Lower Extremity

Orthotics/Orthoses

PT 740
Spring 2023
OBJECTIVES
1. Introduce the appropriate terminology and nomenclature for
LE orthotics and shoewear
2. Discuss indications for various features and types of shoewear
3. Discuss the indications/goals for use of various foot orthotics
4. Discuss the indications/goals for use of various LE orthotics
(ankle, knee, hip)
Nomenclature
Orthosis: External device worn to:
Restrict/prevent motion
Assist motion
Transfer load

 Brace = Orthosis
 Splint = Temporary orthosis
 Orthotist: Designs/fabricates/fits extremity and trunk orthoses
 Pedorthist: Designs/fabricates/fits shoe and foot orthoses ONLY
Terminology
 Named for the joints encompassed and the type of motion control

 Foot Orthoses (FO)

 Ankle-Foot Orthoses (AFO)
 Knee-Ankle-Foot Orthoses (KAFO)
 Knee Orthoses (KO)
 Hip-Knee-Ankle-Foot Orthoses (HKAFO)
 Hip Orthoses (HO)
 Trunk-Hip-Knee-Ankle-Foot Orthoses (THKAFO)
 Terminology
Named for the joints encompassed and the type of motion control

Dorsiflexion Assist AFO :

Posterior Leaf Spring
Steel DF Spring Assist
ToeOff® AFO
Ypsilon™ AFO
Posterior
Leaf Spring
Dorsiflexion
Assist AFO

Plastic insert on posterior leaf spring AFO.

Citation: Chapter 30 Orthotics, O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation, 6e; 2014. Available at:
https://fadavispt.mhmedical.com/content.aspx?bookid=1895&sectionid=136499487 Accessed: February 07, 2023
Copyright © 2023 F.A. Davis Company. All rights reserved
Steel
Dorsiflexion
Spring Assist
AFO

Steel dorsiflexion spring assist.

Citation: Chapter 30 Orthotics, O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation, 6e; 2014. Available at:
https://fadavispt.mhmedical.com/content.aspx?bookid=1895&sectionid=136499487 Accessed: February 07, 2023
Copyright © 2023 F.A. Davis Company. All rights reserved
ToeOFF®
AFO:
Dorsiflexion
Assist

ToeOFF® ankle-foot orthosis. This fiber glass, carbon fiber, and Kevlar orthosis is designed to provide dorsiflexion assistance in the presence of mild to
severe foot drop accompanied by mild to moderate ankle instability. This orthosis is contraindicated in the presence of moderate to severe spasticity or
edema. Courtesy of CAMP Scandinavia AB. SE 254 67 Helsingborg, Sweden.

Citation: Chapter 30 Orthotics, O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation, 6e; 2014. Available at:
https://fadavispt.mhmedical.com/content.aspx?bookid=1895&sectionid=136499487 Accessed: February 07, 2023
Copyright © 2023 F.A. Davis Company. All rights reserved
Ypsilon™ AFO:
Dorsiflexion
Assist

Ypsilon™ ankle-foot orthosis. This carbon composite AFO is designed to provide dorsiflexion assistance in the presence of mild to moderate isolated drop
foot. It promotes free ankle movements (medial, lateral, and rotational movement). The proximal Y-shape provides tibia crest clearance. This orthosis is
contraindicated for an unstable ankle joint or in the presence of moderate to severe spasticity or edema. Courtesy of CAMP Scandinavia AB. SE 254 67
Helsingborg, Sweden.

Citation: Chapter 30 Orthotics, O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation, 6e; 2014. Available at:
https://fadavispt.mhmedical.com/content.aspx?bookid=1895&sectionid=136499487 Accessed: February 07, 2023
Copyright © 2023 F.A. Davis Company. All rights reserved
 Terminology
Named for the joints encompassed and the type of motion control

Plantarflexion Resistance AFO :

Plastic hinged AFO
Steel posterior stop AFO
Plastic
hinged AFO:
Plantarflexion
Resistance

Plastic hinged ankle-foot orthoses. Courtesy of Otto Bock, Minneapolis, MN 55447.

Citation: Chapter 30 Orthotics, O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation, 6e; 2014. Available at:
https://fadavispt.mhmedical.com/content.aspx?bookid=1895&sectionid=136499487 Accessed: February 07, 2023
Copyright © 2023 F.A. Davis Company. All rights reserved
Steel Stirrup
with Posterior
Stop:
Plantarflexion
Resistance

Steel stirrup (left) with posterior stop at its proximal end (arrow). Posterior stop (right) incorporated into a stirrup. A posterior stop is designed to allow
dorsiflexion and prevent or stop plantarflexion.

Citation: Chapter 30 Orthotics, O’Sullivan SB, Schmitz TJ, Fulk GD. Physical Rehabilitation, 6e; 2014. Available at:
https://fadavispt.mhmedical.com/content.aspx?bookid=1895&sectionid=136499487 Accessed: February 07, 2023
Copyright © 2023 F.A. Davis Company. All rights reserved
 Terminology
Named for the joints encompassed and the type of motion control

Full Motion Control

AFO:
Solid AFO
SHOES
 Shoes: Function/Purpose

Transfer body weight to ground

Protect foot from terrain
Protect foot from weather
Distribute weight-bearing forces
Reduce pressure on sensitive areas
Serve as a basis for AFOs/LE bracing
Shoe Components
 Shoe Components

 Upper
Anterior = Vamp
Contains lace stays or straps
Toe boxing
Posterior = Quarter
Heel width
Quarter height
 Shoe Components
Sole
Outer/inner sole can serve as attachment for metal
uprights
Leather vs Rubber soles
Consider shock absorption, traction needs
What type of sole would you recommend for a
patient with Parkinson's Disease?
Consider factors of shuffling gait pattern & episodes of
freezing….
 Shoe Components

Heel:
Height
Counter
 Shoe Components
Reinforcements
Preserve shaping of shoe
Toe boxing
Protects from stubbing and vertical trauma
Shank
Reinforces the sole form anterior heel to metatarsal heads
Counter
Stiffens the quarter
 Shoe Components
Last
Model over which shoe is made
Shoe shape should fit foot shape/type

Curved Last Semi-curved last Straight last

Minimalist Shoes
Zero-Drop Shoes
 Zero-Drop Shoes

HOWEVER: the study was not sufficiently powered for the secondary
hypothesis!
 Consider the PERSON that will be
WEARING the SHOE….AND how the
shoe FEELS on that PERSON!
Recreational Runners: Women had higher injury rate than men
Knee STIFFNESS increases odds of overuse injury
Noted more in runners with higher body weight
Low mental health-related QOL & a (+) Negative affect
score also were predictive factors for injury
Flexibility, arch height, quadriceps angle, rear-foot motion, LE
strength, mileage/week, footwear & history of previous injury
were not significant factors across all overuse running injuries
FOOT ORTHOSES
 Foot Orthoses: GOALS
1. Enhance function by reducing pain
Transference/dispersal of weight-bearing stress to pressure
tolerant sites
Minimizing/eliminating contact of painful areas with the shoe
Accommodating for fixed deformities
Correcting alignment of flexible segments

2. Enhance function by improving transitions

during stance phase
Foot "Orthoses": External Modifications

Attached to sole or heel of shoe

Does not reduce shoe volume

Subject to wear

Not interchangeable
Foot "Orthoses": External Modifications

Heel Wedge
Alters alignment of hindfoot
Example:
Medial Heel wedge used to realign flexible
hindfoot valgus
Medial Heel wedge used to accommodate
a rigid hindfoot varus
Foot Orthoses: External Modifications

Flares/Off-Set Heels
Extends base of shoe
Increases stability of shoe
Impedes pronation/supination
Foot Orthoses: External Modifications
Metatarsal bars
Useful in management of metatarsalgia
Situated proximal to metatarsal heads
Transfers stress from MTPs to metatarsal shafts
Foot Orthoses: External Modifications

Rockers
Transfer and offload plantar pressure
Anterior, posterior or both
Improve gait
Reduce energy consumption
Accommodate for limited ROM
Foot Orthoses: External Modifications

External counters
Motion control
Provides fairly rigid support
“Buttress”, “out-rigger” or “stabilizer”
Foot Orthoses: External Modifications

External Heel Lifts

Leg Length discrepancies >1/2 inch
Foot Orthoses: Internal Modifications

Advantages
Reduce shoe volume
Allows patient to wear different shoes

Inserts versus internal modifications

Foot Orthoses: Internal Modifications

Heel lifts/inserts
Leg length discrepancies <1/2 inch
Achilles tendinitis
Heel spurs
Relief area to minimize pressure
 Foot Orthoses: Internal Modifications

Longitudinal Arch Supports

Prevention/control of pes planus
Foot Orthoses: Internal Modifications

Custom Arch Support: UCBL Insert

Flexible flat foot
Mold made with foot maximally corrected
Controls hindfoot valgus
Limits subtalar neutral

UCBL: University of California Biomechanics Lab

Are Orthotics Necessary? Can Foot Posture be
Improved with Exercise?

Short Foot
Exercises
 Short Foot Exercise Progressions

Heel Raise with

Single Leg Balance
Ball Squeeze
Step Through
“Toe Yoga”
Alternate Toe Lift
Toe Abduction/Adduction
Foot Orthotics

Decisions

Custom vs. Pre-fabricated

Functional vs. Accommodative

 Foot Orthotics
Functional/biomechanical
STJ control
Pain due to altered biomechanics

Accommodative
Provide relief and/or protection
Minimal effect on foot function/motion control
Diabetics, PVD, neuropathy
 Foot Orthotics

Functional: Rigid to Semi-rigid Accommodative

Thin, firm materials: Softer, less rigid
materials
Subortholen
EVA
Polypropylene
Thermocork
Copolymer
Plastazote
Graphite composites
Foot Orthotics:
Functional/Biomechanical
oConsider:
oShoe type
oAmount of motion control
oIntrinsic vs. extrinsic posting
oCost
Functional Foot Orthotics

 EE

Intrinsic Posting Extrinsic Posting

Functional Foot Orthotics: Over
the Counter Options

SuperFeet PowerStep
 Functional Foot Orthotics: Over the
Counter Options
PowerStep ProTech Custom Post
Accommodative Foot Orthotics
High Risk Populations

Patients with amputations,

rigid deformities
 Foot Orthotics: Indications
Abnormal foot motions….
Malalignments of the foot
Unresponsive to stretching/strengthening and/or joint
mobilization
Lower quarter overuse syndromes as a result of
malalignment of the foot
Patellofemoral Pain Syndrome, Posterior Tibial Stress
Syndrome, Plantar Fasciitis, Iliotibial Band Friction
Syndrome
Foot Orthotics: Contraindications

Pes cavus?

Rigid pes planus

Prophylaxis?

Pediatric population?
LE Orthoses
ANKLE Orthoses
ANKLE Bracing/Orthoses Categories

Stirrup Orthoses
Lace-up Orthoses
Elastic Supports
Prophylactic orthoses
Controlled Ankle Motion Walkers (CAM Boots)
 Ankle Stirrup Orthoses
 Prevents inversion/eversion motion
 Allows plantarflexion/dorsiflexion motion

Active Ankle
Air Cast System CaligaLoc
Ankle Lace Up Orthoses
 Similar to ankle taping
 Sometimes used prophylactically

ASO: Ankle Stabilizing Swede-O Ankle Brace

Orthosis
Elastic Ankle Supports
 Compression function
 Specific tendinitis problems

Silicone Elastic Ankle Bauerfeind Achillo Train

Support
Prophylactic Ankle Orthoses

Used to decrease incidence of ankle injuries

Effectiveness: Cost-effective in high-risk populations

Used as alternative to taping

Ankle Bracing: Controlled Ankle Motion
(CAM) Walkers

Indications:
Grade III Ligament Tears or
Fractures

May require more significant

immobilization

Consider Casting vs. functional walking

orthosis
Foot/Toe Drag
Dorsiflexion Assist
Posterior Leaf Spring AFO
Dorsiflexion Spring assist orthosis

Plantarflexion Resistance
Plastic hinged AFO with posterior stop
Steel stirrup with posterior stop
Dorsiflexion Assist

Posterior Leaf Spring AFO Dorsiflexion Spring Assist AFO

 Plantarflexion Resistance

Hinged AFO with posterior stop

XTERN AFO
KNEE Orthoses
 Knee Orthoses: WHY?
Immobilization
Support
Compression
Functional
ACL
Patellofemoral
ROM
Dynasplint, JAS
 Knee Orthoses

Immobilization
Casts
KAFO
Knee immobilizer
 Knee Orthoses

Support/Compression
Medial/lateral stays

Velcro straps

Compressive materials
 Knee Orthoses
Functional ACL Orthosis
❖Control anterior tibial displacement

❖Custom vs. pre-fabricated/Off-The-Shelf

Degree of instability
Level of activity/competition
Patient size
Compliance
 Functional Knee Orthoses: ACL

Examples of commercially available, custom-fit functional knee orthoses.

A. The Bledsoe Ultimate CI. B. The Generation II 3DX. C. The Donjoy 4titude.
(A, Courtesy Bledsoe Brace Systems, Grand Prairie, Tex.; B, courtesy Ossur/Generation II, Viejo, Calif.;
C, courtesy dj Orthopedics, Vista, Calif.)
(Lusardi, Michelle M.. Orthotics and Prosthetics in Rehabilitation, 2nd Edition. W.B. Saunders Company,).
 Knee Orthoses
Patellofemoral Braces
Attempt to limit lateral tracking
Patellar cut outs, lateral buttresses, air bladders, positioning straps
Taping as alternative
 Knee Orthoses

Osteoarthritis Braces

Attempt to offload affected areas

Also provide medial/lateral support

Knee Orthoses: OA

Examples of functional knee orthoses for individuals with painful osteoarthritis.

A. The Thruster 2. B. The Generation II Unloader. C. The Reliever OTS.
(A. Courtesy Bledsoe Brace Systems, Grand Prairie, Tex.; B. courtesy Ossur/Generation II, Viejo, Calif.;
C. courtesy Townsend Design, Bakersfield, Calif.)
(Lusardi, Michelle M.. Orthotics and Prosthetics in Rehabilitation, 2nd Edition. W.B. Saunders Company,).
 Knee Orthoses
Dynamic ROM Splints
Dynasplint
Low-load prolonged duration stretch
Biomechanical creep/physiological remodeling
Wearing schedule: up to 6-8 continuous hours
4 Point Summary
1. NO PAIN while wearing the
Dynasplint® System.
2. Time is the most important
component.
3. Increase tension after 6-8
hours of wear if no more than 1
hour post-wear discomfort
occurs.
4. Decrease tension if unable to
wear.
 Knee Orthoses

Static Progressive ROM splint

Joint Active System (JAS)
Stress-relaxation loading
Wearing time:
Three 30-minute sessions/day
 HIP Orthoses
 Complete Immobilization of Hip:  Controlled Motion of the Hip:
Hip Spica Post-Op Hip Abduction Orthosis
Hip Orthoses
 Pediatric Bracing

Congenital Hip Dislocation

 Pediatric Bracing

Legg-Calve Perthes Disease

Scottish Rite Orthosis
Questions?