Braddom - Lower Limb Orthotics Flashcards
device attached or applied to the external surface of the body to improve function, restrict or enforce motion, or support a body segment
Orthosis
Lower limb orthoses are indicated to
assist gait, reduce pain, decrease weight-bearing, control movement, and minimize progression of a deformity.
knee that has a tendency to hyperextend
back knee
lower extremity specifically refers
Foot
should be used to refer to the portion of the lower limb between the knee and ankle joints.
Leg
between the hip and knee joints.
thigh
refers to the thigh, leg, and foot.
Lower limb
Suffix ankle
Us
Suffix knee
Um
Suffix hip
A
Hindfoot deformity
Valgus
Forefoot deformity
Varus
Bowlegged
Genu varum
Deformity at the hip
Coxa valga
And coxa vara
Calcaneus
Os calcis
Equinis deformity
Plantar flexion deformity
refers to twisting of a portion of a limb.
Torsion
refers to twisting of a portion of a limb that occurs at the joint
Rotation
Inrolling
Pronation
Outrolling
Supination
Taken off orthosis
Doffed
Taken on orthosis
Donned
examination of the patient after the orthosis is fitted.
Checkout
should be pliable so as not to interfere with the normal biomechanics of the foot.
Pliable
durable, allow ventilation, and mold to the feet with time.
Leather shoes
Tongue part is part of the vamp in
Blucher shoe
The quarters overlap the vamp.
Blucher
recommended for patients requiring an orthosis because there is more room to don and doff the shoe and the orthosis because of the open throat
Blucher
quarters meet at the throat.
Bal
vamp is stitched over the quarters at the throat, thereby limiting the ability of the shoe to open and accommodate an orthosis.
Bal
have an effect on rotational components of gait
Foot orthoses
affect the ground reactive forces acting on the joints of the lower limb.
Foot orthoses
most commonly used in over-the-counter orthoses.
Soft type
Orthotists usually provide this type of foot orthoses
Semirigid
Provide more support
Still shock absorbing
Rigid
indicated only for a problem that requires aggressive bracing to control a deformity.
Rigid orthosis
To make a custom foot orthosis, the_____ should be placed in a neutral position before casting.
subtalar joint
ankle rotation, such as hyperpronation, and it is also the position in which the foot functions best
Neutral position subtalar joint
used to treat conditions associated with hyperpronation including pes planus, patellofemoral pain.
Subtalar neutral position
also used for difficult orthotic cases where the fiberglass casting itself can be used as a temporary orthosis to determine whether the mold properly controls the deformity.
Fiberglass casting
Pes planus
Flat foot
Pes planus
Symptomatic relief of pain is obtained by
controlling excess pronation of the foot.
can be defined as a rotation of the foot in the longitudinal axis resulting in a lowering of the medial aspect of the foot.
Pronation of the foot
involves pronation at the subtalar joint, dorsiflexion at the ankle joint, and abduction of the forefoot at the tarsometatarsal joints.
Eversion
The key to controlling excess pronation (of flat foot) is controlling the
calcaneus to keep the subtalar joint in a neutral position.
Pes planus can be due to abnormalities such as
excessive internal torsion of the tibia (which results in pronation of the foot) or
malalignment of the calcaneus.
It is the i action between the tibia and the foot at the subtalar joint that allows pathology outside the foot to cause inrolling of the foot
Pes planus
prevents rotational deformities associated with excessive pronation or supination from occurring
Subtalar neutral postion
Elevation of the anteromedial calcaneus exerts an upward thrust against the sustentaculum tali to help prevent
inrolling.
The orthosis should extend beyond the _____ to provide better leverage for control of the deformity.
metatarsal heads
due to abnormalities such as excessive internal torsion of the tibia (which results in pronation of the foot) or malalignment of the calcaneus.
Pes planus
custom-made foot o sis designed to prevent hyperpronation is also referred to as
UCBL orthosis (or UCB)
two common mistakes noted in custom foot orthoses.
Some Not made by orthotists
some custom foot orthoses do not cup the calcaneus but rather merely serve as a platform to stand on.
Some cases of pes planus are due to ligamentous laxity within the foot.
Mgt
medial longitudinal arch support
term for increased medial length to heel) can also offer medial support, particularly for heavier individuals.
Thomas heel extension
Runners with pes planus
Mgt
purchase a pair of running shoes with a firm medial heel counter as well as shoes with a wide last at the shank
High arched foot
Pes cavus
typical complication of pes cavus
excess pressure along the heel and metatarsal head areas, which can lead to pain
Pain pes cavus prevented by
making the height of the longitudinal support just high enough to fill in the space between the shank of the shoe and the arch of the foot to distribute weight more effectively.
Weight should also be evenly distributed over the metatarsal heads.
Pes cavus
High point
Talonavicular joint
Pes cavus
If the tibia is externally rotated (see Figure 15-2), this can give the appearance of an elevated arch as the foot supinates and the lateral aspect of the foot assumes additional weight-bearing responsibility. In these cases a foot orthosis is custom molded with the subtalar joint in a neutral position to prevent excess supination from occurring.
In these cases a foot orthosis is custom molded with the subtalar joint in a neutral position to prevent excess supination from occurring.
Metatarsalgia
Forefoot Pain
Relief of pain in the forefoot is accomplished by
distributing the weight-bearing forces to an area proximal to the metatarsal heads
Forefoot pain
Placed
inside the shoe just proximal to the second, third, and fourth metatarsal heads. It should also be just proximal to the lateral aspect of the first metatarsal head and medial to the fifth metatarsal head
recommended for cases in which the foot is too sensitive to tolerate a pad inside the shoe.
metatarsal bar
typically 1 ⁄4-inch thick and tapers d tally.
Metatarsal bar
The metatarsal bar is typically 1 ⁄4-inch thick and tapers distally. The distal edge should be proximal to
the metatarsal heads.
can also be used for forefoot pain a ciated with pes cavus.
metatarsal bar
can also be used for metatarsalgia to decrease the force on the metatarsal pad region at push off.
rocker bottom
Prevention of forefoot pain should also be emphasized to patients. Patients should avoid shoes with
high heels or pointed toes, which place excess stress on the metatarsal heads.
Heel Pain
The painful area can be alleviated by using
an orthosis to help distribute weight
can be applied inside the shoe to offer relief in cases of minor discomfort.
Heel pain
Rubber heel pads
recommended for cases in which the foot is too sensitive to tolerate a pad inside the shoe and the heel pain is associated with a chronic condition
calcaneal bar
Spring - heel set on anterior calcaneus
The calcaneal bar is placed
distal to the painful area to prevent the calcaneus from assuming full weight-bearing status.
application of a _____ can also be used to help initiate heel strike anterior and the ground reaction force anterior to the painful calcaneus
Heel pain
rocker bottom shoe
A common cause of heel pain along the anteromedial calcaneus
plantar fasciitis.
common cause of heel pain along the anteromedial calcaneus is plantar fasciitis. Pain occurs at the
attachment site of the fascia along the medial aspect of the heel.
Point tenderness is located over
Heel pain
anteromedial calcaneus.
It is common in people who hyperpronate their feet, thereby placing excess stress on the
It is common in people who hyperpronate their feet, thereby placing excess stress on the
helps prevent excessive inrolling from occurring and reduces the stress placed along the proximal arch.
subtalar joint in a neutral p tion
subtalar joint in a neutral p tion
Heel pain
custom-made UCB o sis
conservative treatment
Heel pain
of shoes with a firm medial heel counter and a wide shank
additional orthotic intervention for plantar fasciitis is the application of a
prefabricated AFO placed in a few degrees of d ion
plantar fascia night splint
is also common in patients with high arches.
Plantar fasciitis
For these patients the medial longitudinal arch undergoes marked stress during weight-bearing.
Plantar fasciitis is also common in patients with high arches.
result of mechanical stress acting through the plantar fascia onto its origin at the calcaneus and are not the source of the pain
Heel spurs related to plantar fasciitis
related to advancing age and are not painful in nature.
Inferior heel spurs
Hyperpronating “flat” foot
UCBL
Temporary mild to moderate metatarsalgia
Metatarsal pad:
Severe metatarsalgia (cannot stand something in shoe) or permanent metatarsalgia (e.g., arthritis)
Metatarsal bar to shoe
Temporary use for Achilles tendinitis or plantar fasciitis
Heel lift:
Fat pad syndrome (heel bruise)
Heel cup
Osteoarthritis with medial compartment narrowing
Lateral heel wedge
For a trial basis only
Ankle foot
Otc
For almost everyone
Ako
Plastic
For long-term use
Custom
the patient >250 lb with a hinged AFO
Metal
Foot drop
Tx
Custom solid (flexible) AFO set at 90 degrees:
Plantar spasticity
Custom solid (rigid) AFO set at 90 degrees:
Hinge Indications
Significant mediolateral instability at subtalar joint but patient with ankle dorsiflexion and plantar flexion (rare)
• Tight plantar flexors in spastic patients with improving lower limb function (they can take advantage of a more “normal” gait via dorsiflexion from midstance to toe-off, and plantar stretching is therapeutic over this part of the gait cycle)
An active patient with foot drop or plantar flexor spasticity can take advantage of the hinged feature during stair climbing, rising from sit to stand, frequent walking, etc.
Kafo
Most common; always used unless posterior offset is indicated
Straight set:
Patient with weak knee extensor triad ( riceps, plantar flexors, and hamstrings)
Posterior offset:
A two-joint system that theoretically simulates femur-tibia translation; standard on most sport orthoses for the above marketing purpose; no clear-cut indications
Polycentric
Most common. Knee locks
Ratchet lock
be difficult to pull up after “settling in” from walking
Drop lock:
Bulkier and less desirable then the drop locks for most patients but necessary for those without fine hand control
Bail lock:
Used to lock an unstable knee in extension, but they are adjusted to account for knee flexion contractures
Dial lock:
Allows flexion and extension hip
Std
Permits flexion and extension but also permits abduction to allow self-catheterization of the urinary bladder and seating in a hip-flexed and abducted position
Abduction
help some causes of Achilles pain by decreasing the amount of stretch placed on the Achilles tendon (by keeping the ankle joint plantar flexed)
Heel lifts
insertion of the tendon into the periosteum of the calcaneus.
Achilles enthesitis
For Achilles enthesitis, a heel lift is meant to be used for weeks—not months—to prevent the development
plantar flexion contracture
can also be helpful for treating plantar flexion spasticity or contracture by increasing the total heel height to help ensure that the patient has a heel strike before toe touch during gait.
heel lift
True leg length is measured from
distal tip of the anterior superior iliac spine to the distal tip of the medial malleolus
Apparent leg length is measured from
midline point such as the pubic s sis or umbilicus to the distal tip of each malleolus.
can be abnormal in cases in which the true leg length is normal but pelvic obliquity is present secondary to conditions such as scoliosis, pelvic fracture, or muscle imbalance.
Apparent leg length
can be used for conservative treatment of osteoarthritis when medial compartment narrowing is present.
Lateral heel wedges
The heel wedges used are 1 ⁄4-inch thick along the lateral border and taper medially.
Lateral heel wedges
stay on a child’s foot better than a low-cut shoe and is recommended during the first few years of life.
high quarter or three-quarter shoe
Pedia
To facilitate_____a heel should not be present.
gait
r mended to permit the natural development of feet
Soft soles
most commonly prescribed lower limb o ses.
Ankle-Foot Orthoses
formerly known decades ago as short leg braces.
most commonly prescribed lower limb o ses.
are relatively c indicated in children because the weight of the brace can cause external tibial rotation
Metal AFOs
now most common in all age-groups.
Afo
Plastic AFOs
can be used effectively to control ankle motion.
Metal or plastic AFOs
AFOs should provide _____ as a safety feature.
mediolateral stability
AFO influence the ff mechanics of gait
amount of dorsiflexion and plantar flexion, movements at the subtalar joint
supination at the subtalar joint, adduction at the tarsometatarsal joints, and plantar flexion at the ankle joint, which results in the foot being in an equinovarus position
Inversion
includes pronation at the subtalar joint, abduction of the forefoot at the tarsometatarsal joints, and dorsiflexion at the ankle joint, resulting in the foot being in a valgus position
Eversion
R tion at the subtalar joint is also accompanied by ________ of the tibia
rotation
can also stabilize the knee during gait.
AFO
prescribed for conditions affecting knee stability, such as genu recurvatum.
AFO
should be considered for c ditions affecting the knee, particularly when a concurrent problem exists at the ankle or subtalar joints.
Afo
plantar flexion creates
Knee extension
Plantar dorsiflexion creates
Knee flexion moment
Morbidly obese patients can require more if not all _____ for durability and subtalar joint stability.
metal componentry
better stabilization of the ankle during the gait cycle.
Metal afo
consists of a proximal calf band, two uprights, ankle joints, and an attachment to the shoe to anchor the AFO
Metal afo
Metal afo
The calf band should be 1 inch below the fibular neck to prevent a
compressive common peroneal nerve palsy
used to close the calf band, because it provides ease of closure for patients with only one functional upper limb.
leather strap with Velcro
U-shaped metal piece p nently attached to the shoe
solid stirrup
Its two ends are bent upward to articulate with the medial and lateral ankle joints
solid stirrup
Solid stirrup
The sole plate can be extended beyond the metatarsal head area for conditions requiring a longer lever arm for better control of
plantar flexion
Has sole plate with two flat channels for insertion of the uprights.
Split stirrup
allows removal of the uprights from the shoes so that the AFO can be worn with other shoes
split stirrup
not as stable as the solid stirrup, and the metal uprights can pop out,
split stirrup
Limits plantar flexion
Posterior
Pin
Assists dorsiflexion
Posterior
Spring
Limits dorsi flexion
Anterior
Pin
Assists plantar flexion
Anterior
Spring
Ind
Plantar spasticity, toe
drag, pain with ankle motion
Posterior
Pin
Flaccid footdrop, knee hyperextension
Posterior
Spring
Weak plantar flexors,
weak knee extensors, pain with ankle motion
Anterior
Pin
has not been d onstrated to be of clinical value.
spring in the anterior channel
are the most commonly used AFOs because of their cost, cosmesis, light weight, interchangeability with shoes, ability to control varus and valgus deformities, provision of better foot support with the customized foot portion, and ability to achieve what is offered by the metal AFO
Plastic AFOs
ankle and subtalar joints can be made more stable under four circumstances:
extend the trim line more anteriorly at the ankle level (a trim line is the anterior border of the plastic AFO); (2) make the plastic material thicker; (3) place carbon inserts along the medial and lateral aspects of the ankle joint; and (4) incorporate corrugations within the posterior leaf of the AFO.
allow full or partial ankle motion
Ankle hinges
should be considered when complete restriction of ankle motion is not required
Ankle hinges
Hinging an AFO adds
mediolateral stability. C
for a patient with s ity with a tendency toward inversion, or for a patient with multiplanar ankle and subtalar flaccidity accompanying a foot drop with a history of twisting the ankle.
hinged AFO f
X The leg component should encompass __ of the leg and should be padded along its internal surface
three quarters
Afo]
The proximal extent should end______ to prevent a compressive common peroneal nerve palsy.
1 inch below the fibular neck
are commonly used for foot drop
Solid AFOs set at 90 degrees
Genu recurvatum can also be treated with a
solid AFO.
he more rigid the AFO, the greater the flexion moment at the knee at heel strike, which helps reverse the extension moment at the knee associated with genu recurvatum.
An equinovarus (or inversion) deformity is controlled by applying forces
Varus
medially at the metatarsal head area and calcaneus.
The next force is applied more proximally along the lateral aspect of the fibula. T
helps prevent inversion at the subtalar and ankle joints
is applied to provide stabilization of the leg portion of the plastic AFO by providing an opposing force to the fibular area
proximal medial tibial force
uses the patellar tendon and the tibial condyles to partially relieve weight-bearing stress on skeletal structures distally, with more weight-bearing distributed along the medial tibial condyle.
patellar tendon–bearing (PTB) AFO
PTB is a misnomer for this orthosis because only about _____of the weight is distributed along the patellar tendon and the medial tibial condyle.
10%
are often prescribed for diabetic ulcerations of the foot, tibial fractures, and relief of the weight-bearing surface in painful heel conditions such as calcaneal fractures, postoperative ankle fusions, and avascular necrosis of the foot or ankle.
PTB AFOs
A custom-molded PTB AFO can reduce weight-bearing in the affected foot by up to___
50%.
indicated when maximum weight-bearing reduction is necessary to ensure proper healing (such as in a debrided diabetic heel ulcer) and reduction of pain
Custom-made PTB AFOs
orthosis serves two purposes: pressure relief and contracture prevention
pressure relief AFO
Pressure Relief Ankle-Foot Orthoses achieved
Pressure relief is achieved at the heel by completely eliminating weight-bearing with the heel cut out, and also by using a hinged lever arm posteriorly that can be adjusted medially or laterally to prevent medial or lateral malleolar pressure sore development. This should be applied on the immobilized or motionless affected lower limb at all times while in bed.
frequently used in demented patients with hip fractures who do not have much lower limb mobility,
patients with a stroke who have dense h plegia.
PRAFO
three most common physiatric AFO prescriptions are those for
foot drop, plantar spasticity, and lumbar s nal cord injury
most common AFO prescription for foot drop i
nonhinged p tic AFO set in a few degrees of dorsiflexion with a posterior trim line.
posterior leaf spring AFO. T
posterior leaf spring AFO. The few degrees of dorsiflexion ensures foot clearance during t
swing phase of gait.
avoidance of hinging not only minimizes bulk,
practical standpoint it keeps the mediolateral dimension of the AFO narrow to best accommodate a variety of shoes and pants.
significant subtalar joint instability (e.g., a patient with a history of inversion injuries and falling
hinged plastic AFO with metal double-action ankle joints (see Figure 15-10) with springs in the posterior channels (dorsi-assist) would provide mediolateral stability yet also permit plantar flexion.
can also provide mediolateral stability for the patient with foot drop.
hinged midline posterior stop AFO
most common AFO prescription for plantar s ticity is
either a hinged custom plastic AFO with a single midline posterior stop or a hinged custom plastic AFO with pins in the posterior channels to provide plantar stop 90 degrees.
s nificant inversion deformity is still present after all other medical treatment measures to manage the spasticity have been exhausted.
hinged custom plastic AFO with pins in the posterior channels to provide plantar stop 90 degrees
as a preferred AFO for an active p ric population with lower limb spasticity.
hinged AFOs with plantar stops at neutral (90 degrees) a
most common lumbar spinal cord injury AFO p scription
bilateral custom plastic ground reaction ( rior tibial shell closing) AFOs fixed in 10 degrees of plantar flexion. T
help create knee extension moments with weight-bearing to add stability to the knees during ambulation
anterior tibial shell closing and 10 degrees of plantar flexion
were formerly referred to decades ago as long leg braces.
Knee-ankle-foot orthoses (KAFOs)
used in patients with severe knee e sor and hamstring weakness, structural knee instability, and knee flexion spasticity.
KAFOs
p vide stability at the knee, ankle, and subtalar joints during ambulation. They are most commonly prescribed bilaterally for patients with spinal cord injuries and unilaterally for patients with polio.
KAFO
three stabilizers to the knee:
quadriceps, the h strings (via eccentric activation at heel strike), and the plantar flexors (plantar flexion creates a knee extension moment)
no quadriceps function
complete femoral neuropathy (
preventing lower limb contractures, enhancing cardiovascular fitness, maintaining upper body strength for activities of daily living, delaying the development of osteoporosis, and decreasing the risk for medical complications, such as deep venous thrombosis.
KAFOs
is a reliable indicator of which spinal cord–injured patients can achieve ambulation status.
proprioceptive
often complements the use of a w chair for ambulation.
KAFOs
also important in predicting the ability to ambulate.
level of the spinal cord injury
generally are not f tional ambulators because of the metabolic cost involved
Adult spinal cord–injured patients with lesions at or above T12 g
have a higher center of gravity and can have a f tional gait with a higher spinal cord lesion
Children
is a predictor of the quality of ambulation.
Muscle function
Some patients with paraplegia, such as those with lower lumbar lesions with some knee extensor strength, are able to ambulate without KAFOs. Ambulation in these patients can often be accomplished with the use of
bilateral plastic ground reaction AFOs (see Figures 15-11 and 15-16) with the ankles fixed in 10 to 15 degrees of plantar flexion.
provides rotation about a single axis
Kj
straight-set knee joint
free flexion but prevents hyperextension.
Kj
straight-set
It is often used in combination with a drop lock, which keeps the knee in extension throughout all phases of gait for further stability.
straight-set
uses a double-axis system to simulate the flexion-extension movements of the femur and tibia at the knee joint
polycentric knee joint
It is p scribed for patients with weak knee extensors and some hip extensor strength
posterior offset knee joint
allows free flexion and extension of the knee during the swing phase of gait and helps keep the orthotic ground reactive force in front of the knee axis for stability during stance.
posterior offset knee joint
n mally posterior to the knee at heel strike, creating a flexion moment at the knee, which requires quadriceps and hamstring muscle contraction to counteract this force.
center of gravity
are used to provide complete stability at the knee. T
Knee locks
has recently become the most c monly prescribed knee lock
ratchet
catching mechanism that operates in 12-degree increments
ratchet
provides the easiest method of simultaneously unlocking the medial and lateral knee joints of a KAFO
The bail lock
is used to stabilize the knee in varying amounts of flexion (Figure 15-27). It can be adjusted in 6-degree increments and is more precise for the management of a knee with a flexion contracture than a KAFO with ratchet locks. Its uses include helping prevent progression of a flexion contracture or assisting with the gradual reduction of a flexion contracture.
dial lock
was designed to provide the patient with paraplegia who has a complete lesion at L1 or higher, with a more functional and comfortable gait
Scott-Craig orthosis
The knee orthosis (KO) known as a Swedish knee cage (Figure 15-29) is used to control minor to moderate genu recurvatum caused by ligamentous or capsular laxity.
Swedish Knee Cage
limiting f tor regarding this knee orthotic prescription is the
patient’s weight
preferred first-line orthotic treatment for osteoarthritis of the knee. (See Osteoarthritis of the Knee in the Foot Orthoses section
foot orthosis with a l eral buildup
is used to allow protected motion within defined limits. 36 It is useful for postoperative and conservative management of knee injuries, and is most commonly applied postoperatively for anterior cruciate ligament–reconstructed knees (Figure 15-31) and patellofemoral pain syndrome.*
Rehabilitative knee bracing
is designed to assist or p vide stability for the unstable knee
Functional knee bracint
are used most commonly to stabilize a laterally subluxing patella or an anterior cruciate l ment–deficient knee
Functional knee bracing
is used for children with a developmental delay in ambulatory skills, and it serves as an initial mobility aid.
caster cart
was also referred to in the past as a swivel orthosis
parapodium
allows crutchless gait
parapodium
hip-guided orthosis
reciprocating gait orthosis (RGO
bilateral hip-knee-ankle-foot orthosis (HKAFO).
Reciprocating Gait Orthosis
children who have used the standing frame, developed good trunk control and coordination, can safely stand, and are mentally prepared for ambulation
RGO
It is useful for hemiplegic and ataxic patients.
walker
