Lower Extremity Foot Orthotics Foot Orthotics (Shoe Inserts): Foot orthotics are designed to evenly distribute the pressure over the entire plantar surface of the foot, alleviate areas that may be sensitive or painful, accommodate/correct for deformities, and improve the overall alignment of the foot, ankle complex and lower limb. Foot Orthoses Designs:

Accommodative: An accommodative foot orthoses is used to accommodate rather than correct a deformity of the foot. These orthoses can be used to prevent or heal skin abrasions or breakdowns, ulcerations, or aid in preventing further deformity from occurring. (Fig.1)

Fig.1

Indications Rigid deformities Diabetic patients Charcot joint Some cavus foot deformities

Fig.2

Corrective: A corrective foot orthosis is fabricated to correct a current deformity or mal-alignment of the lower extremity. (Fig.2)

Indications Flexible foot deformities i.e. pes planus, metatarsalgia

Foot Orthoses

Fig.1

Rigid Orthoses: Rigid orthoses are fabricated from materials that are stiff, strong, and durable. They are effective in transferring weight, limiting motion and stabilizing flexible deformities. (Fig.1)

Indications

Joint laxity Over-use syndromes Sesamoiditis Morton’s neuroma

Semi-rigid Orthoses: Semi-rigid orthoses usually refer to a hybrid orthosis manufactured with a combination of rigid, semi-rigid, and soft materials. They are effective in stabilizing and supporting certain areas of the foot while the softer materials allow for increased comfort and shock absorption. (Fig. 2-3) Indications Athletes with flexible foot deformities Metatarsalgia Planar fasciitis

Fig.2

Fig.3

Soft Orthoses: Soft orthoses are commonly prescribed for patients who have limited or absent sensation. They are effective in providing support and may help to reduce shearing and pressure areas that can cause ulcerations and skin breakdown. (Fig.4)

Fig.4

Indications Diabetes Charcot joint Sensory deficits Peripheral neuropathy Ulcerations Skin breakdown

Lower Extremity Ankle Supports Lower Extremity Ankle Supports: These orthoses are designed primarily to aid in ankle stability and for chronic ankle sprains/strains.

University California Berkley Laboratory Orthosis (UCBL):

A UCB orthosis is designed to control the heel, mid foot, and longitudinal and transverse arches. It provides additional medial and lateral support of the foot complex. (Fig.1)

Indications Excessive inversion or eversion Excessive pronation or supination Posterior tibial tendon dysfunction/rupture

Semi-rigid/Rigid Ankle Orthosis: This orthosis is designed to provide medial and

lateral ankle stability. It can be fabricated to allow for free motion, limited or fixed range of motion.

Fig.1

Indications Ligamentous Instabilities Ankle Instabilities (secondary to chronic sprains/strains) Tendonitis Posterior tibial tendon dysfunction or rupture Inversion/eversion (medial/lateral) instabilities Chronic sprains/strains Posterior tibial tendon dysfunction/rupture

Fig.1

Custom Ankle Orthosis: This orthosis is designed from the cast

or scan of the patient’s foot and ankle. This type of orthosis can be fabricated with a solid (static) or articulated ankle (Fig.1) Indications Severe pes planus (flat foot) Posterior tibial tendon dysfunction/rupture Medial/Lateral Instabilities Neuropathic involvement (i.e. drop foot secondary to neurological pathology) Osteoarthritis Post-operative stabilization

Fig.2Fig.1

Gel/Air Ankle Support: These orthose are designed to provide medial-lateral stability and compression. Some are available with hot/cold gel packs for therapy regimens.

Indications Acute sprains or strains Chronic ankle instability with associated swelling/edema Tendonitis

Plantar Fasciitis Orthosis: These orthoses are designed to provide a passive stretch on the foot and ankle at night and during non-weightbearing. They have adjustable range of motion to accommodate for various positions (Fig.3)

Fig.3

Indications Plantar Fasciitis Slight Ankle Contractures/Tightness

Ankle Foot Orthoses (AFOs) Ankle Foot Orthoses (AFOs): AFOs are designed to provide support, proper joint alignment to the foot and ankle, assist or substitute for muscle weakness, and protect the foot and lower limb.

AFO designs: AFOs can be fabricated from plastic or in a conventional manner from metal and leather components.

Metal or Conventional Orthoses: Metal orthoses are designed to control instability, paralysis and weakness of the foot and ankle complex. The conventional design utilizes metal bands, bars and metal calipers that are attached directly to shoe wear. These designs have been used for many years and are very effective for patients who experience volume fluxuations and swelling. The adjustable straps and buckles can accommodate for volume changes throughout the day. This style is also used in areas where the temperature is very high; the open construction allows the skin to breathe. (Fig.1)

Plastic: Plastic orthosis are designed to fit inside a shoe and

are effective in controlling instabilities, paralysis or weakness at the foot and ankle and aid in pressure distribution. Utilizing this design allows the practitioner to apply corrective or stabilizing pressure over a large area rather than in one specified point.

Fig.1

Posterior Leaf Spring (Dorsi flexion assist) AFO: A dorsi

flexion assist AFO is fabricated with from plastic and is designed to fit inside of a shoe with little effort. It attaches to the limb via a Velcro strap at the proximal edge and is further stabilized with the use of a well-built shoe. It provides support to the ankle and foot, aids in dorsi flexion (picking up the toes), and reduces toe drop/drag when walking. This orthosis does not limit motion of the foot and ankle but acts as a spring to help pick up the patient’s toes to avoid stumbling and falling. (Fig.2)

Fig.2

Indications Drop Foot Neuropathy Peroneal Palsy Multiple Sclerosis Charcot Marie Tooth Disease Weak Dorsi flexors

Semi-Solid AFO: A semi-solid AFO fabricated from plastic is

designed to fit inside of a shoe with little effort. It attaches with a Velcro strap and is stabilized by the use of a well-built shoe. Unlike the dorsi flexion assist AFO this orthosis provides more medial-lateral stability and limitation of motion. (Fig.2)

Fig.3

Indications Drop Foot Neuropathy Minor Mediolateral Instabilities Multiple Sclerosis Weak Dorsi Flexors/Evertors Spinal Cord Injuries MyelomeningoceleCerebral Palsy

Solid Ankle Foot Orthosis (SAFO): a Solid ankle AFO is designed to provide maximum stability of the foot and ankle. This orthosis limits plantar flexion (pointing toes down) and dorsi flexion (lifting toes up), medial and lateral motions. (Fig.1)

Indications Neuropathy Multiple Sclerosis Myelomeningocele Dorsi Flexion and Plantar Flexion Muscle Weakness Joint Instability Spinal Cord Injuries Muscular Dystrophy

Articulated Ankle Foot Orthosis (AAFO): This style of orthosis is designed to provide maximum mediolateral stability while allowing plantar flexion (pointing toes down) and dorsi flexion (lifting toes up). There are various style of ankle joints used to allow for free, variable, and fixed range of motion. (Fig.2)

Fig.1

Indications

Fig.2

Neuropathy Multiple Sclerosis Myelomeningocele Dorsi Flexion and Plantar Flexion Muscle Weakness Joint Instability Cerebral Palsy Spinal Cord Injuries

Lower Extremity Walker Boots Lower Extremity Walker Boots: Walker boots are designed to aid in foot and ankle stability, limit range of motion of the lower extremity. Walker boots are designed with a solid or articulating ankle joint to accommodate for treatment of various injuries, fractures, and pathologies. Each orthosis has a removable inner lining to protect the skin from breakdown, malleolar (ankle) pads for additional stability and comfort, and a rocker bottom sole to provide smooth walking pattern. Walker Boot with Solid Ankle: This orthosis is designed to provide maximum immobilization to the foot and ankle. (Fig.1) Walker Boot with Articulated Ankle: This orthosis is designed to provide maximum mediolateral stability while allowing adjustability of the ankle joint. This orthosis can be locked to eliminate motion or set to allow various amounts of plantar flexion (pointing toes down) and dorsi flexion (lifting toes up). (Fig.2)

Walker Boot with Pneumatic Air Cells (available with solid or articulated ankle): These orthoses incorporate the same clinical characteristics as the solid and articulated ankle walker boots with the addition of pneumatic control Pneumatic air cells allow for circumferential compression that aid in pressure redistribution, enhanced fit and functionality. (Fig.3)

Fig.3

Indications

Fig.1 Fig.2

Foot fractures Post-Operative Management Post-Cast Rehabilitation Management

Fig.4

Acute Ankle Sprains Ligamentous Injuries Acute posterior tibial tendon dysfunction/rupture Achilles tendon rupture/repair

CRO Walker (Charcot Restraint Orthotic Walker): The CRO walker

was designed to provide maximum stability to the foot and ankle complex. Its two piece or bi-valve construction aids in pressure re-distribution, increased stability, and maximum limitation of motion. These orthoses commonly have the addition of a soft inner boot that can be modified to provide relief areas for skin breakdown or abrasions and increased comfort to the patient. (Fig.4) Indications Diabetic neuropathy Foot and ankle ulcerations Charcot joint Post-Operative Management Acute posterior tibial tendon dysfunction/rupture

Lower Extremity (Knee) Soft Supports and Positional Orthoses

Lower Extremity Soft Supports: Often referred to as soft goods, these orthoses include those braces that are fabricated/manufactured from neoprene, canvas, and fabric and can be reinforced with metal/plastic stays for additional support.

Neoprene Knee Sleeve: Neoprene knee sleeves provide limited stability to

the knee joint, compression to help control edema and for comfort, and slightly limit range of motion to aid in rehabilitation.

Fig.1

Donut/Buttress: This is a raised area around the patella (knee cap) to aid

in additional support and proper alignment of the knee.

Side Pulls/Patellar Straps: These straps function in a similar to the donut/buttress to provide additional support at the knee and aid in patellar tracking. (Fig.1)

Joints: This provides increased mediolateral stability while maintaining full

range of motion n flexion and extension. (Fig.2)

Fig.2

Wrap Around Closure: This orthosis is very conducive to those patients

whose hand strength is limited. Rather than pulling up a very tight neoprene sleeve, this option provides the patient with an anterior closure for easy donning and doffing.

Indications Minor knee sprains/strains Post-reconstructive surgery/ligamentous In conjunction with functional knee orthosis: This style of orthosis can be worn with a functional knee orthosis to provide heat, comfort, and compression

Knee Immobilizer: Knee immobilizers are often used to stabilize and immobilize the lower extremity post-operatively and during the acute stage of knee injuries. They provide maximum immobilization of the knee joint and compression. (Fig. 3)

Fig.3

Knee Immobilizer with Hinges: This option allows for

adjustability in range of motion at the knee. The orthosis can be locked or adjusted to prescribed range of motion.

Indications Post-operative knee surgery Acute knee/ligamentous injuries Rehabilitation

Functional Knee Orthosis: Functional knee orthoses are designed to aid in the stability of the knee joint secondary to ligamentous injury, post-operative reconstruction, meniscus damage, and for prophylactic protection. These orthoses is designed to provide maximum stability to the knee joint. Injury to the ligaments of the knee cause unwanted motion/translation between the femur and the tibia. If left untreated this can create significant joint laxity, lead to degenerative joint changes and put the patient at risk for further injury and cause subsequent damage to the surrounding structures. (Fig.1)

Fig.1

Functional knee orthoses can be made to measurements or to a custom model of the patient’s leg.

Indications Anterior cruciate ligament disruption Posterior cruciate ligament disruption Medial/lateral collateral ligament disruption

Meniscus tears Post-operative Ligament reconstruction

Osteoarthritis (OA) Knee Orthosis: OA knee orthoses are designed to reduce the amount degenerative changes of knee joint surface, pain, and joint mal-alignment that occur in patients with osteoarthritis. These orthoses provide a corrective force at the knee to decreasing pain and joint surface degeneration. Many incorporate an adjustable knee joint that can be changed to increase or decrease the corrective forces applied. (Fig.2) OA knee orthosis can be made to measurements or to a custom model of the patient’s leg.

Indications

Osteoarthritis of the knee Excessive valgus/varus Post-operative management

Fig.2

Lower Extremity Fracture Orthoses Distal Tibia/Fibular Fracture Orthosis: Distal tibial/fibular fractures can be treated with a walker boot or tibial fracture orthosis. Your physician determines which style of orthosis is best indicated for your fracture stabilization.

Fig.1

Tibial Fracture Orthosis: The tibial fracture orthosis has a posterior component similar to a solid ankle AFO with an anterior component aiding in compression, immobilization, and stabilization. (Fig.1)

Patellar bar: The tibial bar is an indentation that runs across the patellar tendon (just below your knee cap) used to help reduce the vertical load transmitted through the foot and ankle.

Foot and Ankle Component: The addition of an ankle/foot

component provides stabilization, immobilization, and aids in suspension of the orthosis to prevent distal migration or slipping.

Indications

Distal tibial and fibular fractures Mid-shaft tibial and fibular fractures

Proximal Tibial/Fibular Fracture Orthoses and Distal Femur Fractures: This style of orthosis is often referred to as a KAFO or knee ankle foot fracture orthosis. Due to the location of the fracture site, near the knee, it is necessary to limit or prevent motion at this joint. This helps maintain reduction or stabilization of the fracture allowing the healing process to begin. The knee joint may be fabricated to accommodate complete immobilization, variable range of motion, or free range of motion per the physician’s prescription. (Fig.2)

Fig.2

Indications Proximal tibial and fibular fractures Distal femoral fractures Proximal Femoral Fracture Orthosis: If a patient sustains a proximal femoral fracture they are often prescribed with an orthosis that encompasses the entire lower extremity but also utilizes a hip joint and pelvic band. The addition of the hip joint and pelvic band provide rotational stability and prevent excessive flexion, extension, abduction, and adduction of the leg. Various styles of knee joints and hip joints can be used to provide immobilization and range of motion throughout the rehabilitation process. (Fig.1)

Indications

Proximal Femur Fractures

Fig.1

Knee Ankle Foot Orthoses Knee Ankle Foot Orthoses (KAFOs): KAFOs are designed to provide support, proper joint alignment to the knee, foot and ankle, assist or substitute for muscle weakness, and protect the foot and lower limb. KAFO designs: Knee ankle foot orthoses can be fabricated from several types of materials; plastic, aluminum, stainless steel, and carbon fiber laminate. The style of fabrication is determined by the physician and practitioner relative to their clinical presentation.

Metal or Conventional Orthoses: This style of orthosis is designed to control instability, paralysis

and weakness of the foot and ankle complex. The conventional design utilizes metal bands, bars and metal calipers that are attached directly to shoe wear. This design has been used for many years and is very effective for patients who experience volume fluxuations. Velcro and buckles can be adjusted throughout the day to accommodate for swelling and or edema. (Fig.1)

Metal: Metal materials (aluminum and steel) are also used in the construct of the

sidebars and knee joints. The type of material depends upon the weight, activity, and durability required by the patient. Steel uprights are more durable than aluminum however are associated with increased weight. Aluminum is often used for ease of fabrication and to reduce the overall weight of the orthosis.

Fig.1

Plastic: Plastic orthosis are designed to fit inside a shoe and are effective

in controlling instabilities, paralysis or weakness at the knee, foot and ankle and aid in pressure distribution. Utilization this design allows the practitioner to apply corrective or stabilizing pressure over a large area rather than in one specified point. (Fig.2)

Knee Joint Designs

Free Knee: This design is provides medial-lateral stability to knee joint while allowing free motion in flexion and extension. This style of knee joint is also utilized to prevent genu recurvatum or hyperextension of the knee. By limiting the extension range of motion of the knee joint we can protect and stabilize the posterior knee capsule against further injury and or deformity. Fig.2

Posterior Offset Knee Joint: The posterior offset knee joint is used to aid in knee extension for those patients who exhibit minimal quadriceps weakness. The placement of the mechanical knee joint is just posterior to the anatomical knee joint providing for increased knee stability when walking. This knee joint does not provide for stance control during the gait cycle. The patient must have enough hip flexion and extension strength and momentum to walk in a safe and effective manner. (Fig.3-4)

Fig.3

Ground reaction

force Posterior

offset knee joint Fig.4

Stance Control: Stance control knee joints provide for stability during weight bearing and free flexion (bending) during the swing phase of gait or non-weight bearing. Allowing the knee to bend during the swing phase of gait provides for a more normal gait pattern, is more energy efficient, and decreases the compensatory effects of a locked knee ankle foot orthosis (KAFO). There are several varieties of knee joints; some are operated mechanically while others are operated with computer controllers. (Fig.1-3)

Fig.1 Fig.2 Fig.3

Locked Knee: Locked knee KAFOs are used to provide maximum stability to the patient. These orthoses are locked during the entire gait cycle and can be unlocked for sitting. The locking mechanism is done by a drop lock, bail or French lock, or trigger lock.

o Drop Lock: This design incorporates a ring that slides down over the knee joint providing for a mechanical lock. (Fig.4)

Fig.4

Fig.5

o Bail or French Lock: This style of knee joint incorporates a loop that connects the posterior of both knee joints. Rather than locking each knee jindividually this allows both to be unlocked via a bail or loop design. Bail or French locks are effective for patients wearing bilateral (two) orthoses. (Fig.5)

oint

o Trigger Lock: A trigger lock design is similar to the bail or French lock. This design often uses cables and a trigger switch allowing patients to unlock the knee joint via a point at the proximal edge of the orthosis. It is commonly used for patients with limited dexterity, balance and for increased safety and stability. (Fig.1)

KAFO Indications Lower extremity weakness or paralysis Lower extremity instability Neuropathy Femoral nerve injury Fig.1Spinal cord injury Muscular dystrophy Multiple Sclerosis Polio and Post-Polio syndrome Stroke (CVA: cerebrovascular accident) Myosytosis

Reciprocating Gait Orthoses Reciprocating Gait Orthoses (RGO’s): RGO’s were designed to help patients that suffer from spinal cord injury, Myelomeningocele, spina bifida, and other paralytic disorders walk. Often patients who have sustained paralysis to their lower extremities require the assistance of orthotic devices to walk. One such device, a reciprocating gait orthosis (RGO), is designed to provide as normal method of movement as possible for paraplegic patients. Reciprocating gait is defined as putting one foot in front of the other. The orthosis consists of two-molded plastic knee-ankle-foot orthoses (KAFO) attached to a metal pelvic control band and upright thoracic supports. The posterior section of the pelvic band/thoracic component is fit with either a rocker bar system or cable system. Both function in a similar manner; the rocker system functions much like a seesaw. Shifting weight from one side of the body to the other allows one limb to be stable on the ground while advancing the contra lateral limb. Please keep in mind that there are additional devices that are necessary for these patients to be stabilized. It is common for them to use crutches and/or walkers to aid them in their movement. (Fig.1)

RGO Indications

Fig.1Spinal Cord Injury Myelomeningocele Spina Bifida Paralytic disorders

Adult Hip Abduction Orthosis

Fig.1

Hip Abduction Orthosis: Hip abduction orthoses are designed to maintain appropriate anatomical alignment of the hip or prosthetic hip replacement. The components include a hip/pelvic girdle, thigh cuff, and hip joint. The joints are usually adjustable and set in some degree of flexion and abduction. This alignment positions the head of the femur in the acetabulum allowing for the ligaments, bone, and surrounding musculature to heal. These devices are also used to stabilize patients who suffer from chronic subluxation of the hip. (Fig.1)

Indications Chronic hip dislocations

Degenerative joint disease Total hip joint replacement Post-operative stabilization

Compression Stockings/Sequential Compression Therapy

Compression Stockings: Compression stockings are gradient stockings that help control edema/lymphedema and aid in venous return. Sequential Compression Therapy: These devices are placed around the limb that operative with intermittent compression to aid in controlling lymphedema and venous return. These are often used in hospitals following surgery to help prevent blood clots and aid in lower extremity circulation.

Compression Stockings: These are graded in mmHg. The degree of compression is determined by your diagnoses and physician prescription. They range from as low as 10mmHg to as high as 40mmHg. The lower levels are used in those patients where the edema/venous disruption are not as severe. The higher compression is used in those patients who have severe edema/venous disruption. These are available in pull on as well as with zippers for ease of donning and with closed and open toe versions. (Fig.1)

Compression Therapy Indications Lymphedema Varicose veins Pitting edema Pregnancy

Donning Compression Stockings: Invert (turn the stocking inside out) and then slowly roll the stocking onto the limb. This is often easier than trying to pull it on. Rubber gloves can also be very beneficial creating a better grip when rolling them on. If you have a zipper pay close attention to the skin to ensure that you do not pinch it when donning.

Fig.1