Knee Orthoses (KO)

The Knee joint

• The knee is the largest joint in the body and
lies between the two longest lever arms.
• The joint is exposed to very high forces and
easily damaged because of this
 Functions of the knee joint
• Support body weight
• Absorb shock
• Increase efficiency of walking by reducing
movement of the Centre of Gravity
• Allow forward movement of the body
 Support body weight
• The knee must take the full body weight
whilst in single support.
• At heel strike the forces generated can be
many times more than body weight, especially
when running or jumping
 Absorb shock
• Each time the foot strikes the ground the
forces are transferred through the bones.
• By initially flexing the knee acts to absorb
some the shock (10-15degrees)
 Increase efficiency of walking by reducing
movement of the Centre of Gravity

• By flexing in swing and stance phase the lower

limb can minimize the movement of the CoG.
Allow forward movement of the body
• By flexing and extending as required the knee
makes it easy for the lower limb to be brought
forward and in turn accept body weight.
• This process moves the body forward
 Standing posture
• The basis of standing posture is the Base of
Support (BoS). This is the area between all points
of contact with the floor
• To maintain balance the Centre of Gravity (CoG)
of the body must be kept above the BoS.
• The joints of the body, in particular the lower
limb, take up positions to maintain the CoG
above the BoS.
• If one joint is held in an unusual position, the
other joints will compensate to keep the body
balanced
 Some pathological posture
Hip flexion contracture 15 degrees
-Knee will need to flex more
-Ankle will need to dorsiflex
 Plantar flexion contracture
Possible compensation
Knee will be forced into hyperextension
Hip will be flexed with forward trunk lean
or the foot will rise up on MTP joint
The knee will flex and hip will flex
 Sagittal plane
• Foot flat on the floor
• Tibia at 90° (or leaning
slightly anterior)
• Knee fully extended
• Hip 0°
 KO Introduction
• Knee orthoses have been used as a common
intervention in the protection and stabilization of the
knee joint to decrease a person's pain and improve
their functional and recreational activities
• The KO is usually used for problems that only affect the
knee, and where there are no problems with ankle or
hip.
• The most common use of a KO is where the patient has
some ligament laxity or pain
• Knee orthoses come in many designs and variations
ranging from elastic sleeves that can be purchased at a
sports store, to custom moulded carbon fibre devices
 KO Introduction
• One of the biggest challenge for Knee orthoses is
suspension. If we examine the lower limb it is
somewhat cone shaped – big at the top and thin at
the bottom.
• The natural tendency is to move from the top to the
bottom, from the big area to the small area.
• This is especially true in KO, but we can try to use
the supracondylar area or the bulge of the calf
muscles to achieve suspension.
• (In a KAFO the AFO section is attached and touching
the ground, the device can’t “slip off”.)
 KO Classification
In 1984, the American Academy of
Orthopaedic Surgeons developed a
classification system that grouped knee
orthotics by their intended function
• Prophylactic
• Rehabilitative
• Functional
 Prophylactic knee orthoses
• Designed to reduce the risk of knee injury for
those individuals who are engaged in “high-
risk” activities, especially those individuals
who have a history of previous knee
dysfunction
Or
• attempt to prevent injury (or at least lessen
the extent of injury) in athletes who are at risk
of injury during competition
 Rehabilitative knee orthoses

• Are used to protect a knee that has been

injured or surgically repaired until adequate
tissue healing has occurred
Or are designed to protect the knee and allow
progressive increase in active range of motion
during rehabilitation.
 Functional knee orthoses

• Attempt to provide biomechanical stability

when ligaments are unable to do so during
daily activities
Or
• provide additional protection as rehabilitation
is completed and a patient returns to normal
activities
 Hinge design options
• Hinge options for knee orthoses range from
simple single-axis (unicentric) designs to
complex four-bar polycentric designs.
• Most commercially available "off the shelf"
functional knee orthoses have hinges in one of
three categories: (1) the single-axis hinge, (2)
the posterior offset hinge, or (3) the
polycentric
 The single-axis hinge

• act as a simple hinge; a unicentric hinge

becomes incongruent with the anatomic joint
axis as the instantaneous axis of rotation of
the knee changes with movement through the
range of motion
 Posterior offset
• Designs attempt to improve the match
between orthotic and anatomic axis of motion
by approximating the location of the sagittal
radius of curvature of the posterior femoral
condyles as it articulates with the tibia in
flexion
 Polycentric

• Designs attempt to replicate the

instantaneous axis of rotation of the anatomic
knee joint, using two geared surfaces that
mechanically constrain motion into a defined
path
 Off the Shelf Vs Custom made
• Many off-the-shelf (pre-fabricated) Knee
Orthoses are available on the market from
various companies.
• While they answer most of the needs and are
built very specifically for each different
pathological case, they are not adapted to the
size and shape of each individual and
therefore are not always the best option for
patients with unusual leg shapes
 Off the shelf Pro and Cons
• Fast to deliver to patient
• Visually attractive and therefore
easily accepted by patients
• Does not require (allow) much
modifications, fit might not be
perfect
• Not suitable for clients with unusual
leg shape and/or size
 Off the Shelf Vs Custom made

• Custom made Knee Orthoses are made

following a cast and have an optimal
adaptation to each individual, regardless their
legs' shape and size
 KO Trim lines
• The trim lines can differ a lot depending
on the functional purpose of the KO and
the type of patients it is intended for.
• Long trim KO are going up to the
proximal thigh and down to the malleoli.
• Medium trim KO are trimmed closer to
the knee.
• Short trim KO sometimes do not even
include the entire knee.
KO Long trim lines
KO Medium Trimlines
KO Short trim lines
 Selection of appropriate KO
• The complexity of the knee joint (with its
polycentric axis of rotation for
flexion/extension, asymmetry of the lateral
and medial compartments, and the
arrangement of its muscular and ligamentous
attachments) creates a challenge when trying
to design a knee orthosis that is able to
support, protect, and stabilize the knee in a
multiplanar fashion with the same efficiency
as its own physiological motion
 Selection of appropriate KO
• In order for a P/O to select the appropriate
knee orthosis for the patient, the clinician
needs a mastery of normal knee structure and
function
 anatomy and biomechanical stability of the
knee and patellofemoral joints and the
physiological and accessory motions of the
tibiofemoral and patellofemoral joints
 Anatomy of the Knee
• The Tibiofemoral joint
The knee joint is a hinge-
like articulation
between the medial
and lateral condyles of
the femur and the
medial and lateral tibial
plateau
 The Tibiofemoral joint
• Because of the shape and asymmetry of the
condyles, the instantaneous axis of knee flexion/
extension motion changes through the arc of motion
• In open chain movements (non– weight-bearing
activities), the tibia rotates around the femoral
condyles.
• In closed chain movements (weight bearing
activities), an anatomical locking mechanism is
present in the final degrees of extension as the
longer medial femoral condyle rotates medially on
the articular surfaces of the tibia
 The Tibiofemoral joint
• The menisci increase the concavity of the
tibial articular surface, enhancing congruency
of articulation with the femoral condyles to
facilitate normal gliding and distribute weight-
bearing forces within the knee during gait and
other loading activities.
• The menisci also play an important role in
nutrition and lubrication of the articular
surfaces of the knee joint
 The Tibiofemoral joint
• Stability to the tibiofemoral joint is provided
by sets of ligaments. The medial (tibial)
collateral ligament and the lateral (fibular)
collateral ligament are extrinsic ligaments.
• The collateral ligaments counter valgus and
varus forces that act on the knee. In addition,
two intrinsic ligaments of the tibiofemoral
joint, the anterior cruciate and posterior
cruciate ligaments check translatory forces
that displace the tibia on the femur
 Patellofemoral Joint
• The patella, a sesamoid bone embedded in
the tendon of the quadriceps femoris, is an
integral part of the extensor mechanism of
the knee
• The patella functions as an anatomical pulley,
increasing the knee extension moment
created by contraction of the quadriceps
femoris by as much as 50%
 Patellofemoral Joint
• It also guides the forces generated by the
quadriceps femoris to the patellar ligament,
protects deeper knee joint anatomy, protects
the quadriceps tendon from frictional forces,
and increases the compressive forces to which
the extensor mechanisms can be subjected
 Rehabilitative Knee Orthoses
• Orthoses used in the Commercially available open
postoperative and early cell foam interface that encase
the calf and thigh
rehabilitation of
patients who have had
surgical repair of
damaged cartilage,
ligaments, or bone are
designed to control
knee motion carefully
to minimize excessive
loading on healing
tissues
 Characteristics of Rehabilitative
Knee Orthoses
• The orthosis must be
adjustable to accommodate
changes in limb girth due to
edema or atrophy.
• It must remain in the
desired position on the limb
during functional activities
in stance and in sitting.
• It must be comfortable,
easy to don and doff,
durable, and economical
 Functional Knee Orthoses
• Use of knee orthoses as
functional braces
parallels the
development of the
discipline of sports
medicine since the early
1970s.
 When To Use Knee Orthosis?
• Arthritis
• Post surgery
• Prophylactic
• Sportsperson
 Knee Orthosis for Arthritis
• Joint conditions like knee arthritis,
osteoarthritis, pain in front of the knee or
conditions involving the kneecap, damage to
the cartilage under the kneecap, or any
condition that causes knee pain may warrant
the use of Knee orthosis
 KO Post Surgical Period
• In certain cases, damage to the knee joint may
have to be repaired surgically.
• Knee orthosis may be advised during the post
operative period or during rehabilitation phase so
as to allow time for tissue healing.
• Surgeries performed for degenerated or injured
knee joints may have a longer recovery period
and using appropriate knee orthosis can provide
adequate support, avoid further damage and
help in rehabilitation.
 Prophylactic KO
• Sometimes, knee orthosis may be advised as a
preventive measure, especially for persons at
an increased risk of knee injury or damage.
For example, after a previous ligament injury,
for ligament protection in certain knee
deformities or in sportspersons involved in
running, skiing, volleyball etc
 Sportspersons KO
• Sportspersons may use knee orthosis for running,
which aid in supporting and reducing pain.
• Some studies suggest that knee orthosis for skiing may
help in preventing further ligament injuries especially
in those who have undergone previous ACL
reconstruction surgery.
• Knee orthosis for volleyball can provide cushion effect
while diving, reduce pain and prevent repeated knee
injuries.
• Knee orthosis for basketball are specially designed
considering the need for different knee movements
and provide support, reduce shock and risk of
extended injury
 KO Variants
Elastic / Neoprene KO
• This is a sleeve of
material that provides
some compression to the
tissues around the knee,
and can help to keep the
area warm
• (Arthritis is often more
painful when the joint is
cool.)
• Does not provide ML or
AP instability
• compression helps to
improve proprioception
 KO Variants
Elastic/Neoprene with
flexible sidebar
• As above, with the
addition of minor M-L
control
• The sidebars and joints
are often very small and
as such can not hope to
control the very large
forces at the knee
• The compression and
added stiffness of the
joints aid in
proprioception
 Post-operative KO
• After surgery upon the
knee, following a
fracture close to the
knee, or damage of a
ligament, it is important
to limit the knee motion
until the injury is healed
 Distribution of Forces

Use of large area

Use of long liver arm
 Three (and four) point pressure
systems for knee orthosis
• Through the application
of three point pressure
systems the laxity can
be compensated
(Lateral colateral
ligament laxity)
 Three (and four) point pressure
systems for knee orthosis
• Through the application
of three point pressure
systems the laxity can
be compensated
(Medial colateral
ligament laxity)