Lower Extremity Orthotic Devices

Orthosis
● “Orthos”: To correct or make straight
● External Device applied to body
● Orthotic vs Orthosis
○ Orthotic: Describes the orthosis (adjective)
○ Orthosis: Actual device
Indications
● Substitute for imapired muscle performance
○ Orthosis can help patient during ambulation
● Provide stance phase stability
● Support to enhance alignment
● Limit/enhance motion
● Reduce pain
● Prefabricated Orthosis:
○ Ready made and cheaper
○ Down Side: Less fit/intimate on the lower leg of patient → control expectations are not met
● Custom-Fit Orthosis
○ Better control than prefabricated orthosis
○ More intimate fit (Made specifically to the condition of patient)
○ Contraindications: For condition that causes different sizing (Fluctuating Edema)
● Conventional Double Upright
○ Metals only
○ It will accommodate edema and fluctuating limbs without irritating the limb of patient
Characteristics of a “Ideal” Orthosis
● Function
○ Has to provide stability and assistance in the swing phase of gait
○ It has to be energy efficient
● Comfort
○ Worn for long period (Consider the materials to be used)
○ Easily worn and easily removed by the px
● Cosmesis
○ Has to fit with the peers and society
● Fabrication
○ Minimizes the deformity and assists the px with function activities
○ Should be made within a minimal period with complex design
○ Adjustability should be easy
○ Should be durable
● Cost
○ Should not be very expensive
○ Maintenance should be affordable
Foot Orthoses
● Ranges from arch support to customized/fabricated orthosis
○ Three quarter length insert which extends from Posterior border of shoe to a point just posterior to MT heads
● Functional Foot Orthosis
○ Promote structural integrity
○ Control abnormal foot functioning during foot stance
○ Hyperpronation of the Foot: Functional Foot Orthosis is prescribed to allow the medial arch to be lifted to prevent hyperpronation of
the foot (Aligns the leg)
● Accommodative Foot Orthosis
○ To accommodate the condition/deformity of the patient
○ Distributes pressure
○ Prescribed to patients with fixed deformities that cannot be corrected
● UCBL Insert (University of California Biomechanics Laboratory)

Reference: 1
 ○ Rigid plastic orthosis that stabilizes subtalar/talar joints
○ Prescribed to px with flexible Pes Planus (flat foot)
○ Longitudinal Arch Support

Allows mobility --- Allows more stability

● Heel Seat (Heal Cup)
○ Covers plantar surface of heel
○ Terminates Anterior to Malleolus
○ Flexible flat foot by repositioning heel vertically

● Scaphoid Pad (Soft to Medium Density)

○ Hyperpronated foot
○ Prescribed to px with hyperpronated foot (Elevated the medial arch)

● Sesamoid platform (Distal to halluces Sesamoids)

○ Stabilizes the 1st metatarsal
○ Applied distally to the halluces of the sesamoid bone
○ Transfer load from the MT heads to MT shafts

Conditions
● Pes Planus (Neutral position)
○ UCBL: Prevent Hyperpronation; Runners
○ With Medial Heel Wedge ⇒ Prevent Ankle inversion injury
● Forefoot Pain / Metatarsalgia (Distribute pain proximal to Metatarsal heads)
○ Metatarsal pad/Cookie

Reference: 2
 ○ Metatarsal Bars (Pain associated with Pes Cavus)

○ Rocker Bottom

● Heel Pain (Distribute Weight)

○ Rubber Heel pads
○ Calcaneal Bar (Pain associated with Chronic Condition)
○ Spring Heel (Relief of pressure)
■ Alters ground reaction force anteriorly from the painful calcaneus

○ Rocker Bottom (Help heel strike)

● Plantar Fasciitis (Plantar Fascia Splint help in DF)

Ankle Foot Orthoses

Reference: 3
 ● Calf Band
○ Will add alignment to the orthosis
○ Secures the orthosis in the LE
○ Ex: Plantarflexion Stop (Limiting PF while allowing DF)
■ Calf band will produce a reaction (Will exert an anteriorly directed force)
■ Pushes the Tibia forward promoting dorsiflexion
○ Ex: Dorsiflexion Stop (Limiting DF while allowing PF)
■ Calf Band will exert a posteriorly directed force promoting PF on the ankle area
○ Should be placed 1 inch below the Fibula
■ Since Fibular neck contains superficial nerve and it is very easy to compress
● Metal uprights
● Stirrup
● Shoe Attachment
● AFO: Commonly prescribed orthosis
● MC Prescribed
● Also refereed as “Short Leg Braces”
● Provide mediolateral stability
● Control the alignment and motions of joints
● Primary Goals:
● 2 categories:
○ Static AFO:
■ Inhibit motion in any plane.
■ Most Aggressive
■ Solid AFO
■ Weight-relieving AFO
■ Ground-reaction AFO
○ Dynamic AFO:
■ Allow some degree
■ UCBL
■ Posterior Lift Spring
■ Dynamic AFO
■ Hinge AFO
● Ankle joints
● Spring on the ankle area
● The placements of mechanical joints are midline to the malleoli
● Metal AFO vs Plastic AFO
○ Metal AFO
■ Provides greater stabilization
■ More durable
■ Contraindicated to children (since its heavy and may cause ER of Tibia)
○ Plastic AFO
■ Lighter
■ Commonly used
■ Interchangeable with shoes and other functions

Shoe or Foot Attachments

● Stirrup

Reference: 4
 ○ Solid Stirrup:
■ U-shape
■ Most commonly used
■ Permanently attached to the shoe
○ Split Stirrup:
■ Allows interchangeability of shoes
■ Removable metals which will allow interchangeability of shoes
■ Less durable, heavier, and thicker
● Caliper:
○ Round tube
○ Allows shoe interchangeability
○ At the level of heel area
● Shoe Insert:
○ Made of plastic, provides maximum support and control

Ankle Joints and Control

● Single axis:
○ Prevent no Motion
○ Control/Assist
● Ankle Stops:
○ Plantarflexion (Posterior) Stop: Most commonly positioned at 90*
■ Produce flexion moment knee since it will allow dorsiflexion with restricted Plantarflexion
○ Dorsiflexion (Anterior) Stop: Substitute function in gastrocsoleus
■ Allows foot to perform plantar flexion with restricted dorsiflexion
■ Stabilizes the knee from midstance and toe off
■ Limits both plantarflexion and dorsiflexion
○ Limited Motion Stop: Limits both PF and DF
● Solid Ankle Joint:
○ No Motion
○ Useful for patient who have acute conditions

Reference: 5
 ● Pin
○ Stops motion
● Spring
○ Assists motion
Ankle Assists:
● Dorsiflexion Assist (Posterior Spring)
○ Assists with toe clearance
○ Absorbs stress during heel strike
● Dorsiflexion-PlantarFlexion Assist
○ Anterior spring is compressed during MS and recoil during late stance
○ When converted, it is called Bichannel Adjustable Ankle Lock (BiCAAL)
● Spring Wire Dorsiflexion Assist
○ Spring Wire Uprights
○ Light weight, easily adjustable but offer no Mediolateral (ML) control
● VAPC Clasp Type Orthosis
○ Veteran Administration Prosthetics Center
○ Provides Dorsiflexion
○ Lower end of upright; Metal Clasp
○ Upper end of upright; Passess through sliding attachment
○ Prevents irritation in the calf area

Reference: 6
 ● Valgus Correction Strap
○ Medial T Strap
○ Creates a lateral directed force (T-Shape side)
● Varus Correction Strap
○ Lateral T Strap
○ Other end will create a medial directed force
● Buckled Insert
○ Rigid component
○ Treat Valgus

Components of Plastic AFO

● Foot should extend beyond the Metatarsal Heads
● Leg component should encompass 3 quarters of leg
● To stabilize AFO, adjust trim line, thickness of material, carbon inserts, corrugations
● Parts:

Reference: 7
Solid Plastic Ankle Orthosis
● Rigid AFO
● No ankle joint, Neutral
● Thick Thermoplastic
○ Thicker, the better
● Prevent PF and DF, resists Varus/Valgus

● No ankle joint and positioned in neutral position = No motion in ankle and foot
● The more anterior trim line = No degree of flexibility will occur
○ Useful for px with Plantar Spasticity (Leg is only on neutral)
● If trim line is moved more posteriorly, exposing malleoli = It will allow flexibility
○ Indicated for px with foot drop w/o Mediolateral instability
● The more solid AFO is → the greater the function moment in the knee is during heel strike
○ w/ sach heel → It will absorb the impact and create extension moment on the knee area
AFO with Flange
● Equinus Deformity:
○ Forces at Medial MT heads and Calcaneus and Lateral Flange at Distal Fibula
● Valgus Deformity:
○ Forces at lateral MT heads and Calcaneus and Medial Flange

AFO with flange

Posterior Leaf Spring
● Most common plastic AFO
● Narrow calf shell

Reference: 8
 ● Indications: Impaired / weak Dorsiflexion
Modified Leaf Spring: trimlines are more anterior
● Slightly more resistance to Plantarflexion/Dorsiflexion and Increase ML stability
● Allows the rolling of Tibia forward
● With this type (Narrow calf shell and low trim line) = It can assist the dorsiflexion,but it will offer mediolateral control in the ankle area)

Patellar Tendon Bearing AFO

● Tibial condyles and Patella Tendon
● Partially relieve weight-bearing
● Compression of soft tissues
○ Maintain alignment
● Indications: Diabetic Ulcerations, Tibial Fractures, Painful Heel
● It is likely positioned in 10* of Dorsiflexion (To transfer all weight to bear at the anterior shell)
● Weight is distributed in the Medial Tibial Condyle

Pressure Relief AFO

● Heel cut out
● Hinged Lever Arm Posteriorly
● Prevents pressure sore development
● Indicated: Demented patient, storke

Charcot Relief Orthotic Walker Boot

● CROW boot
● Custom-handed bivalve plastic AFO
● To off-load plantar ulcer / stabilizes progressive deformity
● Charcot Joint Deformity

Reference: 9
 ● Commonly seen in patient with diabetes
● Temporary for ulcer, but permanent for charcot deformity
Spiral AFO
● Permit the leg to rotate
● Control foot (PF, DF, Inversion, and some extent of eversion

● Starts from mediodistal, goes around posteriolry, then anterirly, and finally to medial epicondyle level
Hemispiral AFO
● Only has half turn
● Greater control equinus and varus than spiral

Dynamic AFO
● Flexible Supramalleolar Orthosis
● Posterior and plantar surface is reinforced with posterior shell than flexible AFO
● Disadvantage: frequent need to change socks

● Trimlines end above the malleoli

Reference: 10
 ● Permits DF to facilitate ankle rocker
● Restricts PF during swing phase
● Useful for Px with Spastic Equino Varus
Toe Reducing AFO
● Enhance standing balance and facilitate early gait
● Indications: Spastic LE

Hinged AFO
● Articulated AFO
● Control Tone-Related Equinovarus since it allows rolling of Tibia forward
● Hs its own ankle joint
● Very useful for px with controlled tone related equino varus
● When px move forward, it promote DF of the ankle

Ground Reaction Force AFO

● Impaired motor control of knee
○ Weakness of Quadriceps
● Holds ankle in slight PF to produce an extension moment at the knee of px
● Crouch Gait
○ Bended knee and PF-ed foot
● Contraindicated for px with recurvatum and cruciate insufficiency

Reference: 11
Knee Ankle Foot Orthoses

● Added in KAFO: Knee joints and Thigh bands

Metal KAFO
● Long Leg Braces
● Good trunk and upper body strength
● Indications: Spasticity, Weakness, Instability
● Conventional KAFO vs Thermoplastic KAFO

Conventional KAFO
● Advantages: Durability, Adjustability
● Disadvantage: Heavier, Less cosmetically pleasing
● Indications: Max strength and durability are needed, obesity, fluctuating edema
● Contraindications: Issue with energy expenditure
Thermoplastic KAFO
● Effective control of limb
● Advantages: Lighter, interchangeability with shoes, better cosmesis
● Disadvantages: hot to wear
● Indications: Max limb control, weight of orthosis, control of transverse plane motion
● Contraindications: Obsese, fluctuating edema

Reference: 12
Knee Joints
● Straight set/Single Axis Knee Joint
● Polycentric Knee Joint
● Offset Knee Joint

Free Motion Knee Joint

● Unrestricted flexion and extension
● “Free Knee”
● Prevents hyperextension
● Single axis
● Used in combination with drop lock
● Indications: Px with mediolateral instability and sufficient muscle power

Polycentric Knee Joint

● Double axis system
● Flexion Extension movement of LE
● Frequently used in sport orthoses because it allows minimal rotation in the knee area

Offset Knee Joint

● Extend in early stance
● Indications: Weak Knee extensor
● Allows flexion and extension during swing
● Contraindications: Px with hip/knee flexion contracture

Reference: 13
Serrated Adjustable Knee Joint
● Permits locking in almost any degrees
● Indication: Px with Knee flexion contracture (Holds the knee in one position)
● 6* interval
● Proximal portion:

Knee Locks
● Provide Complete Stability at knee

Ratchet Lock
● Catching mechanism in 12 degree increments
● STS (Sit to Stand): Locks and keeps the gains made toward extension
○ Became the most recommended product
● To Flex: Press down the lock or release the lever

Drop Ring Lock

● MC used to control flexion (applied in both uprights)
○ Mas matrabaho
● Gravity or manual assistance
● Fine motor skills are needed
● Disadvantage: STS Transition, limited hand function, significant LE spasticity, dependence on AD when standing

Pawl Lock
● Bail Lock, Swiss, French, Schweitzer

Reference: 14
 ● Easier lock than Drop Ring because it is simultaneous with the knee joint
○ Elevate bail to release
● Spring loaded
● Easy release when flexion force exits at knee joint
● To flex: Just lift the bail

Spring Loaded Pull-Rod

● Used only for unilateral upright
● Spring recoils to drive the ring down

Adjustable Knee Lock

● Gradual stretching of knee flexion contracture
● Fan Lock
○ Incorporated in a drop ring lock
○ Maintains knee position
○ Permits full knee flexion in sitting

Accessory Pads and Straps

● Knee Caps: To avoid uncomfortable contact between lib and orthotic cuffs
● Leather Knee Cap: Control knee buckling
● Knee Straps: promoted correcting force
○ Genu valgum/Varum
○ G Varum: Place the knee strap at the medial side of the knee and will provide latera directed force
■ Thigh and calf bands will provide medially directed force to correct genu varum

Reference: 15
Single Upright Orthosis
● Removal of Medial upright
● One upright only

Scott Craig Orthosis

● Named after Bruce Scott
● “Double bar hip stabilizing orthosis”
● Indication: SCI patient
● Provides orthotic stabilization
● Anterior Tibial band will prevent the tibia from going forward, stabilizing knee extension
● Calcaneus posteriorly located and foot is in slight dorsiflexion

Supracondylar KAFO
● End of KAFOs are above the condyles

Reference: 16
 ● Resist recurvatum and provide ML stability
● Ankle in slight PF
● Allows sitting
● Protrudes when sitting (colored)
● New ones have a knee joint to prevent end to be protruded

Stance Control KAFO

● Locks knee in extension during stance but allows knee flexion during swing

Swedih Knee Cage

● Knee orthosis
● Minor to moderate Gen recurvatum
● Permits full knee flexion
● Prevents hyperextension
● 2 Bands anteriorly and 1 band posteriorly
● Threeway Knee Stabilizer: Same with swedish
○ Pivotable attachments make it more cosmetic
○ 2 Bands anteriorly and 1 band posteriorly

Sport Knee Orthoses

● Prophylactic: Prevents or reduces knee injuries
● Rehabilitative: Allows protectie motion on the injured area within limits (Postop)
● Functional: Assists or provide stability for unstable knee

Reference: 17
Prophylactic Knee Orthosis

Lenox Hill Derotation Knee Brace

● Control mediolateral instability, rotational instability, and multiple ligament impairment
● For patient with ligamentous instability
○ Prevent sports knee injuries

Lerman Multi-Ligamentous Knee Control Orthosis

● Same with Lenox Hill
● Also for prevention and management of sport knee injuries
● Only difference is the condylar pads

Patellofemoral Orthoses
● Infrapatellar strap
● Palumbo

Reference: 18
Neoprene Sleeves
● Knee Pain and Protection

Valgus (Unloading) Orthosis

● Unload medial knee compartment
● Knee OA

Cars-UBC Orthosis
● Canadian Arthritis and Rheumatism Society - University of British Columbia
● 2 Cuffs connected by a rod
● Medial Rod: Genu Varum
● Lateral Rod: Genu Valgum

Reference: 19
Hip Knee Ankle Foot Orthoses
Hip Knee Ankle Foot Orthosis

Conventional HKAFO
● Hold both LEs in stable upright
● Ambulation: You can perform Hop to gait patterns or swing to ambulation pattern

Thermoplastic HKAFO
● Lighter in weight

Reference: 20
Pelvic Band
● Unilateral Pelvic Band: Metal band, encompasses involved side
● Bilateral Pelvic Band: Contract most prominent of buttocks
● Double or Pelvic Girdle: Maximum degree of control
● Silesian Belt: Cannot control sagittal motion

Hip Joints and Locks

● Single axis: Prevents abd/add
○ Incorporating Drop Lock: Can resist flexion and extension
○ Allows standing and ambulation
● Dual Axis: Prevent Flexion/extension and Abduction/adduction
○ Has a separate control for flexion extension abd add
● Drop Ring or Pawl Lock: Restrict flexion/extension
● Two position hip lock: Locks both at hip extensions nd 90* flexion
○ Useful for: px with difficulty in sitting d/t spasticity

Reference: 21
Hip Orthosis
● Resist Adduction
● Indications: Spastic Adductors, Elderly (THR)

Hip Guidance Orthosis and Parawalker

● Both requires assistive device for ambulation
● HGO is stable in stance but allows pendular swinging for clearance
● Parawalker provides more support in thorax and trunk
○ Uses a smaller hip joint
○ Standing and ambulation for upper thoracic level SCI

Special Purpose Orthoses

Ischial Weight Bearing Orthosis
● Impairment of femur or knee
● Quadrilateral/Ischial brim

Reference: 22
 ● Quadrilateral Brim
○ Anteromedial: Adductor Longus
○ Posteromedial: hamstring
○ Posterolateral: Gmax
○ Anterolateral Rectus Femoris

Paralytic Disorders
● Standing Frame Orthosis
● Parapodium
● Reciprocal Gait Orthosis
● Caster Cart

Standing Frame
● Control knees and trunk
● Children can pull themselves up
● Swing through gait in // bars

Parapodium
● With unlocking knees and hips
● Unlikely become functional walker

Swivel Waker
● Holds bdy upright with swiveling feet

Reference: 23
Reciprocating Gait Orthosis
● HKAFO
● Used for walking
● Hip joint can be flexed and abducted
● Assist reciprocating motions
● Dual Cable-coupling system
Advanced RGO - Single Cable
● Allows Standing with unilateral or no UE support

Hybrid Orthosis: FES

● Major benefit of RGO-FES: Distance speed of walking, energy cost
● Walking speed: Hybrid = 0.20-0.45 m/sec
○ Limited community walking 0.6 m/sec
○ Healthy Adult = 1.0 - 1.3 m/sec

Caster Cart
● Children with developmental delay
● Serves as initial mobility aid
● Deep Sucket - Balance problems

Patten Bottom
● Total elimination of weight bearing
● Ischial tuberosity / Patellar Tendon to floor pads

Reference: 24
Orthoses in orthopedic Care
● Gaol: Prevention of Deformity and Disability
● DDH / Congenital Hip Dislocation
○ Pavlik Harness:
■ Birth to 6 months
○ Van Rosen
○ Ilfeld Splint:
■ Degree of Abd can be controlled by adjusting the cross bar
○ Frejka Pillow
○ Hip Spica Cast

● Leg Calve Perthes Disease

○ For avascular necorsis
○ Atlanta/Scottish-Rite Hip Abduction Orthosis:
■ Allows child to walk
○ Toronto Orthosis: LWE in IR and ER
○ Newington Orthosis
○ Trilateral Orthosis:
○ A-Frame

Reference: 25
 ● Angular and Rotational Deformities
○ Dennis Brown Splint:
■ Spreader bar
■ By bending the bar valgus/varus, positioning is achieved
■ Indications: Club foot, Pronated Foot, Abnormal Tibial Torsion
○ A Frame Orthosis:
■ Apply Corrective forces for more proximal abnormalities
○ Torsion Shaft Orthosis
■ Apply rotary forces to distal segments
■ Indications: Mild scissorng gait, Spastic Hemiplegia, Abn To-in/out

● Hip Rotation Control Straps

○ Allows reciprocal gait
○ One control for ER, one for IR
● Internal Rotation Control Strap:
○ With Dacron waist belt
○ Tapes are taut in standing promoting ER
● External Rotation Control Strap
○ Does not require waist belt
○ Single ant strap connecting bilateral uprights

Fracture Orthoses
● Maintain anatomical position, limit motion, unload weight

Reference: 26
 ● Fracture Stability: Hydrostatic Pressure and lever arm
● Short Leg Walker: Achilles Tendon Repair, fx of distal tibia/fibula/ankle/foot, severe ankle sprain
○ Advance: Wound inspection and skin care
○ Disadvantage: Less effective immobilization
● KAFO Fracture Orthosis: Long term protection
○ Fracture of mid/distal femur, knee fracture

Reference: 27