fundamentally higher population rate. Finally, other sample-specific factors (e.g., time since amputation, level of amputation, prosthesis use, and pre-amputation pain) may also play a role in the difference. Thus, while the higher observed prevalence of telescoping highlights a meaningful occurrence in this cohort, caution is warranted in generalizing this rate to the broader population of individuals with limb loss. Future studies with larger, more heterogenous samples will help clarify the true prevalence of the telescoping phenomenon.

The findings of this study provide greater insights on the telescoping phenomenon by highlighting factors related to age, amputation location, and psycho-social profiles. For instance, those who reported telescoping tended to be younger than those who did not. This may reflect greater neuroplasticity earlier in adulthood, which could increase susceptibility to perceptual phenomena like telescoping (52). Younger individuals may also engage in higher activity levels and adopt prostheses more quickly, amplifying sensory input that may impact perceived limb length (53, 54). Nevertheless, evidence from prior studies suggests that reduced prosthesis use may be associated with shorter phantom limbs (55), while meaningful sensorimotor engagement through prosthesis use can lengthen previously shortened phantoms through use-dependent cortical reorganization (12, 56), highlighting the complexity of the relationship between sensory engagement and telescoping. In addition, the complicating role of vision when wearing a prosthesis may affect telescoping irrespective of use-dependent changes in brain reorganization since telescoped phantoms often lengthen to assume the proportions of the prosthesis as appreciated by sight (57). Younger individuals may also be more likely to notice and report phantom-related changes, whereas older adults may have more stable somatosensory maps and less pronounced distortions. In terms of other demographic or clinical characteristics, including sex, marital status, education, or time since amputation, no significant findings were detected, which may suggest that underlying neurocognitive or perceptual mechanisms related to body representation following limb loss play a larger role in telescoping.

Telescoping was more frequently reported among individuals with upper limb amputations compared to those with lower limb amputations, especially those who lost a right upper limb below the elbow. This finding suggests that limb type and dominance may influence the occurrence of this phenomenon. One possible explanation lies in differences in cortical representation, as upper limbs, and especially the dominant right hand, occupy greater sensory and motor cortical areas, which may make body image distortions such as telescoping more likely (58–60). Although hand dominance was not measured in this sample, population base rates suggest that most participants were likely right-handed. This pattern may align with some prior reports indicating higher prevalence of telescoping in upper than lower limb amputees (24, 61, 62). Future studies should include hand dominance as a variable to better account for this factor.

Although the present study did not find significant group differences in ratings of PLP intensity, RLP intensity, or pain interference, there was a negative association between PLP intensity and percent telescoping. One interpretation is that greater telescoping may reflect adaptive cortical reorganization that, for some individuals, co-occur with lower PLP intensity (11). Conversely, higher pain may disrupt embodiment and reduce telescoping. It is also plausible that effects are non-linear or moderated by factors such as age, level of amputation, or time since amputation, which could attenuate simple between-group contrasts but still yield within-group correlations (63). In line with this, recent work indicates that primary somatosensory hand representations can remain stable before and up to five years after upper-limb amputation (64). This individual variability in cortical reorganization may dilute differences between those who do and do not endorse telescoping, even as associations within a single group (e.g., those who endorse telescoping) still emerge. Ultimately, such factors would have to be investigated in larger samples.

In terms of psychological variables, participants who reported telescoping also endorsed significantly higher levels of anxiety and depression, which may reflect maladaptive coping or increased vigilance toward altered body perceptions such as a shorter than normal phantom limb. It is also possible that higher levels of anxiety or depression may contribute to increased attention to bodily sensations or perceptual distortions, which could influence the experience or reporting of telescoping. Further research is needed to clarify the direction of this relationship, though we hypothesize that the perceptual changes associated with telescoping may contribute to elevated anxiety and depressive symptoms rather than the reverse. The broader research evidence might therefore suggest that individuals who experience telescoping could be more vulnerable to increased pain. At the same time, between-group differences were not found between telescoping and PLP intensity, RLP intensity, or pain interreference. Further, within the telescoping subgroup, greater percentage of telescoping was associated with lower PLP intensity. Group differences also were not found in optimism or resilience, suggesting that telescoping is not uniformly associated with either protective or harmful psychosocial factors. Taken together, these findings suggest that telescoping should not be interpreted as a marker of greater pain intensity or interference. A dual-process interpretation may explain the results whereby: (a) the presence of telescoping may be distressing for some individuals, contributing to elevated symptoms of anxiety and depression via uncertainty and increased symptom monitoring, while (b) the degree of telescoping, once present, may be indicative of adaptive cortical reorganization that co-occurs with lower PLP intensity for a subset of participants. Clinically, this pattern points to a mixture of affective responses to an unusual sensation and, in some cases, potentially beneficial neuroplastic change.

These findings underscore the importance of incorporating psychosocial assessment into the care of individuals who report phantom limb telescoping, with particular attention to screening for anxiety and depression. The observed associations with anxiety and depression suggest that, for some individuals, telescoping may be accompanied by negative affective responses (e.g., uncertainty, heightened monitoring of boldly sensations, difficulty coping, etc.). Tailored interventions, such as acceptance and commitment therapy to address unhelpful coping strategies or cognitive-behavioral therapy to reduce symptoms of anxiety and depression, may help alleviate distress and support better psychological adjustment (65–67). Theoretically, the results contribute to ongoing debates regarding whether telescoping should be considered solely a perceptual phenomenon or one that is also intertwined with psychosocial outcomes.

A notable strength of this study is its inclusion of both clinical and psychosocial variables, allowing for a more comprehensive understanding of the factors associated with telescoping beyond pain intensity alone. The use of standardized and validated measures for constructs such as pain, catastrophizing, anxiety, depression, and resilience further enhances the reliability and comparability of the findings. Likewise, the measure of telescoping used in the present study provides a more in-depth and precise way to quantify what has been a difficult phenomenon to assess. Despite these strengths, several limitations should be acknowledged. First, the relatively small final sample size (N = 51) reduced the statistical power to detect more subtle group differences and may limit the robustness of the observed effects. Second, because recruitment was conducted online, the sample may not be representative of the broader population of individuals with limb loss; in particular, the overrepresentation of telescoping and White participants raises concerns about generalizability across diverse demographic groups. Third, all measures relied on self-report, which introduces the possibility of recall bias and variability in how participants understood and reported telescoping. Fourth, participation bias may have occurred, as individuals experiencing higher levels of distress, depression, or limited social support may have been less likely to enroll, potentially influencing the generalizability of our findings. Finally, the cross-sectional design does not establish the temporal relationship between variables, preventing us from determining whether changes in telescoping preceded or followed the development of pain, and/or the psychosocial factors.

This study demonstrated that telescoping was more common among younger individuals with upper limb amputations, particularly on the right side, below the elbow, and was associated with higher levels of anxiety and depression. Percent telescoping was negatively associated with PLP intensity in correlational analyses. Nevertheless, no associations were present between telescoping and RLP intensity, pain interference, and most other psychosocial variables, including optimism and resilience. Taken together, these findings suggest that telescoping is not a stand-alone marker of overall pain burden and may reflect a mix of affective responses (e.g., anxiety/depression) and, for some individuals, adaptive reorganization. Clinically, the results highlight the value of routine screening for anxiety and depression, and they point to the potential utility of supportive interventions aimed at improving adjustment among individuals who report telescoping.

Future research should extend these findings by examining the longitudinal course of telescoping and its relationship with psychosocial adjustment over time. Prospective studies could help determine whether telescoping precedes or follows psychological distress, thereby clarifying its causal role. Neuroimaging approaches may also provide important insights into the cortical reorganization and sensorimotor mechanisms underlying telescoping. Intervention studies are needed to test whether strategies such as cognitive-behavioral therapy for catastrophizing or mindfulness-based approaches for anxiety can reduce distress linked to telescoping. Additionally, recruiting larger and more diverse samples will improve the generalizability of results, while incorporating rich qualitative approaches is essential to capture the lived experience of telescoping, deepen understanding of the phenomenon, and inform the design of meaningful and sustainable interventions.