Anew Life Prosthetics and Orthotics | Amber Bywater | Fall 2021

1. Exercise and Sports Science
Internship Experience
Anew Life Prosthetics and Orthotics | Amber Bywater | Fall 2021

2. Internship
Learning
Objectives
III.C.1.e.) Knowledge of the activities of daily living (ADLs) and how they relate to overall health
initial level of knowledge: proficient/average Current level of knowledge: expert
How it will be measured: PowerPoint presentation
I.E.1.e.) Knowledge of muscle action terms including anterior, posterior, inferior, superior, medial, lateral,
supination, pronation, flexion, extension, adduction, abduction, hyperextension, rotation, circumduction,
agonist, antagonist, stabilizer
initial level of knowledge: basic Current level of knowledge: proficient
How it will be measured: PowerPoint presentation
I.E.2.a.) Skill in identifying major bones, muscles and joints
initial level of knowledge: basic/poor Current level of knowledge: proficient
How it will be measured: PowerPoint presentation
III.A.2.a.) Skill in using active listening techniques
initial level of knowledge: basic Current level of knowledge: expert
How it will be measured: PowerPoint presentation
III.B.2.e.) Skill in developing intervention strategies to increase self-efficacy and self-confidence
initial level of knowledge: basic Current level of knowledge: proficient
How it will be measured: PowerPoint presentation
Learning Objectives are all
Incorporated into the
PowerPoint
-
Throughout the PowerPoint, underlined text
indicate where Learning Objectives are
incorporated

3. Project Focus: Charcot Restraint Orthotic Walker
(CROW)
What is a Charcot Restraint Orthotic Walker?
• CROW boot consists of fully
enclosed ankle/foot orthotic with
rocker bottom sole
• A CROW boot is a rigid boot
designed to accommodate and
support someone with Charcot
neuroarthropathy/Charcot
arthropathy
Supports the foot and ankle
• Orthopedic surgeon may
recommend this to reduce pain,
minimize further deformity, and
prevent ulcer development
Deformities cause foot to bend
out of shape
• Orthotics can vastly improve the
quality of life of an individual by
encouraging proper blood flow and
support

4. Charcot Neuroarthropathy Description and
Symptoms
Charcot is a destructive disease of the bone structure and joints of the foot and ankle
associated with peripheral neuropathy/loss of sensation
Patients may experience fractures or dislocations of the bones/joints with little or no trauma
Other symptoms include swelling, redness, warmth in the foot/ankle, fractures, dislocations,
deformities, collapse of the midfoot arch, and instability of the ankle and hindfoot may occur
Some patients may develop calluses and ulcers

5. Diagnosis
Criteria for
CROW
• From the beginning of initial symptoms,
diagnosis may take several weeks or even
months
• Essentially, the bones in the feet and ankle
can collapse, requiring compression to
maintain foot shape and assist with proper
healing
• Early X-rays may show soft tissue swelling
with changes in bone and joint structure
• Charcot is often misdiagnosed because
symptoms mimic injury and infection
Immobilization and elevation can help to
differentiate between infection and early
Charcot
(Feinblatt, n.d.)

6. Causes of Charcot Neuropathy
Charcot results from diverse
conditions such as diabetes
mellitus, leprosy, syphilis
and dislocations of the foot
and/or ankle
Changes in circulation may
cause resorption and
weakening of bone,
increasing the chance of
fracture/dislocation
Charcot occurs when
bones/joints in the foot
break or pop out of place
with little to no initial injury
Broken bones and
dislocations can occur
causing deformities and the
resulting stress placed on
the foot can cause ulcers
Charcot can affect the
opposite foot as well as
reoccur in the same foot

7. Who Benefits
From Using a
CROW Boot?
Charcot commonly occurs amongst diabetics
Resulting nerve damage and poor circulation are complications
of diabetes that can cause Charcot (Weatherford, 2017)
In the case of a patient observed at Anew, he contracted a staph infection
which caused the bones in the arch of the foot to collapse
Patients with acute Charcot can begin use of the CROW after any swelling
subsides (can take months). Those with severe cases may need surgery
prior to or instead of the use of a CROW boot
Mild and moderate Charcot cases and deformities benefit the most from
the CROW boot

8. Treatment of
Charcot Through
Implementation of
a CROW boot
• The Charcot Restraint Orthotic Walker is custom-made to
fit the patient’s foot
The boot helps to compress the foot and ankle so individuals with
this destructive disease can continue to live a quality life while the
bones and joints of the foot and ankle have an ideal environment
to heal in. The compression prevents further injury, and the boot
distributes weight equally while supporting the ankle. By
distributing pressure equally, the CROW removes excessive forces,
giving the foot time to heal
The bones and joints of the foot and ankle include the talocrural
joint, subtalar joint, tibiotalar joint, tibia, fibula, talus, lateral and
medial malleolus, calcaneus, tarsals, metatarsals,
metatarsophalangeal joints, cuboid, navicular bone and the
medial/lateral/intermediate cuneiforms
• If the foot/ankle are not protected, the foot may continue
to deform and will not regain normal shape
The CROW boot is extremely important in maintaining the
structure of the extremity, prevention of further injury and
deterioration to the area
• The boot serves its purpose preventing individuals from
living a diminished quality of life and enhancing the
likelihood that they can continue to perform ADLs
independently
(Feinblatt, n.d.)

9. Risks and
Complications
Associated with
Charcot
Neuropathy
• Deformity can lead to skin ulcers from the
resulting bone pressing against the shoe or
ground
• Joints may become unstable because of tissue
replacing the bone in the joint. This is called
“floppy foot” and can also cause ulcers. Joints
may heal incorrectly or not at all
• An infected ulcer unable to heal can be limb-
threatening and result in amputation
• Nerve damage and loss of sensation in the
lower extremities can increase the risk for
further injury, due to lowered ability to detect
intense pressures
(Charcot Foot, 2019).

10. Recovery Process
for Charcot
Neuropathy
• First and most important treatment is to rest
and take the weight off the affected foot
Offloading helps prevent inflammation and
stops the condition from worsening,
preventing deformity
• Foot may be temporarily casted for 8-12 weeks
prior to being put in a boot. Crutches, a knee-
walker, or a wheelchair may be used after initial
injury to avoid putting any weight on the
affected limb
When redness, swelling and heat have
subsided the cast may be removed
• After the cast is removed the patient is given a
prescription for footwear, commonly a CROW
boot. The physician may also recommend
changes in activity to avoid further trauma
• The custom fitted shape of the boot allow for
the return of walking, standing,, and
performance of activities for daily living such as
driving
• The CROW boot allows weight to be
distributed to the affected limb while
minimizing pressure and giving the injury a
chance to heal
(Charcot Foot, 2019), (Feinblatt, n.d.)

11. Stages of Charcot
Neuroarthropathy
Healing and
Recovery
Stage 1
Acute -
Fragmentation may
lead to pain,
redness, swelling,
and warmth
•After weeks of onset,
x-rays may show soft
tissue swelling, bony
fragmentation & joint
dislocation
Stage 2
Subacute -
decreased
redness/swelling
/warmth
•X-rays show early
bone healing
Stage 3
Chronic,
reconstruction-
consolidation -
Redness, swelling
and warm
sensations resolved.
Bone shows healing
with residual
deformity often
present
(Feinblatt, n.d.)

12. How an OT
Would
Facilitate
Recovery and
Rehabilitation

13. How OT/PT
Would
Facilitate
Recovery and
Rehabilitation

14. The Casting Process of a CROW Boot
Start by showing the patient a model so that they know what to expect and what it will
look like
Important to walk the patient through each step, explaining what you do before you do it
It is just as important to actively listen to the patient who will describe the obstacles they
experience with the condition, as well as their goals with this treatment option
Lay paper down on the floor beneath the patient’s leg/foot to keep casting materials to a
confined space and prevent materials from getting on surrounding objects and surfaces
Instruct the patient to roll their pant leg up to their knee removing any socks, stockings or
shoes that may interfere with casting

15. The Casting Process of a CROW Boot
Socks/stockings are placed over the patient’s extremity to protect their skin from the casting materials and
a wax pen is used to mark any bony prominences
Wrap the affected leg foot and ankle in dampened soft plaster bandage and holding the foot and ankle
at a 90° angle until the wrapped cast dries and sets in place
When wrapping the extremity, start most superior, close to the knee, and wrap the cast around and down
toward the ankle and foot. Have the patient lift their foot off the ground and continue to wrap all the way
down to their toes
Massage the dampened wrap so that the various layers mold together
Make any further markings on the cast with a wax pen to assist with proper alignment of the cast once it
is cut off and removed. This way the cast will better replicate the exact shape of the patient’s leg, ankle,
and foot, and any sensitive areas/bony prominences can be compensated for by adding relief in those
areas in the final product
Once cast is dry, use knife to cut down vertically from the patella to the distal phalanges so that the wrap
can be pulled apart and taken off. Once the cast/wrap is cut, the stocking underneath can be removed as
well

16. The Fabrication Process
• With the cast of the patient’s foot completely set and dry, the cast
can be filled with plaster. Once the plaster has then set and dried
inside the cast, the cast itself can be cut open and removed again
Smooth out and shape any imperfections in the plaster mold to avoid any
rough surfaces in the final product
Make any necessary modifications to the plaster mold
• Layer stockings over the plaster mold of the patient’s leg
• A foam piece for the foot insert is cut out and heated up in an oven.
Once heated and malleable, the foam is placed on the plantar
surface of the plaster mold and held there with bandages to form
the shape of the foot until it cools down and sets
Be sure the bandages are wrapped tightly so the foam takes the shape of
the plantar surface

17. The Fabrication Process
• The next step is to use crepe foam to also align with the
plantar surface on the mold. A pencil can be used to draw
the outline of the plantar surface, this outline can then be
used on the crepe to cut out the exact size needed
• Use adhesive/glue on the initial foam piece on the bottom
of the sole/plantar surface, then repeat the process with the
crepe foam by heating it in the oven and then gluing it to
the initial foam piece. Wrap both foam pieces in bandages
tightly around the sole of the foot mold to form to the
shape of the foot
• Once both foam pieces have cooled down and the
glue has dried and set, both are grinded down
together to form the interior inserts of the boot

18. The Fabrication Process
• The plaster mold of the patient’s foot/leg should still be
covered with a stocking to prepare for the fabrication of
the interior lining material and the outer external
Aliplast shell
Anterior and posterior portions are made separately, should
avoid seams with anything weightbearing
• Interior lining (Aliplast) is heated in an oven and
wrapped around the plaster mold of the patient’s leg
Lining is wrapped completely around the leg to make up
the anterior and posterior components
Important to smooth out any lumps or bumps for a
comfortable fit. Any air trapped inside is vacuum-sealed out
Excess material is removed, and the anterior and posterior
portions are cut out. When cutting the material, be sure not
to cut too deep into the plaster mold

19. The Fabrication Process
• With the interior lining (Aliplast) still attached to the plaster
mold of the patient’s leg, plastic (i.e. Volara) is heated in an
oven and transferred to the mold to form the exterior outer
shell
The plastic makes up the exterior shell of the CROW boot and the anterior and
posterior components are made separately. (Shown in the video is the anterior
component of the CROW boot being made)
• The heated plastic is wrapped around the leg mold and secured
posteriorly to make the anterior component of the external
outer shell
Once the plastic has time to cool down, it will harden and can be modified. Excess
materials will be grinded down and edges will be smoothed out
• Similarly, the posterior component of the boot is made the
same way, repeating the process with a new heated piece of
plastic, however, it is wrapped and secured anteriorly

20. The Fabrication
Process
• Once the plastic has cooled down and
hardened, it can be cut open with a saw to
expose the layers that make up the outer,
exterior shell of the CROW boot
Excess material is removed, and rough edges are
grinded down and smoothed out.
With the boot in an upright position the superior most
part of the boot needs to be grinded down to be
parallel with the ground.
The edges where the anterior and posterior
components meet will be smoothed out and modified
to fit with one another
• Pictured is how the edges appear before
they are grinded down and smoothed out

21. The Fabrication Process
How Material is Shaped and Molded
• Here is how one
smooths the edges on
prosthetic socket for an
above-the-knee
amputee
(press play to watch video)
• The same process is
performed grinding
down and shaping the
plastic external shell of
a CROW boot

22. The Fabrication Process
• After excess materials have been
removed and the edges have been
cleaned up and smoothed out, this
is what the resulting posterior
portion of the exterior shell should
look like.
• The anterior portion slides right over
top of the posterior portion of the
CROW boot like a puzzle piece, and
the two components are attached by
a series of Velcro straps

23. The Fabrication Process
• A layer of crepe material is glued to the plantar
surface with the addition of a rocker bottom
The shape of the foot is traced onto crepe material and cut out.
The crepe is heated in the oven and formed over the bottom of
the boot and wrapped in elastic bandage to ensure it takes shape
of the foot
• Once the crepe has cooled down, excess material can
be grinded down and the rounded rocker bottom
shape is formed
• When an ideal rocker bottom shape has been
achieved, the tread can be attached to the bottom of
the crepe on the plantar surface
If the heel rocker is too large, it can make the patient fall back. If
it is too small, it can cause premature pressure forcing the knee
into flexion
• The rocker bottom immobilizes the talocrural joint in
the ankle, and the rounded plantar surface assists with
a normal gait pattern while the ankle is immobilized

24. The Fabrication Process
o The Velcro straps that assemble to boot are first
measured medially to laterally at the superior
most part of the boot, middle of the boot, and
sometimes inferior most at the toes
o After measuring and cutting the ribbon
necessary to make the straps, line it with hook
and pile (Velcro)
You want more hook than pile, for example a 24” long ribbon
will have 14” of hook material (a little over half)
o Sew on hook and pile to the ribbon/strap, holes
will be drilled in the ends to attach the straps to
the boot
o Chafe goes on the medial side of the boot, the
strap runs through it
o Holes are drilled through the pile side and 2
holes are drilled on the back side of the boot
o Push the rivet through the hole made in the
boot. On the outside of the boot, push the hole
made in the strap through the rivet, and secure
with a washer, securing as tight as possible
Round out the head of all the rivets so that the user’s skin
doesn’t get caught or injured when slipping their leg into the
boot
Make sure the rivet is not going to interfere with any bony
prominences or areas that need relief

25. The Fitting Process
• Just as with the casting process, explain what steps are going to be taken, show them a boot and
explain its’ components. Educate them on how the design will help them with Activities of Daily
Living (ADLs)
Explain the height difference experienced with the CROW and how the platform will offset symmetrical
leg lengths (the affected limb with the CROW boot on will be longer than the unaffected limb). This
height difference may feel odd for some time. Wearing platform shoes with the CROW boot may help to
balance the difference.
Explain rocker bottom of the boot, how it facilitates a natural heel-to-toe gait and immobilizes the ankle
joints (immobilization prevents varus and valgus, keeping the foot and ankle in subtalar neutral position)
• Have the patient remove their socks and shoes and apply a knee-high stocking to the affected
limb
Recommend that they wear knee-high stockings along with the CROW boot to help absorb any moisture
from perspiration
• Explain how the boot has an anterior and posterior shell. Remove the anterior panel and explain
how the strapping works
Have the patient place their foot into the posterior shell. If everything fits comfortably then strap on the
anterior shell
Start strapping at the toe strap, then assemble the ankle strap, and lastly the calf strap. Strapping from
the toes up helps with proper alignment and pushes any swelling upwards rather than down toward the

26. The Fitting Process
• Have the patient practice walking around with the boot on to get a feel for it. After some
time, have them rest to remove the boot and stockings to check the limb for any redness
or marks
If the redness or compression marks last for more than approximately 15-20 minutes, the boot may
need the be made to fit more comfortably. Marks and redness that disappear shortly after removing
the boot are not a concern.
• Have the patient demonstrate how they would put on and take off the boot themselves
after you’ve walked them through it to ensure they are doing it correctly on their own
• Go over break-in/wearing schedule they should follow for the initial 1-2 weeks of wearing
the boot as well as cleaning and care
Emphasis placed on periodically checking the limb for redness/red spots brought on by the boot

27. How To Put On a CROW Boot
Instruct patient to put boot on
first thing in the morning as
swelling is least in the morning,
swelling progresses throughout
the day
1.) Apply long sock or stocking
making sure there are no
creases
2.) Place the affected limb inside
the posterior piece of the
CROW boot, sliding the heel all
the way to the back of the boot
3.) If the posterior piece fits
comfortably, attach the anterior
piece of the CROW boot,
making sure that it slides
over/on top of the posterior
piece
4.) Fasten the straps on the boot
starting most inferior and
working your way up, strapping
all the straps ending with the
one most superior

28. “Break-In” or
Wearing Schedule
With a CROW boot
specifically, it is essential to
wear the boot any time the
patient is mobile, regardless of
wearing schedule. This is
essential, as ambulation
without it can cause further
injury.

29. Cleaning and Care of the CROW Boot
• The CROW should be cleaned daily with warm water and soap. Rubbing
alcohol may also be used but can cause skin irritation.
• Avoid excessive heat being near the CROW boot as it may damage the
materials
• The CROW boot foot inserts can be removed and cleaned with a rag of
warm water and soap, but never submerge it in water
• The Aliplast is closed so it will not absorb water
• Make sure the CROW boot is completely dry before putting it back on.

30. Resources
Anew Life Prosthetics and Orthotics. (2021). https://anewlifepando.com
Charcot Foot; Symptoms, Causes, Diagnosis, Treatment & Management.
Cleveland Clinic. (2019, January 22).
https://my.clevelandclinic.org/health/diseases/15836-charcot-foot.
Jeanne, Y., Feinblatt, J., & Sathe, V. Charcot Restraint Orthotic Walker (CROW).
Foot Care MD. https://www.footcaremd.org/conditions-treatments/injections-
and-other-treatments/charcot-restraint-orthotic-walker.
Weatherford, B. (n.d.). Diabetic (Charcot) Foot. OrthoInfo. Retrieved from
https://orthoinfo.aaos.org/en/diseases--conditions/diabetic-charcot-foot/.