Lower Limb OrthosesLower Limb Orthoses
DefinitionDefinitionAn orthosis is defined as a deviceAn orthosis is defined as a deviceattached or applied to the externa...
Indications• Assist gaitAssist gait• Reduce painReduce pain• Decrease weight bearingDecrease weight bearing• Control Movem...
Lower Limb Orthoses assistLower Limb Orthoses assistnonambulatory patients withnonambulatory patients withtransfer and mob...
PrinciplesPrinciples• Use only as indicated and for as long asUse only as indicated and for as long asnecessary.necessary....
Principles…Principles…• The orthotic knee joint should be centredThe orthotic knee joint should be centredover the promine...
Principles…Principles…• Most orthoses utilize a three-point systemMost orthoses utilize a three-point systemto ensure prop...
Foot Orthoses (FOs)Foot Orthoses (FOs)• FOs affect the ground reactiveforces acting on the joints of thelower limb.• They ...
FOs in Pes Planus…FOs in Pes Planus…• Symptomatic control of pain can be obtained bySymptomatic control of pain can be obt...
FOs in Pes Planus…FOs in Pes Planus…• The key to controlling excess pronation isThe key to controlling excess pronation is...
FOs in Pes Planus…FOs in Pes Planus…• Cases of pes planus due to ligamentous laxityCases of pes planus due to ligamentous ...
Thomas Heel & Reverse ThomasThomas Heel & Reverse ThomasHeelHeel
FOs in Pes Cavus…FOs in Pes Cavus…• A typical problem with pes cavus is excessA typical problem with pes cavus is excesspr...
Pes Cavus Orthosis…Pes Cavus Orthosis…
Metatarsalgia (Forefoot Pain)Metatarsalgia (Forefoot Pain)• Relief of pain in the forefoot is accomplished byRelief of pai...
““Cookie”Cookie”
Metatarsalgia (Forefoot Pain)…Metatarsalgia (Forefoot Pain)…• A metatarsal bar is an external modification andA metatarsal...
Metatarsal BarMetatarsal Bar
FOs in Heel PainFOs in Heel Pain• Rubber heel pads inside the shoe can offerRubber heel pads inside the shoe can offerreli...
FOs in Heel Pain…FOs in Heel Pain…• A common cause of heel pain along theA common cause of heel pain along theanteromedial...
FOs in Heel Pain…FOs in Heel Pain…• Plantar fasciitis is also common in patientsPlantar fasciitis is also common in patien...
FOs in Heel Pain…FOs in Heel Pain…Heel liftsHeel lifts are of help inare of help in• Achilles enthesitis where it decrease...
FOs in Osteoarthritis of the KneeFOs in Osteoarthritis of the Knee• Lateral heel wedgesLateral heel wedges can be used for...
Ankle-Foot Orthoses (AFOs)Ankle-Foot Orthoses (AFOs)• AFOs were formerly called short leg braces.AFOs were formerly called...
Metal AFOsMetal AFOs• The metal AFO consists of a proximal calf band,The metal AFO consists of a proximal calf band,two up...
Metal AFOs…Metal AFOs…• Ankle joint motion is controlled by pins orAnkle joint motion is controlled by pins orsprings inse...
Metal AFOs…Metal AFOs…• AA solid stirrupsolid stirrup is a U shaped metal pieceis a U shaped metal piecepermanently attach...
Double-action Metal Ankle Jointwith Solid Stirrup
Metal AFOs…Metal AFOs…• A split stirrup can be used instead of aA split stirrup can be used instead of asolid stirrup.soli...
Ankle Stops and Assists in MetalAnkle Stops and Assists in MetalAFOsAFOs• Plantar Stop (Posterior Stop)Plantar Stop (Poste...
Plantar Stop ( Posterior Stop)Plantar Stop ( Posterior Stop)• The plantar stop is used to control plantarThe plantar stop ...
Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• Since the dorsiflexors cannoteccentrically activate to per...
Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• The proximal portion of the AFO alsohas an effect on knee ...
Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• The greater the plantar flexionresistance, the greater the...
Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• The posterior stop should be set at the minimalamount of p...
Dorsiflexion Stop ( Anterior Stop)Dorsiflexion Stop ( Anterior Stop)• An anterior stop is used to compensate for theAn ant...
Dorsiflexion Stop ( Anterior Stop)Dorsiflexion Stop ( Anterior Stop)• The anterior stop assists with push-offassists with ...
Dorsiflexion Assist (PosteriorDorsiflexion Assist (PosteriorSpring)Spring)The posterior spring serves two purposes.• It su...
Metal Dorsiflexion Assist Ankle JointMetal Dorsiflexion Assist Ankle Joint(Klenzak Ankle Joint)(Klenzak Ankle Joint)
Metal AFO Varus /Valgus ControlMetal AFO Varus /Valgus Control• Valgus and varus deformities are associated withrotation o...
Metal AFO Varus /Valgus ControlMetal AFO Varus /Valgus Control• The medial T strapmedial T strap helps create a forcedirec...
Plastic AFOsPlastic AFOs• Advantages include cosmesis, light weight,interchangeability with shoes, ability tocontrol varus...
Plastic AFOs…Plastic AFOs…• The weight of the orthoses is not as important asthe influence of the ground reactive force cr...
Custom Plastic Solid AFO with PosteriorCustom Plastic Solid AFO with PosteriorTrimline to Allow Some Flexibility withTriml...
Plastic AFO ComponentsPlastic AFO Components• The foot component of the AFOshould extend beyond the metatarsalheads.• The ...
Plastic AFO Components…Plastic AFO Components…• Plastic AFOs can be hinged at the ankle.• Ankle hinges allow full or parti...
(Plastic AFO Components)(Plastic AFO Components)Elite Midline Posterior Stop ArticulatedElite Midline Posterior Stop Artic...
The Solid Plastic AFOThe Solid Plastic AFO• The term solid refers to an AFO that is made of asingle piece of plastic and d...
The Solid Plastic AFO…The Solid Plastic AFO…• The AFO can be fixed in a few degrees of plantar flexionto provide stability...
Plastic AFO Varus /Valgus ControlPlastic AFO Varus /Valgus Control• An equinovarus or inversion deformity iscontrolled by ...
Plastic AFO Varus/Valgus ControlPlastic AFO Varus/Valgus Control• A three point system also exists at thefoot level to hel...
Patellar Tendon-Bearing AFOs• A PTB AFO uses the patellar tendon and thetibial condyles to partially relieve weight bearin...
Patellar Tendon-Bearing AFOs• The orthoses are bivalved and fit snuglywith the use of Velcro straps or buckles.• A custom-...
Prefabricated Bivalved PTB AFO
Knee Ankle Foot OrthosisKnee Ankle Foot Orthosis• KAFOs were formerly referred to as long legbraces.• In addition to the c...
Knee Ankle Foot Orthosis…Knee Ankle Foot Orthosis…• They are most commonly prescribed bilaterallyfor patients with spinal ...
Ground Reaction or FloorGround Reaction or FloorReaction OrthosisReaction Orthosis• Some paraplegic patients such as those...
Ground Reaction Orthosis…Ground Reaction Orthosis…• The plantar flexion provides anextension momentextension moment at the...
Ground Reaction OrthosisGround Reaction Orthosis
Knee JointsKnee JointsThree types• Straight set knee joint• Polycentric knee joint• Posterior offset knee joint
Straight Set Knee JointStraight Set Knee Joint• Provides rotation about a single axis• Allows free flexion• Prevents hyper...
Straight Set Knee JointStraight Set Knee Joint
Polycentric Knee JointPolycentric Knee Joint• Uses a double axis system to simulatethe flexion-extension movements ofthe f...
Polycentric Knee JointPolycentric Knee Joint
Posterior Offset Knee JointPosterior Offset Knee Joint• Prescribed for patients with weak kneeextensors and some hip exten...
Knee OrthosesKnee OrthosesSwedish Knee CageSwedish Knee Cage• Used to control minor to moderateUsed to control minor to mo...
Swedish Knee CageSwedish Knee Cage
Osteoarthritis Knee OrthosisOsteoarthritis Knee OrthosisUses the same orthotic threepoint principleThe three point systemd...
Sport Knee OrthosisSport Knee OrthosisSport KOs can be divided intothree types• Prophylactic• Rehabilitative• Functional
Sport Knee OrthosisSport Knee OrthosisProphylacticProphylactic• Prophylactic knee bracing attempts toprevent or reduce the...
Sport Knee OrthosisSport Knee OrthosisRehabilitativeRehabilitative• Used to allow protected motionwithin defined limits• U...
Sport Knee Orthosis-Sport Knee Orthosis-FunctionalFunctional• Designed to assist or provide stability forDesigned to assis...
Sport Knee Orthosis-FunctionalSport Knee Orthosis-FunctionalLenox Hill Spectralite Knee OrthosisLenox Hill Spectralite Kne...
Reciprocating Gait Orthosis (RGO)Reciprocating Gait Orthosis (RGO)• Formerly known as the Hip-guided orthosisFormerly know...
Reciprocating Gait Orthosis (RGO)Reciprocating Gait Orthosis (RGO)• Obesity, advanced age, lack of patient motivationObesi...
Isocentric Reciprocating GaitIsocentric Reciprocating GaitOrthosis (RGO)Orthosis (RGO)
Lower limb orthoses
Lower limb orthoses
Lower limb orthoses
Lower limb orthoses
Lower limb orthoses
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Lower limb orthoses

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Lower limb orthoses

  1. 1. Lower Limb OrthosesLower Limb Orthoses
  2. 2. DefinitionDefinitionAn orthosis is defined as a deviceAn orthosis is defined as a deviceattached or applied to the externalattached or applied to the externalsurface of the body to improvesurface of the body to improvefunction, restrict or enforcefunction, restrict or enforcemotion, or support a bodymotion, or support a bodysegment.segment.
  3. 3. Indications• Assist gaitAssist gait• Reduce painReduce pain• Decrease weight bearingDecrease weight bearing• Control MovementControl Movement• Minimize progression of aMinimize progression of adeformitydeformity
  4. 4. Lower Limb Orthoses assistLower Limb Orthoses assistnonambulatory patients withnonambulatory patients withtransfer and mobility skills andtransfer and mobility skills andhelp ambulatory patients inhelp ambulatory patients inbecoming safe walkers.becoming safe walkers.
  5. 5. PrinciplesPrinciples• Use only as indicated and for as long asUse only as indicated and for as long asnecessary.necessary.• Allow joint movement wherever possibleAllow joint movement wherever possibleand appropriate.and appropriate.• Orthoses should be functional during allOrthoses should be functional during allphases of gait.phases of gait.• The orthotic ankle joint should be centredThe orthotic ankle joint should be centredover the tip of the medial malleolus.over the tip of the medial malleolus.
  6. 6. Principles…Principles…• The orthotic knee joint should be centredThe orthotic knee joint should be centredover the prominence of the medial femoralover the prominence of the medial femoralcondyle.condyle.• The orthotic hip joint should be in aThe orthotic hip joint should be in aposition that allows the patient to sitposition that allows the patient to situpright at 90 degrees.upright at 90 degrees.• Patient compliance will be enhanced if thePatient compliance will be enhanced if theorthosis is comfortable, cosmetic andorthosis is comfortable, cosmetic andfunctional.functional.
  7. 7. Principles…Principles…• Most orthoses utilize a three-point systemMost orthoses utilize a three-point systemto ensure proper positioning of the limbto ensure proper positioning of the limbwithin the orthosis.within the orthosis.• For e.g.., a knee that has a tendency forFor e.g.., a knee that has a tendency forhyperextension can be treated with a kneehyperextension can be treated with a kneeorthosis that applies force posterior to theorthosis that applies force posterior to theknee but also applies forces anteriorlyknee but also applies forces anteriorlyalong the leg and thigh.along the leg and thigh.
  8. 8. Foot Orthoses (FOs)Foot Orthoses (FOs)• FOs affect the ground reactiveforces acting on the joints of thelower limb.• They also have an effect overrotational components of gait.
  9. 9. FOs in Pes Planus…FOs in Pes Planus…• Symptomatic control of pain can be obtained bySymptomatic control of pain can be obtained bycontrolling excess pronation of the foot.controlling excess pronation of the foot.• Pronation of the foot can be defined as a rotationPronation of the foot can be defined as a rotationof the foot in the longitudinal axis resulting in aof the foot in the longitudinal axis resulting in alowering of the medial aspect of the foot.lowering of the medial aspect of the foot.• It is also referred to as inrolling.It is also referred to as inrolling.• Eversion involves pronation and abduction at theEversion involves pronation and abduction at thesubtalar joint and dorsiflexion at the ankle joint.subtalar joint and dorsiflexion at the ankle joint.
  10. 10. FOs in Pes Planus…FOs in Pes Planus…• The key to controlling excess pronation isThe key to controlling excess pronation iscontrolling the calcaneus to keep the subtalarcontrolling the calcaneus to keep the subtalarjoint in a neutral position.joint in a neutral position.• A custom-made foot orthosis designed to preventA custom-made foot orthosis designed to preventhyperpronation is also referred to as a UCBLhyperpronation is also referred to as a UCBLorthosis denoting the University of Californiaorthosis denoting the University of CaliforniaBiomchanics Laboratory where original workBiomchanics Laboratory where original workregarding this type of orthosis was performed inregarding this type of orthosis was performed inthe 1940s.the 1940s.
  11. 11. FOs in Pes Planus…FOs in Pes Planus…• Cases of pes planus due to ligamentous laxityCases of pes planus due to ligamentous laxitymay be treated with a medial longitudinal archmay be treated with a medial longitudinal archsupport for alleviating pain.support for alleviating pain.• A Thomas heel extension can also offer medialA Thomas heel extension can also offer medialsupport particularly for heavier individuals.support particularly for heavier individuals.• For runners who have pronated feet, a firmFor runners who have pronated feet, a firmmedial heel counter and a wide last at the shankmedial heel counter and a wide last at the shankcan help prevent pronation at the subtalar joint.can help prevent pronation at the subtalar joint.
  12. 12. Thomas Heel & Reverse ThomasThomas Heel & Reverse ThomasHeelHeel
  13. 13. FOs in Pes Cavus…FOs in Pes Cavus…• A typical problem with pes cavus is excessA typical problem with pes cavus is excesspressure along the heel and metatarsal headpressure along the heel and metatarsal headareas, which can lead to pain.areas, which can lead to pain.• This can be prevented by making the height ofThis can be prevented by making the height ofthe longitudinal support just high enough to fillthe longitudinal support just high enough to fillin the space between the shank of the shoe andin the space between the shank of the shoe andthe arch of the foot to distribute weight morethe arch of the foot to distribute weight moreeffectively.effectively.• The lift is extended just to the metatarsal headThe lift is extended just to the metatarsal headarea to help distribute and alleviate pressure overarea to help distribute and alleviate pressure overthe metatarsal weight-bearing area.the metatarsal weight-bearing area.
  14. 14. Pes Cavus Orthosis…Pes Cavus Orthosis…
  15. 15. Metatarsalgia (Forefoot Pain)Metatarsalgia (Forefoot Pain)• Relief of pain in the forefoot is accomplished byRelief of pain in the forefoot is accomplished bydistributing the weight-bearing forces to an areadistributing the weight-bearing forces to an areaproximal to the metatarsal heads.proximal to the metatarsal heads.• This can be achieved by either internal orThis can be achieved by either internal orexternal modification.external modification.• A metatarsal pad also referred to as a ‘cookie’A metatarsal pad also referred to as a ‘cookie’can be placed inside the shoe just posterior to thecan be placed inside the shoe just posterior to thesecond, third and fourth metatarsal heads.second, third and fourth metatarsal heads.
  16. 16. ““Cookie”Cookie”
  17. 17. Metatarsalgia (Forefoot Pain)…Metatarsalgia (Forefoot Pain)…• A metatarsal bar is an external modification andA metatarsal bar is an external modification andis indicated in metatarsalgia in cases in whichis indicated in metatarsalgia in cases in whichthe foot is too sensitive to tolerate a pad insidethe foot is too sensitive to tolerate a pad insidethe shoe.the shoe.• The metarsal bar is typically ¼ inch thick andThe metarsal bar is typically ¼ inch thick andtapers distally.tapers distally.• The distal edge should be proximal to theThe distal edge should be proximal to themetatarsal heads.metatarsal heads.• The bar can also be used for forefoot painThe bar can also be used for forefoot painassociated with pes cavus.associated with pes cavus.
  18. 18. Metatarsal BarMetatarsal Bar
  19. 19. FOs in Heel PainFOs in Heel Pain• Rubber heel pads inside the shoe can offerRubber heel pads inside the shoe can offerrelief in minor discomfort.relief in minor discomfort.• A calcaneal bar is recommended for casesA calcaneal bar is recommended for casesin which the foot is too sensitive to toleratein which the foot is too sensitive to toleratea pad inside the shoe and the heel pain isa pad inside the shoe and the heel pain isassociated with a chronic condition.associated with a chronic condition.• The calcaneal bar is placed distal to theThe calcaneal bar is placed distal to thepainful area to prevent the calcaneus frompainful area to prevent the calcaneus fromassuming full weightbearing status.assuming full weightbearing status.
  20. 20. FOs in Heel Pain…FOs in Heel Pain…• A common cause of heel pain along theA common cause of heel pain along theanteromedial calcaneus is plantar fasciitis.anteromedial calcaneus is plantar fasciitis.• It is common in people who hyperpronate theirIt is common in people who hyperpronate theirfeet, thereby placing excess stress on the medialfeet, thereby placing excess stress on the mediallongitudinal arch.longitudinal arch.• Conservative treatment should include a pair ofConservative treatment should include a pair ofshoes wih a firm medial heel counter and a wideshoes wih a firm medial heel counter and a wideshank.shank.• In cases in which conservative management hasIn cases in which conservative management hasfailed, custom-made shoes such as the UCBL isfailed, custom-made shoes such as the UCBL isindicated.indicated.
  21. 21. FOs in Heel Pain…FOs in Heel Pain…• Plantar fasciitis is also common in patientsPlantar fasciitis is also common in patientswith high arches.with high arches.• The medial longitudinal arch undergoesThe medial longitudinal arch undergoesmarked stress during weight bearing.marked stress during weight bearing.• This can be treated with either an elevatedThis can be treated with either an elevatedarch support or a heel well that helpsarch support or a heel well that helpsdistribute pressure along the medialdistribute pressure along the mediallongitudinal arch.longitudinal arch.
  22. 22. FOs in Heel Pain…FOs in Heel Pain…Heel liftsHeel lifts are of help inare of help in• Achilles enthesitis where it decreases theAchilles enthesitis where it decreases theamount of stretch placed on th Achillesamount of stretch placed on th Achillestendon by keeping the ankle joint plantartendon by keeping the ankle joint plantarflexed, and inflexed, and in• treating plantar flexor spasticity ortreating plantar flexor spasticity orcontracture by increasing the total heelcontracture by increasing the total heelheight to help ensure that the patient has aheight to help ensure that the patient has aheel strike prior to toe touch during gait.heel strike prior to toe touch during gait.
  23. 23. FOs in Osteoarthritis of the KneeFOs in Osteoarthritis of the Knee• Lateral heel wedgesLateral heel wedges can be used forcan be used forconservative treatment of Osteoarthritisconservative treatment of Osteoarthritiswhen the medial compartment narrowingwhen the medial compartment narrowingresults in genu varum.results in genu varum.• The heel wedges used are ¼ inch thickThe heel wedges used are ¼ inch thickalong the lateral border and taperalong the lateral border and tapermediallymedially..
  24. 24. Ankle-Foot Orthoses (AFOs)Ankle-Foot Orthoses (AFOs)• AFOs were formerly called short leg braces.AFOs were formerly called short leg braces.• Metal or plastic AFOs can be used effectively toMetal or plastic AFOs can be used effectively tocontrol ankle motion.control ankle motion.• AFOS should provide mediolateral stability as aAFOS should provide mediolateral stability as asafety feature.safety feature.• It should be remembered thatIt should be remembered that plantar flexionplantar flexioncreates a knee extension moment andcreates a knee extension moment anddorsiflexion a knee flexion moment.dorsiflexion a knee flexion moment.
  25. 25. Metal AFOsMetal AFOs• The metal AFO consists of a proximal calf band,The metal AFO consists of a proximal calf band,two uprights, ankle joints and an attachment totwo uprights, ankle joints and an attachment tothe shoe to anchor the AFO.the shoe to anchor the AFO.• The posterior metal portion of the calf bandThe posterior metal portion of the calf bandshould be 1.5 to 3 inches wide in order to evenlyshould be 1.5 to 3 inches wide in order to evenlydistribute pressure.distribute pressure.• The calf band should be 1 inch below the fibularThe calf band should be 1 inch below the fibularneck to prevent a compressive common peronealneck to prevent a compressive common peronealnerve palsy.nerve palsy.
  26. 26. Metal AFOs…Metal AFOs…• Ankle joint motion is controlled by pins orAnkle joint motion is controlled by pins orsprings inserted into channels.springs inserted into channels.• The pins are adjusted with a screw driver to setThe pins are adjusted with a screw driver to setthe desired amount of plantar flexion andthe desired amount of plantar flexion anddorsiflexion.dorsiflexion.• The spring is also adjusted with a screw driver toThe spring is also adjusted with a screw driver toprovide the proper amount of tension necessaryprovide the proper amount of tension necessaryto aid motion at the ankle joint.to aid motion at the ankle joint.
  27. 27. Metal AFOs…Metal AFOs…• AA solid stirrupsolid stirrup is a U shaped metal pieceis a U shaped metal piecepermanently attached to the shoe.permanently attached to the shoe.• Its two ends are bent upward to articulate withIts two ends are bent upward to articulate withthe medial and lateral ankle joints. The proximalthe medial and lateral ankle joints. The proximalstirrup attachment sites are shaped to enforce thestirrup attachment sites are shaped to enforce thedesired movements at the ankle joint.desired movements at the ankle joint.• The sole plate can be extended beyond theThe sole plate can be extended beyond themetatarsal head area for conditions requiring ametatarsal head area for conditions requiring alonger lever arm for better control of plantarlonger lever arm for better control of plantarflexion such as in plantar flexor spasticity.flexion such as in plantar flexor spasticity.
  28. 28. Double-action Metal Ankle Jointwith Solid Stirrup
  29. 29. Metal AFOs…Metal AFOs…• A split stirrup can be used instead of aA split stirrup can be used instead of asolid stirrup.solid stirrup.• It has a sole plate with two flat channelsIt has a sole plate with two flat channelsfor insertion of the uprights.for insertion of the uprights.• The uprights are now called calipers asThe uprights are now called calipers asthey can open and close distally to allowthey can open and close distally to allowdonning and doffing of the AFO.donning and doffing of the AFO.• A split stirrup allows removal of theA split stirrup allows removal of theuprights from the shoes so that the AFOsuprights from the shoes so that the AFOscan be worn with other shoes.can be worn with other shoes.
  30. 30. Ankle Stops and Assists in MetalAnkle Stops and Assists in MetalAFOsAFOs• Plantar Stop (Posterior Stop)Plantar Stop (Posterior Stop)• Dorsiflexion Stop (Anterior Stop)Dorsiflexion Stop (Anterior Stop)• Dorsiflexion Assist ( PosteriorDorsiflexion Assist ( PosteriorSpring)Spring)
  31. 31. Plantar Stop ( Posterior Stop)Plantar Stop ( Posterior Stop)• The plantar stop is used to control plantarThe plantar stop is used to control plantarflexor spasticity or help incrementallyflexor spasticity or help incrementallystretch plantar contractures.stretch plantar contractures.• The plantar stop is most commonly set atThe plantar stop is most commonly set at90 degrees.90 degrees.• An AFO with a plantar stop at 90 degreesAn AFO with a plantar stop at 90 degreesproduces a flexion moment at the kneeproduces a flexion moment at the kneeduring heel strike.during heel strike.
  32. 32. Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• Since the dorsiflexors cannoteccentrically activate to permit contactwith the ground, the ground reactiveforce remains posterior to the kneeafter heel strike, which creates aflexion moment at the knee andpossibly an unstable gait.
  33. 33. Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• The proximal portion of the AFO alsohas an effect on knee stability.• The posterior portion of the proximalAFO exerts a forward push on theproximal leg to increase the kneeflexion moment after heel strike.• The opposite occurs at toe-off , withan extension moment at the knee.
  34. 34. Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• The greater the plantar flexionresistance, the greater the flexionmoment at the knee at heel strike, andthe greater the need for active hipextensors to prevent the body fromcollapsing forward on a bucklingknee.
  35. 35. Plantar Stop ( Posterior Stop)…Plantar Stop ( Posterior Stop)…• The posterior stop should be set at the minimalamount of plantar flexion required to clear thefoot during swing-through.• Remember, the plantar flexion creates a kneeextension moment at the knee after heel strike.• This creates a more stable gait than when theankle plantar stops are set in any degree ofdorsiflexion.
  36. 36. Dorsiflexion Stop ( Anterior Stop)Dorsiflexion Stop ( Anterior Stop)• An anterior stop is used to compensate for theAn anterior stop is used to compensate for thefunction of the gastrocnemius /soleus complex.function of the gastrocnemius /soleus complex.• It is used in conditions with weak calf muscles orIt is used in conditions with weak calf muscles orweak quadriceps (because of its effect on theweak quadriceps (because of its effect on theknee).knee).• Weak calf muscles allow the ankle to enterWeak calf muscles allow the ankle to enterdorsiflexion.dorsiflexion.• The anterior stop set at 5 degrees of dorsiflexionThe anterior stop set at 5 degrees of dorsiflexionbest substitutes for gastrocnemius/ soleusbest substitutes for gastrocnemius/ soleusfunction.function.
  37. 37. Dorsiflexion Stop ( Anterior Stop)Dorsiflexion Stop ( Anterior Stop)• The anterior stop assists with push-offassists with push-off and assists theknee joint into extension. It should be used incombination with a stirrup with a sole extension to themetatarsal heads to simulate the action of the calfmuscles.• The dorsiflexion stop simulates the gastrocnemius /soleus function by causing the heel to rise during thelatter part of stance rather than remaining flat on theground.• The shoe pivots over the metatarsal heads creating anextension moment at the knee that helps stabilize theknee from midstance to toe-off.
  38. 38. Dorsiflexion Assist (PosteriorDorsiflexion Assist (PosteriorSpring)Spring)The posterior spring serves two purposes.• It substitutes for concentric contraction ofdorsiflexors to prevent flaccid foot drop after toe-off.• It also substitutes inadequately for the eccentricactivation of the dorsiflexors after heel strike.• The metal dorsiflexion assist ankle joint is alsoknown as a Klenzak ankle joint.
  39. 39. Metal Dorsiflexion Assist Ankle JointMetal Dorsiflexion Assist Ankle Joint(Klenzak Ankle Joint)(Klenzak Ankle Joint)
  40. 40. Metal AFO Varus /Valgus ControlMetal AFO Varus /Valgus Control• Valgus and varus deformities are associated withrotation of the subtalar joint.• A T strapT strap is attached along the side of the shoedistal to the subtalar joint to help minimize thisdeformity.• T straps are either medial or lateral.• A medial T strap is used to control a valgusdeformity.• The medial T strap is sown to the medial aspectof the shoe and the belt is cinched around thelateral upright.
  41. 41. Metal AFO Varus /Valgus ControlMetal AFO Varus /Valgus Control• The medial T strapmedial T strap helps create a forcedirecting the subtalar joint inward whichcounteracts the pronation and abductiontendency at the subtalar joint.• The opposite is true for a lateral T straplateral T strapused to control or minimize the tendencyfor varus at the subtalar joint.
  42. 42. Plastic AFOsPlastic AFOs• Advantages include cosmesis, light weight,interchangeability with shoes, ability tocontrol varus and valgus deformities,provision of better foot support with thecustomized foot portion and ability toachieve what is offered by the metal AFO.• Energy consumption is equal with a plasticsolid AFO or a metal double upright AFO.
  43. 43. Plastic AFOs…Plastic AFOs…• The weight of the orthoses is not as important asthe influence of the ground reactive force createdby the presence of the orthosis.• The same orthotic principles apply for plasticand metal orthoses.• The plastic AFO prescribed for toe clearanceshould be just rigid enough to provide resistancefor toe clearance. Excessive resistance to plantarflexion can make the knee unstable after heelstrike and create a knee flexion moment.
  44. 44. Custom Plastic Solid AFO with PosteriorCustom Plastic Solid AFO with PosteriorTrimline to Allow Some Flexibility withTrimline to Allow Some Flexibility withPlantar FlexionPlantar Flexion..
  45. 45. Plastic AFO ComponentsPlastic AFO Components• The foot component of the AFOshould extend beyond the metatarsalheads.• The foot plate can be extended beyondthe toes to reduce the spasticityaggravated by toe flexion..
  46. 46. Plastic AFO Components…Plastic AFO Components…• Plastic AFOs can be hinged at the ankle.• Ankle hinges allow full or partial ankle motion,which can permit a more natural gait.• Plastic ankle joints can be a good choice forchildren and metal ankle joints for adultsparticularly heavy adults.• Newer designs have a single midline posteriorrod/spring mechanism which functions like themore traditional medial and lateral dualposterior spring assist mechanism.
  47. 47. (Plastic AFO Components)(Plastic AFO Components)Elite Midline Posterior Stop ArticulatedElite Midline Posterior Stop ArticulatedAFOAFO
  48. 48. The Solid Plastic AFOThe Solid Plastic AFO• The term solid refers to an AFO that is made of asingle piece of plastic and does not have anklejoints.• Solid AFOs set at 90 degrees are commonly usedfor foot drop. Solid AFOs are also used to treatconditions of the knee.• It should be remembered that plantar flexioncreates knee extension and dorsiflexion kneeflexion at heel strike.
  49. 49. The Solid Plastic AFO…The Solid Plastic AFO…• The AFO can be fixed in a few degrees of plantar flexionto provide stability at the knee during the stance phase ofgait.• Genu recurvatum can also be treated with a solid AFO.• The more rigid the AFO, the greater the flexion momentat the knee at heel strike which helps reverse theextension moment at the knee associated with genurecurvatum.• The flexion moment of the knee also becomes greater ifthe ankle is placed in a few degrees of dorsiflexion.
  50. 50. Plastic AFO Varus /Valgus ControlPlastic AFO Varus /Valgus Control• An equinovarus or inversion deformity iscontrolled by applying forces medially at themetatarsal head area and calcaneus.• The next force is applied more proximally at thelateral aspect of the fibula. This helps preventinversion at the subtalar and ankle joints.• A more proximal medial tibial force is applied toprovide stabilization of the leg portion of theplastic AFO by applying an opposing force to thefibular area.
  51. 51. Plastic AFO Varus/Valgus ControlPlastic AFO Varus/Valgus Control• A three point system also exists at thefoot level to help prevent supination ofthe foot related to the equinovarusdeformity.• A three point system is again appliedto control plantar flexion deformityassociated with equinovarus.
  52. 52. Patellar Tendon-Bearing AFOs• A PTB AFO uses the patellar tendon and thetibial condyles to partially relieve weight bearingstress on skeletal structures distally, with moreweight bearing distributed along the medial tibialcondyle.• It is often prescribed for diabetic ulcerations ofthe foot, tibial fractures, relief of the weight –bearing surface in painful heel conditions suchas calcaneal fractures, postoperative anklefusions and avascular necrosis of the foot orankle.
  53. 53. Patellar Tendon-Bearing AFOs• The orthoses are bivalved and fit snuglywith the use of Velcro straps or buckles.• A custom-moulded PTB AFO can reduceweight bearing in the affected foot by 50%.
  54. 54. Prefabricated Bivalved PTB AFO
  55. 55. Knee Ankle Foot OrthosisKnee Ankle Foot Orthosis• KAFOs were formerly referred to as long legbraces.• In addition to the components of an AFO, theKAFO also includes knee joints, thigh uprightsand a proximal thigh band.• KAFOs are used in patients with severe kneeextensor and hamstring weakness, structuralknee instability and knee flexion spasticity.• The purpose of the KAFO is to provide stabilityat the knee, ankle and subtalar joints duringambulation.
  56. 56. Knee Ankle Foot Orthosis…Knee Ankle Foot Orthosis…• They are most commonly prescribed bilaterallyfor patients with spinal cord injuries andunilaterally for patients with polio.• Good trunk control and upper body strength areneeded in order to ambulate with KAFOsbecause these devices are used in combinationwith ambulation aids, such as walkers andLofstrand forearm crutches.
  57. 57. Ground Reaction or FloorGround Reaction or FloorReaction OrthosisReaction Orthosis• Some paraplegic patients such as thosewith lower lumbar lesions with some kneeextensor strength are able to ambulatewithout KAFOs. Ambulation in thesepatients can often be accomplished withthe use of bilateral plastic ground reactionground reactionAFOAFOs with the ankles fixed in 10 to 15degrees of plantar flexion.
  58. 58. Ground Reaction Orthosis…Ground Reaction Orthosis…• The plantar flexion provides anextension momentextension moment at the knee duringgait for stability with ambulation.• The proximal anterior tibial shellclosing provides further stability atthe knee from midstance to toe-off.
  59. 59. Ground Reaction OrthosisGround Reaction Orthosis
  60. 60. Knee JointsKnee JointsThree types• Straight set knee joint• Polycentric knee joint• Posterior offset knee joint
  61. 61. Straight Set Knee JointStraight Set Knee Joint• Provides rotation about a single axis• Allows free flexion• Prevents hyperextension• Often used in combination with a droplock• The lock keeps the knee in extensionthrough all the phases of the gait cycle.
  62. 62. Straight Set Knee JointStraight Set Knee Joint
  63. 63. Polycentric Knee JointPolycentric Knee Joint• Uses a double axis system to simulatethe flexion-extension movements ofthe femur and the tibia at the kneejoint• Adds bulk to the orthosis• Most frequently used in sport kneeorthosis
  64. 64. Polycentric Knee JointPolycentric Knee Joint
  65. 65. Posterior Offset Knee JointPosterior Offset Knee Joint• Prescribed for patients with weak kneeextensors and some hip extensor strength• Allows free flexion and extension of theknee during the swing phase of gait• Helps keep the orthotic ground reactionforce in front of the knee axis for stabilityduring stance
  66. 66. Knee OrthosesKnee OrthosesSwedish Knee CageSwedish Knee Cage• Used to control minor to moderateUsed to control minor to moderate genugenurecurvatumrecurvatum due to ligamentous or capsulardue to ligamentous or capsularlaxity.laxity.• The articulated version of the orthosis allows fullThe articulated version of the orthosis allows fullknee flexion and prevents hyperextension.knee flexion and prevents hyperextension.• It uses a three point system with two bandsIt uses a three point system with two bandsplaced anterior to the knee axis (one above andplaced anterior to the knee axis (one above andone below the knee) and a third band posterior toone below the knee) and a third band posterior tothe knee joint in the popliteal area.the knee joint in the popliteal area.• It also has a thigh band with longer uprights toIt also has a thigh band with longer uprights toobtain better leverage at the knee joint.obtain better leverage at the knee joint.
  67. 67. Swedish Knee CageSwedish Knee Cage
  68. 68. Osteoarthritis Knee OrthosisOsteoarthritis Knee OrthosisUses the same orthotic threepoint principleThe three point systemdistribution is achieved by astrap that is applied across theknee joint.The limiting factor regardingthis orthotic prescription is thepatient’s weight and obesity.
  69. 69. Sport Knee OrthosisSport Knee OrthosisSport KOs can be divided intothree types• Prophylactic• Rehabilitative• Functional
  70. 70. Sport Knee OrthosisSport Knee OrthosisProphylacticProphylactic• Prophylactic knee bracing attempts toprevent or reduce the severity of kneeinjuries.• No evidence to support their use• Associated with increased energyconsumption which can impairathletic performance
  71. 71. Sport Knee OrthosisSport Knee OrthosisRehabilitativeRehabilitative• Used to allow protected motionwithin defined limits• Useful for postoperative andconservative management of kneeinjuries
  72. 72. Sport Knee Orthosis-Sport Knee Orthosis-FunctionalFunctional• Designed to assist or provide stability forDesigned to assist or provide stability forthe unstable kneethe unstable knee• Most commonly used to stabilize a laterallyMost commonly used to stabilize a laterallysubluxating patella or an anterior cruciatesubluxating patella or an anterior cruciateligament-deficient kneeligament-deficient knee• Use has been shown to be effective only atUse has been shown to be effective only atloads much lower than those placed on theloads much lower than those placed on theknee during athletic participationknee during athletic participation
  73. 73. Sport Knee Orthosis-FunctionalSport Knee Orthosis-FunctionalLenox Hill Spectralite Knee OrthosisLenox Hill Spectralite Knee Orthosis
  74. 74. Reciprocating Gait Orthosis (RGO)Reciprocating Gait Orthosis (RGO)• Formerly known as the Hip-guided orthosisFormerly known as the Hip-guided orthosis(HGO)(HGO)• Its purpose is to provide contralateral hipIts purpose is to provide contralateral hipextension with ipsilateral hip flexion.extension with ipsilateral hip flexion.• The RGO is appropriate for children who haveThe RGO is appropriate for children who haveused the standing frame, developed good trunkused the standing frame, developed good trunkcontrol and coordination, can safely stand andcontrol and coordination, can safely stand andare mentally prepared for ambulation.are mentally prepared for ambulation.• Good upper limb strength, trunk balance andGood upper limb strength, trunk balance andactive hip flexion are important positiveactive hip flexion are important positivevariables.variables.
  75. 75. Reciprocating Gait Orthosis (RGO)Reciprocating Gait Orthosis (RGO)• Obesity, advanced age, lack of patient motivationObesity, advanced age, lack of patient motivationscoliosis, spasticity and contractures arescoliosis, spasticity and contractures aresignificant negative factors.significant negative factors.• Gait is initiated with active unilateral hip flexionGait is initiated with active unilateral hip flexionand can be assisted by swaying the trunk whenand can be assisted by swaying the trunk whenhip flexion is inadequate.hip flexion is inadequate.• Contralateral hip extension occurs passively withContralateral hip extension occurs passively witheach step employing either cables or the ‘teeter-each step employing either cables or the ‘teeter-totter’ concept.totter’ concept.• Crutches are used with the RGO to provide aCrutches are used with the RGO to provide acontrol mechanism.control mechanism.
  76. 76. Isocentric Reciprocating GaitIsocentric Reciprocating GaitOrthosis (RGO)Orthosis (RGO)
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