Exam 4: Orthotics Part 1, Shoes Flashcards
What are the five components of an ideal orthotic (in order from most important to least important)?
- Control
- Comfort
- Adaptability (Changeability)
- Cost
- Cosmesis
What are 3 questions that you should ask yourself and 2 considerations when addressing Control in an orthotic?
- What do you want to control?
- Can you control it with an orthotic?
- Is your orthoses controlling what you want it to control?
Considerations:
- Make sure that the orthotic doesn’t hinder other motions, and if does, decide if we are okay with that.
- Try to maintain biomechanical correctness everywhere else (especially at joints above and below)
What are 4 considerations for for orthosis comfort?
- We never ever ever want to increase a pt’s pain (pt will not wear orthosis if it hurts)
- ease of donning and doffing
- Check for pressure points (don’t want pressure ulcer)
- Temperature: sweat in heat can cause pistoning and skin breakdown (especially in plastic orthoses)
What are 3-4 things about cosmesis in the ideal orthosis?
We want them to be:
- Able to be worn with usual clothing
- Not too noticeable
- people may think of you/treat you differently when they see you have an orthosis.
- Hopefully they look nice and are small as possible
However, function may be more important than cosmesis.
Two considerations for adaptibility in the ideal orthosis:
Why?
- Consider is this person going to change (get more/less function with time?
- Is it possible to make the orthosis more adaptable?
It may cost more initially to provide an orthosis that can be adapted later, but it is likely worth it because you won’t need to purchase entirely new one later (an entirely new orthosis is often hard to get covered insurance)
Explain how the importance of cost fits into the ideal orthosis
Cost is important but it is less important than many other essential components of an ideal orthotic because if an orthotic does not provide control, comfort, and adaptability it is not worth wearing (and the pt will not wear it). In fact, it could do more harm than good.
Cosmesis isn’t usually more important than cost, but I guess it would be if the person refused to wear it because of socal anxiety, etc.
6 Things an orthosis can do (with examples for some):
- Stability in mobility
- Stability in immobility
- Correct deformity
- Accommodate deformity
- Late RA
- Prevent Deformity/Injury
- Early RA
- Assist in Motion
- tenodesis splint
- AFOs that assist with motion
- FES
- electrically assists motion
When represented in vector form, what are the three components of force?
magnitude
direction
point of application
T/F: Orthotics are great because they can facillitate stretching of muscle contractures and stiff joints.
Mostly False
We shouldn’t use orthoses for stretching (ecept for sometimes in hand splints - and that must be doen carefully and correctly).
How many points of force do we need in each plane and direciton of motion an orthosis attempts to control?
(in other words, in order to stablize a joint from moving in a certain direction, how many points of force do we need?)
Each plane and direction of motion that the orthosis attempts to control has a three-point loading systm
Some orthosis designs use additional forces, acting as balanced systems containing four, five, six or more points, to allow better control of rotational translational motion of the joint or provide effective conrol of motion in multipule planes.
What is a three-point loading (or control) system?
From the book: In a three-point loading or control system, a proximal and a distal force applied in the same direction are countered by (or balanced against) a third force applied in the opposite direction at a point somewhere in between them.
In the picture: I think the bottom two might technically be 4-point loading/control systems, but they have the same effect (the two points are just avoiding pushing directly on the malleolus. Also, the (not pictured) shoe is providing force in A.
When trying to stablize a joint, what must the net force equal?
0
For example, in a three piont loading or control system, a priximal and distal force applied in the same direction are countered by (or balanced against) a third force applied in the opposit edirection at a point smewhere in between them. The sum of the two forces equals the 3rd force. The two forces are pushing in the direction opposite the 3rd force, so the two forces and the third force cancel each other out and the net force at the joint is zero.
What happens if we have too much force over a small area or our forces are out of balance?
Pressure* is too high if the area of force is too small.
If pressure is to high over an area it will cause tissue breakdown.
*Pressure = force/area
Why should we assess forces?
In order to make sure the orthotic is not putting undue pressure on tissue (and causing skin breakdown, pain, etc)
What are some good ways to assess forces (pressure)?
What if pt has impaired sensation?
Ask how it feels? (unless they don’t have sensation)
Observation (skin checks)
- redness
- lack of redness
- indentation
- blister/blood
True/False: If someone develops blisters, pain, or skin breakdown when wearing their new orthosis, then it must be a bad fit.
False
Any addition to someone’s body must be gradually introduced. Even if the orthosis is a good fit, wearing it too long too soon can cause skin breakdown, pain, blisters, etc.
It could be a bad fit, but this isn’t evident just because someone experiences pain and blisters.
What is a wearing schedule?
A schedule of how long to wear a new orthosis each day to gradually build up to wearing it full time.
Describe a wearing schedule for starting to wear an AFO that Dr. B recommended in class. (5 steps)
- start with 5 minutes with no activity (especially for splint), Take it off, take off the socks, look, ask how it felt
- wear for 10 minutes, then check again
- If they can wear for 15 minutes and it’s ok,
- let them stand on it (just sit <-> stand)
- Try to walk with them if sit <->stand is okay
**Inspection should be at boney prominences, rim around top, wherever there is a strap
***look for pressure, then friction, then shear (will likely occur in this order)
AFO: What about Socks? (4)
- Make sure socks cover entire AFO
- White
- Cotton
- Not too much constriction at the top
AFO: What about shoes? (2-3)
Will need a shoe that the orthotic will fit in that also fits pt’s foot.
- Usually this will require going up 1 to 0.5 size
- Shoe must open far enough down towards vamp to allow donning of shoe while wearing AFO
- usually requires laces or velcro closure
**Tennis shoes are usually good
Name the parts of the shoe that Dr. Bringman wanted us to know:
- Sole
- Heel
- Upper
- Vamp
- Tongue
- Rear Quarters
5 Things to remember about the Sole
- typically has some thickness
- Shock absorption (should have some amount)
- Influences time spent in IC
- soft increases amount of time you stay in initial contact
- hard decreases amount of time you stay in IC
- Provides Traction (or not)
- Rigidity influences toe off (toe rocker/3rd rocker)
- flexible (most common) allows normal toe off (toe rocker)
- example: athletic shoes
- rigid results in an abbreviated toe off (toe rocker)
- examples: some types of dress shoes, some women’s heels
- flexible (most common) allows normal toe off (toe rocker)
Sole density influences what?
How?
Influences time spent in IC
- soft increases amount of time you stay in initial contact
- hard decreases amount of time you stay in IC
What does does sole rigidity influence?
how?
examples?
Rigidity influences toe off (toe rocker/3rd rocker)
- flexible (most common) allows normal toe off (toe rocker)
- example: athletic shoes
- rigid results in an abbreviated toe off (toe rocker)
- examples: some types of dress shoes, some women’s heels
4 things to know about the Heel
- can change height
- If chronically too high, pt may not be able to reach neutral ankle ROM
- change density for shock absorption
- Can add lift to outside of the shoe
- For someone with over ⅜ inch leg length discrepancy (too much difference to take care of by putting a heel-lift inside the shoe.
- But this makes shoe really heavy
- Orthotist is the person to do this
- If If leg length discrepancy is 6-8 inches or more, a prosthesis that foot will fit into is considered and likely to be recommended (see picture)
When do you add to the outside of the shoe for a leg length difference?
Who does this?
What is a complication?
At what point is this impractical?
- Add to outside of shoe (to Heel) for someone with over ⅜ inch leg length discrepancy (too much difference to take care of by putting a heel-lift inside the shoe).
- But this makes shoe really heavy
- Orthotist is the person to do this
- If If leg length discrepancy is 6-8 inches or more, a prosthesis that foot will fit into is considered and likely to be recommended (see picture)
Things to know about the Tongue and closure
- The blucher-style closure can be opened slightly more than the bal oxford closure to alloww the foot into the shoe
- The tongue is an extension of the vamp in a blucher-style closure
- The tongue is seperate in the bal-type oxford.
- There is also a lace-to-toe (surgical) style shoe that is the most accomodating (reminds me of rentable ice skates, roller skates, or bowling shoes).
Closure can be through velco or laces
Describe Forefoot Valgus
Forefoot Valgus
looking from calcaneus forward
- big toe down
- fifth toe up
how should you wedge fixed forefoot valgus?
Why?
put wedge lateral to keep foot from twisting when weight bearing.
(accommodate the deformity)
Describe forefoot varus
looking from calcaneus forward
- big toe up
- fifth toe down
how should you wedge flexible forefoot varus?
Why?
lateral wedge to correct deformity
how should you wedge fixed forefoot varus?
Why?
place wedge medial wedge to accommodate deformity
Describe Rearfoot Valgus
What does it cause?
common/uncommon?
calcaneus bottom angles laterally (top angles medially)
- causes flat-foot, navicular drops, rest of foot follows
- This is what happens to the majority of people
Describe Rearfoot Varus
What does it cause?
common/uncommon?
- calcaneus superior part points medial, superior part points lateral
- Causes pes cavus
- majority of people get rearfoot valgus (not varus)
how should you wedge flexible rearfoot valgus?
Why?
use medial wedge (under calcaneus at this point, not the arch) to prevent inward collapse (correct deformity)
keep the calcaneus more stable
how should you wedge fixed rearfoot valgus?
Why?
use lateral wedge just to build it up (accomodate deformity)
(could put in some support for medial side to prevent further deformity)
how should you wedge flexible rearfoot varus?
Why?
use lateral wedge to correct deformity
how should you wedge fixed/rigid rearfoot varus?
Why?
accommodate deformity with medial wedge
4 things to know about the metatarsal bar
- build up on sole of shoe proximal to the met heads (said it twice, prob important)
- creates fulcrum proximal to met heads
- takes axis of movement off big toe (and other met heads) and shifts it to just behind met heads
- Takes pressure off the met-heads
- makes toe off faster
Describe a rocker bottom
- rocker bottom is more like a curve under the stiff sole to allow for a normal roll through without having metatarsal head flexion
- (so foot stays stiff but it feels like a more normal roll-through)
- Also prevents met head flexion and protects met heads from extra pressure
Why would Dr. Bringman choose one post op shoe sole over the other?
- If pt is allowed to weight bear, he prefers a true rocker (with a smooth under dome) because it allows most normal gait.
- If they need to keep weight off metatarsals completely, he may choose one of the other ones. (that have tilts towards the back and lacking large chunks of under sole in the front
