L3 LE Orthotics Flashcards
Full length lifts
complete full length shoe lifts on one side accommodate for leg length discrepancies
can also compensate for the patient not obtaining adequate ankle/knee/hip flexion on the opposite limb
Heel lift
typically used to accommodate PF contractures
also used for achilles tendonitis
Heel Wedge
supports calcaneal inversion or eversion or valgus at the ankle
medial wedge = inhibits calcaneal eversion
lateral wedge = inhibits calcaneal inversion
Heel cushion
soft pad that is placed on the heel of the inner sole to cushion the heel. goal is to reduce heel pain. often used for patients with calcaneal spur or plantar fasciitis
Heel cup
rigid insert that covers the plantar surface of the calcaneus and extends upwards. helps to stabilize the calcaneus in a neutral position as well as provide shock absorption for the heel. commonly used for pts with calcaneal spur or plantar fasciitis
Metatarsal Bar
adds a rocker to the metatarsal area to take weight off the rays
Rocker Sole
allows for smooth transition from heel strike to toe off with limited ankle motion
Use of shoes with orthoses
most orthoses rely on shoe to kep foot in contact with foot plate
-non slip sole on shoe and laces to mid foot
-depth of shoes is important and width of toe box
-watch for slipping at the heel
Accommodative Foot Orthoses
we are accommodating a certain position/condition of the foot. foot is not correctable or has pain with correction
used for RA, healed fractures, CMT, diabetes
Functional Foot Orthoses
designed to realign the bones and joints in the foot in order to decrease stress within the knee, ankle, foot
reduce pronation, supination, support calcaneus. usually will include wedging or posting to prevent abnormal compensatory movement within joints
What is the difference between functional and accommodative orthotics?
a functional orthosis is normally made of a firmer material, such as plastic and designed to realign the foot and body in accordance with ROM and flexibility
an accommodative orthosis is supporting the foot in its current position
Materials of Foot Orthoses
Top cover
Mid layer
Base layer
Top cover
soft neoprene type material, shock absorbing foam or leather
Mid layer
shock absorbing layer
Base layer
rigid foam, cork, or thermoplastic
Reliefs
reliefs will be modified into positive model to unload areas of the foot
i.e metatarsal heads, base of 5th metatarsal, plantar fascia
Additions
met pads to relieve pressure on metatarsal heads
extrinsic wedging at heel or forefoot for support
Varus wedge
wedge is on the medial aspect of the orthosis
force applied is shifted laterally resulting in supination/inversion and improved pronation control
Valgus Wedge
wedge is on the lateral aspect of the orthosis
force applied is shifted medially resulting in pronation/eversion
UCBL
type of foot orthosis used to stabilize the subtalar and tarsal joints in stance
indicated for rearfoot valgus/varus and pes planus
contraindicated with rigid foot deformity
SMO
supramalleolar orthosis
only crosses ankle joint, does not have any joints
control mid foot and calcaneal misalignment
mainly used in peds, adult foot may not take the forces needed for correction
Off the shelf
-used when pt does not have the need for the custom shape
-lower cost
-main benefit for swing phase deficits
-good option for early gait training
-limited benefit for more complex abnormalities
Custom AFO
-molded from cast
-thermoplastic or carbon fiber
-used when patient has deformation or will need more support in single or multiple planes
-higher cost
-best choice for complexity
Prximal Shell
-controls forward or backward progression of the tibia during stance
-can either be anterior or posterior shell
Anterior shell
provides stance phase knee stability by limiting tibial forward progression when AFO is solid and very stiff
limits DF in stance
may lead to knee hyperextension
Posterior Shell
beneficial for more complex gait abnormalities impacting both knee flexion and extension in stance
may allow greater DF than an anterior shell during stance depending on AFO stiffness
Trimlines
contact position of the material that can be cut more anteriorly or more posteriorly
trimlines impact stiffness of AFO
can be posterior or anterior cut
Anterior Trimline
material extends more anteriorly providing increased control and less motion
the more anterior the trimline, the more the stiff the AFO
Posterior Trimline
material provides less contact, providing decreased control and allowing more motion
anterior trimlines can be cut to be more posterior as control, muscle strength, improves
posterior to malleoli decrease ML control
Ankle Strap
secures the ankle into the AFO and limits heel positioning
Posterior Strap
allows adjustments for amount of DF
T-strap
can assist in controlling ankle varus/valgus
Double Metal Upright AFO
-hinges allow motion
-DF/PF stops set by adjusting screws in each channel
-springs can be added for DF assist
-excellent choice for edema
-allows modifications as recovery progresses
-attaches to the shoes
Benefits of double metal upright AFO
-can provide DF assist
-adjustable as pts needs change
-allows for volitional muscle activation
-can control stance phase knee flexion/extension based on adjustment at ankle
Considerations of Double metal upright AFO
not appropriate for PF spasticity
need adequate ankle PROM
need stable M/L stability
Solid or Rigid AFO
provides rigid support of the ankle in the desired position
anterior trimlines
thicker material
fixed at ankle, in slight PF, neutral or DF based on control needed
Benefits of solid AFO
-increase ankle DF during swing
-stiffness adjustability by changing trimlines
-increase stance phase knee flex or ext by restricting ankle motion
-decrease clubfoot (inv/pf) during stance
-possible ankle control with PF spasticity
-improve static balance
Limitations of solid AFO
reduced ability to allow volitional muscle control
bulk and weight of the AFO
does not allow for ankle DF during functional movements such as sit to stand
Ground Reaction AFO
provides knee stability through a posteriorly directed force at proximal tibia
fixed at ankle in slight PF
GRF anterior to the knee which prevents knee instability and collapse
anterior shell for added tibial control
carbon or plastic options
Benefits of GRAFO
-increases DF during swing
-strong stance phase knee flex control
-anterior proximal contact of AFO leads to stance phase knee extension
-increases static balance
GRAFO Considerations
not appropriate for someone with genu recurvatum, strong hypertension thrust in stance, quads spasticity
bulk and weight of AFO may be limiting
Semi-rigid AFO
-provides varying degrees of rigidity based on design and materials used
-more posterior trimlines compared to solid AFO
-ankle in slight PF, neutral or DF based on control needed
-some ankle motion allowed based on material thickness/flexibility
-material property choices restrict or allow motion
Benefits of semi-rigid AFO
-increase DF during swing
-adjustability of stiffness by changing trimlines
-control stance phase knee flexion or extension by limiting ankle motion
-increase gait speed if AFO has fewer restrictions to movement
-may increase dynamic balance based on design
Semi-Rigid AFO Considerations
-may not be appropriate for patient with PF spasticity
-does not provide as much support at the knee compared to a rigid AFO
-limited use if pt has equinaovarus (club foot)
Posterior Leaf Spring AFO
-most posterior trimline
-more ankle motion allowed due to material flexibility
-minimal to no medial lateral ankle support
-minimal to no effect at the knee
Benefits of posterior leaf spring AFO
increase DF in swing
lightweight
prefabricated options
increase gait speed
Considerations for posterior leaf spring AFO
not appropriate with PF spasticity or knee instability
Articulating AFO
-ankle joint is incorporated into the AFO
-provides varying degrees of
motion at the ankle through hinges and optional stops
-DF/PF stops
-resist and assist options available
-allows for control at the knee with restricting or helping motion
-allows for volitional muscle activation
Considerations of Articulating AFOs
-bulk and weight of AFO
-not indicated for someone with PF spasticity ≥ 3
-less medial/lateral stability compared to solid AFO
Stops
limit ROM to restrict movement when strength, ROM, or motor control are decreased
stops can be set to accommodate limits of joint ROM
PF stop
created when posterior materials contact
can decrease genu recurvatum and equinovarus
DF stop
created when anterior materials contact
can increase stability by decreasing stance phase knee buckling
Springs
assist movement when strength and/or control are decreased
can assist DF during swing b/c of recoil
can also assist with eccentric control of PF during loading response to reduce foot slap
Dynamic AFOs
enhance or resist ankle motion while allowing some motion and/or energy storage
Carbon Fiber AFO
stores and releases energy to assist PF for push-off
minimal medial/lateral ankle support
minimal to no adjustability
Benefits of carbon fiber AFO
DF assist
increases push off force
allows for volitional muscle activation
allows for increased gait speed
Considerations for Carbon Fiber AFO
not indicated for equinovarus, knee buckling, genu recurvatum, limited ankle ROM, PF spasticity
Equinovarus
Clubfoot, also known as talipes equinovarus (TEV), is a common foot abnormality, in which the foot points downward and inward. The condition is present at birth, and involves the foot and lower leg
Arizona AFO
-custom gauntlet style AFO
-leather with thermoplastic reinforcement
-used for failed fusions
-dx of OA or post tibial tendon dysfunction
-immobilizes ankle but allow for toe roll over
Mods for AFO
padding
medial/lateral flange
extrinsic wedging
Padding
bony prominences to protect skin
Medial/lateral Flange
restricts medial or lateral forces
Extrinsic wedging
additional control over lateral or medial forces
KO
custom or off the shelf
based on anatomic challenges, knee deformation
stabilize knee after ACL/PCL
off load OA
can be used for hyperextension
KAFO
-provided to compensate for weakness, paralysis or skeletal problems which cause lower limb instability
-appropriate for pts with knee hyperextension and/or knee weakness
-always custom fabricated
Free motion KAFO
no restriction or assistance
Posterior offset
provides stability at the knee when knee is in full extension
Drop lock
locked in extension when standing
must manually unlock to sit
Stance lock knee joints
knee joint locks at extension and unlocks at toe load
HKAFO
indiciations include traumatic paraplegia, spina bifida, muscular dystrophy and rotational control
RGO
reciprocating gait orthosis
BIL HKAFO that provides contralateral hip extension with ipsilateral hip flexion
seen in rehab, peds, paralysis
FES
functional electrical stimulation
alternative to traditional orthoses for pts with foot drop and intact peroneal nerve
force sensor is worn to detect heel off and heel strike
CPG for FES w/AFO
strong evidence of benefit for individuals for LE lack of motor control post CHRONIC stroke
both methods provide immediate orthotic effects at ankle
FES –> more therapeutic effects, better for faster walkers
AFO–> more compensatory effects, better early in treatment
What to use for insufficient knee flexion to clear floor during swing
small lift contralateral shoe
no orthotic componentry available
What to use for insufficient DF during swing
FES orthosis
single axis AFO with DF assist and PF stop
posterior leaf spring
dynamic AFO
What to use for mid to late stance knee hyperextension
heel lift
AFO with PF stop
solid ankle AFO in DF
What to use for knee instability/buckling
AFO with DF stop
ground reaction AFO with DF stop
KAFO with posterior offset knee, knee lock, or stance lock and free swing
What to use for Excessive supination
foot orthosis with forefoot valgus post
lateral hindfoot wedge
AFO with lateral flange
What to use for excessive pronation
foot orthosis and varus post
UCBL
SMO
Arizona AFO
AFO with medial flange
Functional Training needed for LE ORthosis
gait
stairs
navigating various surfaces
ramps
sit to stand
People with blocking DF will have difficulty with
STS, ascending ramps, squatting, descending stairs
People with blocking PF will have difficulty with
descending ramps, eliminates active push off
