Updated: 6/7/2021

Orthotics

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  • Summary
    • Orthotics are lower extremity supportive apparel that provide soft tissue protection, bone/joint stability and control of body segment motion.
    • Orthotics play an important role in the nonoperative treatment of foot and ankle pathology.
    • The type of orthotic needs to be specific for the underlying bony or ligamentous pathology in order to provide appropriate functional support.
  • Overview
    • Uses
      • off-load areas of high pressure and decrease shear forces
      • cushion vulnerable soft tissue sites (ex. diabetics)
      • correct flexible deformities and accomdate rigid deformities (ex. pes planovalgus)
      • eliminate painful motion (ex. hallux rigidus)
      • replace lost motion, improve gait and ambulation (ex. ankle fusion)
    • Options
      • type of stabilization
        • static: rigid device, supports body segment in fixed position
        • dynamic: mobile device, permits body segment motion
        • combination
      • material
        • metal, plastic, leather, synthetic fabric
      • body region
        • named for joints controlled (ankle and foot = "ankle-foot-orthosis" or AFO)
    • Principles
      • patient-related
        • soft tissue
          • at risk (diabetics)
          • tolerant to compression and shear forces
        • functional level of patient
          • orthotic should match
        • pathology being addressed
          • soft tissue conditions
          • flexible or rigid deformity
          • painful motion
          • weakness / loss of function
      • orthotic-related
        • three-point pressure control system
        • should be aligned at the approximate anatomic joint
        • design should be
          • simple, easy to put on and take off
          • lightweight
          • durable
          • aesthetically acceptable
  • Foot Orthoses
    • Shoes
      • shoes are a type of orthosis
      • can be modified to correct or accommodate deformity, minimize painful motion and optimize gait mechanics
      • shoe selection
        • extra depth shoe
          • additional space allows for placement of foot orthosis and can accomodate foot deformity
        • stiff, supportive shoe
          • flexible foot (ex. flexible pes planovalgus)
        • soft, accommodating shoe with shock-absorbing sole (running shoe)
          • rigid, bony foot
        • custom shoe
          • severe deformity (ex. Charcot foot)
      • shoe modifications
        • can be internal (placed inside the shoe) or external (built up outside the shoe)
          • internal modifications are more mechanically effective but reduced space in shoe
          • external modifications preserve shoe volume but affect cosmesis and are more prone to wear
        • can modify heel, sole or both
        • adjustable closures
          • laces, elastic laces, velcro
          • high top lace up sneakers may help patients with poor distal proprioception
            • provides feedback more proximally to help with balance
        • sole excavation and padding
          • excavation makes room for bony prominences
          • padding cushions painful sites
            • metatarsal pads, toe crest, scaphoid pad
        • cushioned heel
          • soft pad with compressible material cushions heel
          • helpful for painful heel pad atrophy
        • flares
          • material added to external medial or lateral shoe
          • provides wider base of support and increases medial-lateral stability
          • useful for ankle instability
            • lateral flare resists inversion
            • medial flare resists eversion
        • wedges
          • internal or external
          • sole, heel or both
          • lateral sole wedge useful for pes cavovarus with fixed forefoot pronation, allowing entire forefoot to reach the ground without compensatory hindfoot varus
          • medial wedge useful for flexible pes planovalgus (posterior tibial tendon dysfunction) corrects hindfoot valgus
          • heel wedges useful for fixed varus/valgus knee deformity
            • lateral heel wedge unloads medial compartment of the knee
        • heel lift
          • useful for equinus deformity or leg length discrepancy
        • rocker soles
          • helps transfer body weight forward
          • can destabilize the knee by transferring body weight forward rapidly
            • pay careful attention when prescribing to patients with balance or proprioception issues
          • types
            • mild rocker
              • most common
              • mild angle at toe and heel
              • relieves metatarsal head pressure and assists witeh forward propulsion
            • heel-to-toe rocker
              • more angled at toe and heel
              • reduces pressure at heel strike and need for ankle motion
              • useful for patients with ankle or subtalar arthritis or fusion, midfoot amputation or calcaneal ulcers
            • toe only rocker
              • angled at toe
              • increases weight bearing proximal to metatarsal heads
            • severe angle rocker
              • more angled at toe
              • further decreases pressure distal to metatarsal heads
              • useful for relief of metatarsal head or toe tip ulcerations
            • negative heel rocker
              • angled at toe and midfoot, with heel height lower than that of sole
              • useful to accommodate fixed dorsiflexion deformity
            • double rocker
              • two shorter rocker soles centered over the forefoot and hindfoot
              • reduces pressure at midfoot
              • useful for midfoot prominences, such as Charcot foot
        • extended shank
          • embedded between the layers of the sole
          • can be carbon fiber or steel
          • functions as a splint, to reduce forefoot and/or midfoot motion
          • useful for hallux rigidus (Morton's carbon-fiber extension) and midfoot arthritis
    • Foot orthoses (inserts/inlays)
      • Heel cup
        • rigid plastic insert
        • covers plantar surface of the heel and extends posteriorly, medially and laterally
        • useful to prevent lateral calcaneal shift in flexible pes planovalgus
      • University of California Biomechanics Laboratory (UCBL) orthosis
        • constructed with rigid plastic over a cast of the foot held in maximum manual correction
        • includes the heel and midfoot, with rigid medial, lateral and posterior walls
        • holds the heel in a vertical neutral position
        • designed for flexible pes planovalgus
          • if deformity is rigid, the UCBL will become painful and could lead to skin breakdown
      • Longitudinal arch support
        • can be applied medially or laterally
        • prevents depression of subtalar joint and corrects for pes planus
  • Ankle Orthoses
    • Arizona brace
      • combination of a UCBL and lace-up ankle support
      • useful for flexible pes planovalgus
        • provides more rigid hindfoot support
    • Ankle foot orthosis (AFO)
      • construction
        • composed of a footplate, calf support and a calf band
        • can be made of plastic, metal and leather
      • indications
        • correct or prevent ankle deformity by assisting in muscular weakness or overactivity involving ankle dorsiflexion, plantarflexion, inversion or eversion
        • ankle position indirectly affects knee stability with ankle plantarflexion providing a knee extension dorce and ankle dorsiflexion providing a knee flexion force
      • types
        • divided broadly into non-articulating and articulating
        • non-articulating
          • more aesthetically pleasing
          • constructed of plastic, composite materials or leather and metal
          • functionally places a flexion force on the knee during weight acceptance because they are positioned in neutral ankle position
          • does not allow gradual eccentric plantarflexion in early stance
          • the trim lines of plastic AFOs determine the degree of flexibility in the late stance phase
            • described as having maximal, moderate or minimal resistance to ankle dorsiflexion
        • articulating
          • allows a more natural gait pattern and adjustment of plantarflexion and dorsiflexion
          • adjustable ankle joints can be set to the desired range of ankle motion
          • mechanical ankle joints
            • control or assist ankle dorsiflexion or plantarflexion by means of stops or assists
            • also control medial-lateral stability of the ankle joint
            • limits on ankle motion affect knee stability
              • unrestricted plantarflexion allows normal weight acceptance in early stance
              • plantarflexion causes a knee flexion moment during weight acceptance
              • dorsiflexion stop provides a knee extension moment during late stance
      • specific designs
        • posterior leaf spring (PLS) AFO
          • most common AFO
          • narrow calf shell and narrow ankle trim line behind malleoli
            • used for compensating weak ankle dorsiflexors and resisting ankle plantarflexion
            • no medial-lateral control
          • useful for foot drop
        • solid AFO
          • wider calf shell with trim line anterior to malleoli
            • prevents plantarflexion, as well as varus/valgus deviation
        • hinged AFO
          • adjustable ankle hinges can be set to the desired range of ankle dorsiflexion or plantarflexion (fixed)
          • limit motion for multiplanar ankle instability or ankle pain
          • useful for spina bifida patients with mid-lumbar level function
        • ground reaction AFO
          • plastic extends proximally over the pretibial area and distal trim line extends to the forefoot
          • provides maximal resistance to plantarflexion and encourages knee extension
          • useful for cerebral palsy patients with incompetent or overly lengthened triceps surae and mild crouch gait
        • patellar tendon bearing AFO
          • allows weight distribution to patellar shelf
          • reduces weight bearing forces through foot
        • immobilization AFO (ex. CAM walker)
          • simple off-the-shelf AFO
          • removable protection for lower extremity injuries that require immobilization but permit weight bearing and casting is unnecessary
          • ex. ankle sprain, stable ankle fracture, Achilles rupture
        • free motion ankle joint
          • unrestricted ankle dorsiflexion and plantarflexion
            • unrestricted dorsiflexion allows calf muscle strengthening and stretching of the plantarflexors (ex. Achilles)
            • unrestricted plantarflexion allows normal weight acceptance in early stance
          • provides only medial-lateral stability
          • useful for ankle ligamentous instability
        • plantarflexion ankle joint stop
          • restricts plantarflexion but allows unrestricted dorsiflexion
          • provides a knee flexion moment during weight acceptance
            • should not be used in patients with quadriceps weakness
          • useful for patients with foot drop during swing phase and flexible pes equinus
        • dorsiflexion ankle joint stop
          • restricts dorsiflexion but allows unrestricted plantarflexion
          • promotes a knee extension moment during the loading response
            • prevent buckling of the knee in stance in presence of quadriceps or plantarflexion weakness
          • useful for patients with weakness of plantarflexion during stance
        • limited motion ankle joint stop
          • restricts both dorsiflexion and plantarflexion
          • useful for global weakness of muscles around ankle joint
        • dorsiflexion assist spring joint
          • coil spring in the posterior channel
          • counteracts plantarflexion and aids dynamic dorsiflexion during swing phase
          • useful for dorsiflexion weakness with preserved ankle motion
        • varus-valgus correction straps (T-straps)
          • strap contacts skin medially and buckled to the lateral upright is used for valgus correction
          • strap attached laterally and buckled on the medial upright is used for varus correction
        • supramalleolar orthosis (SMO)
          • shortest of the AFOs, ending right above the malleoli
          • controls varus/valgus and supports heel in neutral vertical position
          • useful for flexible pes planus, planovalgus, hyper-pronated foot
  • Knee Orthoses
    • Knee ankle foot orthosis (KAFO)
      • construction
        • consist of an AFO with medial uprights, a mechanical knee joint and two thigh bands
        • can be made of metal, plastic and leather
        • quadrilateral or ischial containment brim limits the weight bearing of the thigh, leg and foot
      • indications
        • quadriceps weakness or paralysis, to maintain knee stability
        • flexible genu varum or valgum
        • more difficult to place and remove than AFOs
        • not recommended for patients with moderate to severe cognitive dysfunction
      • specific designs
        • double upright metal KAFO
          • most common
          • AFO with two metal uprights extending proximally to the thigh to control knee motion and alignment
          • consists of a mechanical knee joint and two thigh bands between the two uprights
        • Scott Craig orthosis
          • cushioned heel with a T-shaped foot plate for medial-lateral stability
          • ankle joint with anterior and posterior adjustable stops, double uprights, a pretibial band, a posterior thigh band
          • knee joint with pawl locks and bail control
          • hip hyperextension allows the center of gravity to fall behind the hip joint and in front of the locked knee and ankle joints
          • with 10° of ankle dorsiflexion alignment, a swing to or swing through gait with crutches is possible
          • used for standing and ambulation in patients with paraplegia from a spinal cord injury
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