FYBPO - Orthotics - AIIPMR Lectures.

FYBPO – Orthotics
AIIPMR Lectures – Imp notes

ORTHOSIS : It is a Latin word derived from ORTHOGAN . Ortho
means to make something straight .It is fitted on the external
part of the body & is fabricated to improve the function of that
particular part .
ORTHOTIST / PROSTHETIST :
The person who fabricate the device .He must posses the
knowledge of engineering as well as human body so as to
make efficient device to enhance the body function .
REHABILITATION : It is a team work carried out to restore the
persons requirement or to bring him to normal lifestyle .

Rehabilitation can be physical , social or financial so it requires
experts from respective field .
Rehabilitation team consist of
1.PMR SPECIALIST (PHYSIATRIST)
2.ORTHOPAEDIC SURGEONS
3.PROSTHETIST & ORTHOTIST
4.PHYSIOTHERAPIST
5.OCCUPATIONAL THERAPIST
6.MEDICAL SOCIAL WORKERS
7.PSYCHOLOGIST
8.REHABILITATION NURSES

ORTHOSIS : is defined as an externally applied
device used to modify the structural & functional
characteristic of neuromuscular & skeletal systems .
ORTHOTICS : is defined as the science & art involved in
treating patient by the use of an orthosis. It refers to
the field of assessment &fabrication of orthosis .
ORTHOTIST : is defined as a person who have
completed an approved course of education &
training & is authorized to design , measure & fit the
orthosis .

MATERIALS USED FOR FABRICATION OF ORTHOSIS
•Metals & plastics are the basic materials used .
• Steels , alloy of aluminum (Duralium)
• Titanium & its alloy are also used .
• Minor use of copper , brass rivets .
• Nickel & chromium plating.
• Fabrics , Rubbers , Leathers .
• PVC (Poly Vinyl Chloride )
• HDPE (High Density Poly Ethylene )
• PP (Polypropylene )
• Orfit ( Low Temperature Thermoplastics )
• Velcro, webbing, press buttons ,D-rings for fastening

SELECTION OF MATERIALS : material should fulfill
following criteria
• Simple method of fabrication
• Allows controlled deformation
• Provides stiffness or resilience
• Reduce breakages from impact / repeated loading
Strength of material is the first important factor
considered for selection of material .
Stress & strain are two properties which determines material
strength .
Mechanical property of material is determine by theTension
test i.e. by Stress – Strain curve .

ALUMINIUM :
• Lighter in weight .
• Easier to work than steel .
• More subject to fatigue failure than steel but can
be made strong by increasing thickness .
• For equal volume & under same load aluminium is
3 times greater than iron .
DURALIUM :
• Increased strength compare to aluminum .
• Lighter in weight .
• Easily shaped to follow body contour .
• It is widely used in making orthotic joints .

PLASTICS :
This is most widely used in orthotics.
It has following properties :
• Suitable for direct application to the patient or to
an anatomical model .
• Easy to mold to desire form .
• Little or no toxicity .
• Unaffected by fluid such as water ,urine ,oil ,etc.
• Radiolucent .
• Easy to modify or manipulate .
• Quick setting or hardening time .
• Easily available .
• Available in different colours ,cosmetically good .

• Plastics are synthetic materials made form raw
chemical materials called as MONOMERS .
• A monomer ( one chemical unit ) such a ethylene
is reacted with other monomer molecules into long
chain of repeating ethylene units forming polymer
Polyethylene .
• Polystyrene is formed from styrene monomer .
• Polypropylene is formed by propylene monomer .
• Polymers consists of atoms of carbon in
combination with other elements.
Generally plastics are available in two types :
1. THERMO PLASTICS &
2.THERMOSETTING PLASTICS :

THERMOPLASTICS :
• These can be soften when heated & hardened when cooled so
can be molded & remolded by heating .
• Divided into LOW TEMPERATURE THERMOPLASTIC
& HIGH TEMPERATURE THERMOPLASTICS .
• LTT shaped directly on the body by heating in water
around 60 to 80 degree .
• LTT cannot be used where high stress is anticipated as in
lower limb appliances .
• Mainly used in upper limb orthotics ,spinal orthotics
• It has good elastic memory i.e. can be brought to
original shape after reheating in water .

HIGH TEMPERATURE THERMOPLASTICS :
• It must be shaped over a body model as it require
dry heating in oven around 180 degree .
• Much more resistant to creep i.e. change in shape
with continued stress & heat so ideal for long term
use or permanent use in lower limb orthotics .
• Don’t have elastic memory .
• Vacuum forming technique can be used .Commonly
used HTT in orthotics are :
• Fabrication process is time consuming as it require
model of body part .
• e.g. Polypropylene , Polyethylene , Copolymers etc.

1 .POLYPROPYLENE :
• Very rigid material with an extremely stable molecular
structure .
• Temp. required for softening is 190 degree .
• Tough , odourless & has high impact strength with good
mechanical properties .
• One of the lightest thermoplastic .
• Sensitive to strong oxidizing agent & extreme cold
• Can withstand to higher temperature .
• Easily washable in soap & water .
• Available in different colors
• It shows 1.5 %to 2 % of shrinkage .

POLYETHYLENE :
• It has good toughness & flexibility with good dimensional
stability .
• Has good electrical & cold resistance .
• Light in weight & nontoxic .
• Classified as High density & low density .
• Low density used for nonweight bearing brace such as upper
limb bracing .
• High density used for weight bearing supports & spinal
jackets .
• HDPE may suffer from fatigue when subjected to repeated
stresses .
• Melting temp.is 180 & shows shrinkage of 1.5-2%

COPOLYMERS : is used where some flexibility is required as in
prosthetic check sockets . Melting temperature is 190 degree &
also shows shrinkage .
ACRYLICS :
• it is polymerized from methyl methacrylate monomers .
• Light weight, high transparency, good dimensional stability &
resistance to breakage .
• Available in the form of sheets , rods , tubes &molding powder
. Unaffected by alkalis & nonoxidizing acids .
• Melting temp. 150 – 160 degree Celsius .
• Fire precaution must be taken during handling .

ABS (Acrylonitrile Butadiene Styrene ) :
• Good dimensional stability & tough .
• Have hard surface ,good chemical & weather resistance .
• Suitable for extreme fatigue resistance as in chair seats &
back .
• Molding temp .is 275 – 325 degree Celsius .
• Widely used for wheelchair seat inserts .
PVC (Poly Vinyl Chloride ) :
• Has good flexibility .
• Substitute for metal bands of orthosis .
• Can be shaped by heat gun , oven not required .
POLYURETHANE FOAM : used for cosmetic covering

THERMOSETTING PLASTICS :
• These are based on polyester & epoxy resins .
• They are in liquid form & can be cured at room temperature &
atmospheric pressure .
POLYESTERS :
• These are useful for lamination purpose .
• When reinforced with fibers provide good strength
• Can be pigmented to skin color .
• Do not absorb moisture & can be kept clean by washing with
soap & water .
• Not affected by organic solvents & weak acids .
• Affected by sunlight & strong acids & alkalis .
• When cured chemically stable with no smell .

EPOXY RESINS :
• It is low molecular weight ,syrup like liquid which is cured
with hardener to crosslink thermoset structure that are hard &
tough .
• Good chemical & weather resistance .
• Excellent adhesives .
• Not affected by weak acids or alkalis but are slightly affected
by strong acids & alkalis .
•More expensive than polyester resins .
• Inconvenient to use than thermoplastics .
• Can cause skin , eye or respiratory tract irritation so needs
careful handling .

OBJECTIVES OF ORTHOTIC TREATMENT :
1.Relieve pain
2.Correct deformities
3.Prevent deformities
4.Increase or decrease range of joint motion
5.Compensate for segment length or shape
6.Manage abnormal neuromuscular function
7.Protect injured tissues
8.Promote healing
9.Provide psychological comfort
10.Realign the skeleton

COMMON GOALS OF ORTHOSIS :
1.Stabilize weak or paralyzed segment / joint
2.Support damaged or diseased segment
3.Limit or assist motion across joint
4.Control abnormal or spastic movements
5.Unload the distal segment
NOMENCLATURE OF ORTHOSIS :
It is decided by International Organization for
Standardization (ISO) terminology .
It describe the orthosis with reference to the body segment
they encompass .

1 . FO : Foot Orthosis
2 . AFO : Ankle Foot Orthosis
3 . KO : Knee Orthosis
4 . KAFO : Knee Ankle Foot Orthosis
5 . HO : Hip Orthosis
6 . HKO : Hip Knee Orthosis
7 . HKAFO : Hip Knee Ankle Foot Orthosis
8 . SIO : Sacroiliac Orthosis
9 . LSO : Lumbo Sacral Orthosis
10 . TLSO : Thoraco LumboSacral Orthosis
11 . CO : Cervical Orthosis
12 . CTO : Cervical Thoracic Orthosis
13 . CTLSO : CervicalThoracicLumboSacraOrthosis

COMPONENTS USED FOR ORTHOSIS CONSTRUCTION:
1 . INTERFACE COMPONENTS :these are in direct contact with
the user & are responsible for
transmitting forces for functioning of orthosis.
e.g. pads, straps, shoes , bands etc.
2. ARTICULATING COMPONENTS : these are used to
allow or control the motion of anatomical joint
e.g. Knee joints ,Ankle joints , Hip joints etc.
3 . STRUCTURAL COMPONENTS : these connects the
Interface & articulating components & maintain the alignment
of the orthosis e.g. Joint Uprights
4 . COSMETIC COMPONENTS : provides shape ,colour
& feature to orthosis e.g. covers , padding , sleeves .

Orthosis can be classified as per their function :
1 . STATIC ORTHOSIS : these provides no motion across the joint
or segment involved therefore Stabilization is the primary goal
of giving orthosis.
2 . DYNAMIC ORTHOSIS : these provides motion across joint .
These can be specifically given as Limited motion in two plane or
in any one plane or No motion in any plane or Free motion
depending on the patients body requirement .
3. PROGRESSIVE ORTHOSIS : these can be designed
to have different biomechanical functions as per the
progression of deformity .

PRINCIPLES OF ORTHOTIC APPLICATION :
1.Adequate surface area : for comfortable pressure
distribution .
2 . Joint Positioning : positioning the joint to correct
anatomical position is very important for efficient
functioning of orthosis .
3 . Avoid localized compression of nerves .
4 . Accommodate the local lesions .
5 . Donning & doffing should be easy .
6 . Energy expenditure with brace should be less.
7 .Orthosis should be durable & cost effective .
8 . Maintenance & repairing of orthosis should be easy

PRINCIPLES OF FABRICATION :
DATA COLLECTION :
• Accurate collection of patients data is a key for properly
design & functioning of orthosis .
• Accurate physical measurement ensure correct fit of device on
patients body .
METHOD OF MEASUREMENTS :
• Old method is two dimensional tracing of limb profile on
paper .
• New method is to create three dimensional model of limb on
which orthosis is fabricated .
• Modern method is CAD-CAM i.e. Computer Aided Design &
Computer Aided Manufacturing .

1 . TWO DIMENSIONAL TRACING :
• Used specially for making metal & leather orthosis
• It gives appropriate circumference & diameter of the patients
body .
• It shows the location of the mechanical joints .
• It can be done with the patient supine while taking
measurement for lower limb .
• When profile of the
torso is required it is
done in standing
against the wall .

• Care must be taken to keep the tracing tool i.e. pen or
pencil perpendicular to the paper surface & parallel to the
body surface .
• If this in not done then the resulting diameter will be
either too wide or to narrow & orthosis will not fit
correctly
2. THREE DIMENSIONAL MEASUREMENT :
• This is known as casting of body part & is done with
Plaster of Paris bandages .
• It gives dimensionally stable model .
• It accurately gives critical location for mechanical joints &
areas requiring pressure relief .

PLASTER OF PARIS (GYPSUM / CALCIUMSULPHATE) :
• POP is manufacture by crushing & grinding the purest form of
Gypsum & heating it to remove excessive water forming
hemihydrates of calcium sulphate known as POP .

CaSO4 . 2H2O + Heat = CaSO4. ½ H2O + 11/2 H2O
Gypsum POP Water
• Plaster get expansion during setting .
• Setting process of POP is made of two component
1. Thermal Expansion resulting from an increase in
temperature of the cast .
2. True Setting Expansion due to growth of gypsum
crystals .
• Setting is relatively short process & is completed by
chemical formation & interlocking of gypsum crystals .
• Setting is completed when heat is no longer given off .

• Drying takes longer time than setting .
• Drying is completed with evaporation of excessive
moisture from the cast .
• Setting completed in 5-45 minutes whereas drying
completed in 8 – 24 hours depending on the thickness of
the cast .
• Setting & drying time are determined by
1. Type of plaster & amount of water added .
2. Temperature of water (cold water retard setting
& warm water accelerate setting )
3 . Thickness of cast
4. Air circulation around cast
5.Air temperature & humidity

CASTING PROCEDURE :
• Before casting body area is protected with soft
dressing such as stockinet which also act as a
separating agent .Mention polish can be used .
• Sensitive areas are marked with copying pencil .
• POP bandages are wrapped around & after setting
it is removed .This mold is called as Negative Mold.
• After it get dry it is filled with POP powder paste
& solid mold is made which is called as Positive Mold
• Necessary modifications are made over + ve mold
& exact replica of body is made over which orthosis
is fabricated .

3 . IMPRESSION MEASURENENT :
• This method is used where only a replica of plantar surface
is required e.g. foot impression .
• Low density Poly Urethane Foam is used to make the
impression of the foot .
• The foam is compressed under partial weight bearing as
the patient gently pushes into the
material which
retains the foot ‘s
plantar contour .

4 . CAD-CAM TECHNOLOGY :
• It gives less inconvenience to patient while creating
positive model .
• Two techniques are used for collecting data :
1 . Measurement & 2 .Scanning
• Data is forwarded to computer which creates an image
of the model ( - ve model )
• Orthotist manipulate the image & then information
is exported to CAM equipment (modification)
• With the given information foam block is carved which
act as a positive model that is used to fabricate the
custom orthosis .

FOOT AND ANKLE ANATOMY
• 26 bones
• Forefoot
– Metatarsals
– phalanges
• Mid foot
– 5 tarsals
• Rear foot
– Talus and
– Calcaneus

Rear foot : Talus & Calcaneus
• Provides stability & shock absorption during initial
stance phase
• Lever arm for Achilles tendon during plantar flexion
• Talus – no muscles attach to it
• Calcaneus
- Calcaneal tubercle – posterior side
- Sustentaculum tali – medial side - helps support the
talus
flexor hallicus longus - passes through the medial groove
- Peroneal tubercle – lateral side
• Inferior talus & Superior calcaneus takes part in
formation of subtalar joint .

MID FOOT : 5 Tarsal bones
Formed by Navicular , Cuboid & 3 Cuneiforms.
Basic function of mid foot is :
•It helps in shock absorption.
• It forms Medial longitudinal arch.
• Navicular tuberosity provides insertion for Tibialis
posterior .
FOREFOOT :
Formed by 5 Metatarsals .
•Metatarsals – proximal base, body, distal head .
•Phalanges – MTP, PIP, DIP, IP joints
•Plantar fascia is a main part of forefoot .
•Fore foot provides lever during pre-swing phase .

• Intrinsic muscles – muscles contained within the foot
• Extrinsic muscles – muscles originating from lower leg
or femur
• Supination – inversion + adduction + plantar flexion
• Pronation - eversion + abduction + dorsiflexion
• Inversion – movement of the plantar aspect of the
calcaneus toward the midline of the body
• Eversion – movement of the plantar aspect of the
calcaneus away from the body
• Dorsiflexion – flexion of the ankle, pulling the foot &
toes toward the tibia
• Plantar flexion – extension of the ankle, pointing the
foot & toes
• Ray – series of bones formed by the MT & phalanges

Intrinsic Muscles of the Foot
• All originate &
insert within
the foot
– Extensor
digitorum
brevis - dorsum
of foot
– Remainder are
in a plantar
compartment
in 4 layers on
plantar surface
of foot

First (superficial) layer: Abductor hallucis, flexor digitorum
brevis, abductor digiti minimi (quinti)
Second (middle) layer: Quadratus plantae, lumbricales (4)

Third (deep) layer: Flexor hallucis brevis, adductor hallucis, flexor
digiti minimi brevis
Fourth (deep) layer: Dorsal interossei (4), plantar interossei (3)

• Grouped by location
– Medial - attach to great toe proximal phalanx
• Abductor hallucis & flexor hallucis brevis - medially
• Adductor hallucis - centrally beneath metatarsals
– Central location
• Beneath the foot
• Quadratus plantae, 4 lumbricales, 4 dorsal interossei,
3 plantar interossei, flexor digitorum brevis
• Dorsal compartment
–Extensor digitorum brevis
– Lateral – attach on lateral aspect of base of 5th
phalange
proximal phalanx
• abductor digiti minimi, flexor digiti minimi brevis

• Grouped by action
• 4 muscles act on great toe
• abductor hallucis - abduction of great toe & assists flexor hallucis
brevis in flexing great toe at MP joint
• adductor hallucis - adduction of great toe
• extensor digitorum brevis - extension of great toe at MP joint
• 4 lumbricales flexors of the 2nd
to 5th
phalanges at MP joints
• quadratus plantae flexors of 2nd
, 3rd
, 4th
, & 5th
phalanges at DIP jt .
• 3 plantar interossei
• adductors & flexors of proximal phalanxes of 3rd
to5th
phalanges
• 4 dorsal interossei
• abductors & flexors of 2nd
, 3rd
, & 4th
phalanges MP joints
• flexor digitorum brevis
• flexes middle phalanxes of 2nd
, 3rd
, 4th
, & 5th
phalanges
• extensor digitorum brevis
• extends great toe & 2nd
, 3rd
, 4th
phalanges at MP joints
• 5th
toe muscles
• abductor digiti minimi abducts proximal phalanx
• flexor digiti minimi brevis flexes proximal phalanx

Extrinsic Muscles of the Foot
• Extensor hallucis longus (EHL)
• Extensor digitorum longus (EDL)
• Flexor hallucis longus (FHL)
• Flexor digitorum longus (FDL)
• Triceps Surae (Gastrocnemius, Soleus, Plantaris)
• Peroneus longus, brevis, tertius
• Tibialis anterior
• Tibialis posterior

Movements of Toes
• Toe flexion
– movement of toes
toward plantar
surface of foot
• Toe extension
– movement of toes
away from
plantar surface of
foot

Metatarsophalangeal Joints
• Classified as condyloid-type joints
• Great toe metatarsophalangeal (MP) joint flexes 45º &
extends 70º
• MP joints of the four lesser toes
• 40º of flexion
• 40º of extension
• also abduct & adduct minimally

• Great toe interphalangeal (IP)
joint flexes from 0º of full
extension to 90º of flexion
• Proximal interphalangeal (PIP)
joints in lesser toes flexes from
0º extension to 35º flexion
• Distal interphalangeal (DIP)
joints flexes 60º & extend 30º
• Much variation from joint to
joint & from person to person

Movements of Foot
• Pronation
– combination of ankle dorsiflexion,
subtalar eversion, & forefoot
abduction (toe-out)
• Supination
– combination of ankle plantar
flexion, subtalar inversion, &
forefoot adduction (toe-in)
• Eversion
– turning ankle & foot outward;
abduction, away from midline;
weight is on medial edge of foot
• Inversion
– turning ankle & foot inward;
adduction, toward midline; weight
is on lateral edge of foot

MOTION AT THE FOOT :
1. Dorsiflexion : 20 degree (Extensor haiiucis longus &
Peroneous tertius )
2.Planter flexion : 50 degree (Gastro soleus ,tibialis
posterior, Flexor hallucis longus & digitorum longus )
3 . Inversion : 30 degree ( subtalar motion ) foot is
4 . Eversion: 10 degree (subtalar motion) off ground
5. Abduction & Adduction : transverse tarsal motion
6 . Supination & Pronation : occur when foot is on
the ground .
METATARSOPHALANGEAL JOINTS :
1.Dorsiflexion : 60 degree
2.Planter flexion : 20 degree

Subtalar joint motion is tri-
planar
Pronation
Eversion, abduction,
dorsiflexion
Supination
Inversion, adduction,
plantar flexion
Torque developed by foot
movement transmits
proximally1:1 relationship
between degree of
Supination and tibial external rotation &
Pronation and tibial internal rotation .

ARCHES OF THE FOOT :
• Foot act as a lever for forward propulsion during walking ,
running or jumping .
• For all this purpose foot is designed in the form of elastic
arches who sustain stress of weight & thrust
• Arches are present from birth but in infant not visible
clearly because of fat .
• Arches are segmented & concave in shape .
• Two types of arches present in the foot :
1. LONGITUDINAL ARCHES
2.TRANSVERSE ARCHES
Arches are formed due to specialized articulation &
placement of foot bone & various joints .

LONGITUDINAL ARCHES :
•Lies along the long axis of foot one on the lateral
side & one on the medial side with calcaneum as a
common posterior pillar .
MEDIAL LONGITUDINAL ARCH :
• It is higher , more mobile & resilient than lateral .
• It absorbs forces of the weight & thrusts .
• It consist of calcaneum ,talus ,navicular ,cuneiform,
& inner three metatarsal bone .

Head of first three metatarsal forms
ANTERIOR END OF ARCH .
Medial tubercle of calcaneus forms
POSTERIOR END OF ARCH .
Superior articular surface of the body of talus forms
SUMMIT i.e. highest point of the arch .
PILLARS :
Anterior pillar is long & weak , formed by talus , navicular ,
three cuneiform & three metatarsal .
Posterior pillar is short & strong formed by medial half of
calcaneus .
Main joint of the medial longitudinal arch is talo-calcaneum –
navicular .

LATERAL LONGITUDINAL ARCH :
• It extend from calcaneum-cuboid & outer two
metatarsals .
• ANTERIOR END formed by head of the fourth & fifth
metatarsals .
•POSTERIOR END formed by lateral tubercle of calcaneum .

SUMMIT :
It is on the superior surface of articular facet calcaneum .
PILLARS :
Anterior pillar is long & weak formed by the cuboid fourth &
fifth metatarsals .
Posterior pillar is short & strong formed by the lateral half of
calcaneum .
2.TRANSVERSE ARCHES :
• It is the side to side concavity seen in cross section & is
mostly marked at the base of metatarsal .
• Two transverse arches are there
POSTERIOR TRANSVERSE ARCH :
•Formed by greater part of tarsus & metatarsus .
•It is incomplete arch as only lateral ends comes in contact
with ground .

• The half dome of one foot is completed by a similar dome in
the opposite foot when two foot are approximated .
ANTERIORE TRANSVERSE ARCH :
• It is formed by the head of 5 metatarsal bones .
• It is complete as the heads of the first & fifth metatarsal
comes in contact with the ground .

Functions of Arches :
1 .Distribute the body weight to the weight bearing
areas i.e. heel ,ball of the toes & lateral border of foot .
2. Elasticity of arches helps in walking & running .
3. Springs of the arches act as a shock absorbers .
4 .Concavity of arches protects soft tissue, nerves.

TIE BEAMS OR BOW STRINGS :
They connects two ends of arches .
Planter aponeurosis is the main part of tie beam .
In toe extension the aponeurosis is stretched & arch is
heightened .
Along with Spring ligament & planter ligament ,
Planter aponeurosis helps in maintaining transverse arches
of the foot .

FAT OF THE SOLE :
•Mainly composed of fatty tissue & some fibrous tissue .
• Fibrous tissue divides fat into small globules which get
compressed by external pressure but do not get displaced ,
they change the shape & transmit the thrust to neighbouring
globules .
• In this way the weight is distributed to a wider area .
• Compressibility of the fatty tissue of the sole dampen the
impact on the foot & reduces the thrust on the bone .

WEIGHT DISTRIBUTION ON THE FOOT :
• Body weight is transmitted to the bones of foot through talus
• Weight is equally divided on two legs .
• Half of the weight of each leg is transmitted to the heel &
remaining half to the MT heads .
• 1/3 rd is born by 1st
MT .
• Remaining is distributed
evenly on other
four MT heads .
• If total body weight is
divided into 12 parts then
6 parts will come on the heel
2 parts on 1st
MT head &
1 part each on other
four MT heads .

THE FOOT WEAR :
FUNCTION OF THE FOOTWEAR :
• Transfer body weight to the ground .
• Protection of weight bearing surface .
• Provides Comfort to the weight bearing areas .
• Decreases pressure from planter surface .
• Provides base for caliper attachment .

Shoes used with orthosis needs special features .
Efficiency of the orthosis to assist the patient depend on
proper shoe fitting .
Properly fit shoe must fulfill following demands :
1 . Firmness of heel counter .
2 . Closure mechanism i.e. either laces or Velcro straps .
3 . Adequate heel height .
4 . Shape of shoe .
5 . Flexibility of the sole .
6 . Adequate room in the toe box .
7 . Size of the shoe .

PART OF THE SHOES :
• Main components of the shoes are Sole , Heel , upper lining
& reinforcements .
• Generally shoe has two soles Outer sole which contacts the
floor ,made up of leather or synthetic material & should be 6
mm thick . Inner sole made up of leather & lies under the
foot .
• Space between anterior portion of the sole & the floor is
known as TOE SPRING which produces rocker effect to
facilitate toe off .
HEEL :
• Contour & height of the heel affects the function
of the shoes & foot .

• Normal heel height for
children is 18 mm or 3/4 “
• 37 mm i.e. 1 ½ “ for
adolescent girl &
• 20 – 25 mm i.e. 7/8 – 1”
for men
• Highest heel for ladies
should not exceed
50mm/2”
• High heels causes
Postural problems as
shown in the diagram

SHOE LASTS : It is a solid three dimensional model of the foot on
which shoe is fabricated .
Last may be made up of
Wood , cork or plaster
cast as in case of Bespoke
last

PATTERN OF SHOES :
• These are based on the height of shoe quarter .
1 . DERBY SHOE :
In this shoe quarter extends to a level just below the malleoli .
It is more cosmetic & does not restrict ankle & subtalar
movements .
2 . BOOTS :
It covers the malleoli & gives better grip to the foot .
Ankle & Subtalar motions are restricted betterly .

Depending on the style of throat shoes are described as :
1 . OXFORD SHOE :
It is given when person can wear the shoe easily without wide
opening .
2 . LACE TO TOE SHOE :
In this lacing extends up to the toes making it easy to wear
for patient having severe foot deformity .

MATERIALS USED IN THE FOOTWEAR :
Mainly two types of materials are used
1 . Natural materials : leather , metal , wood , cork fabrics ,
rubbers etc.
2 . Synthetic materials : synthetic fibers , plastics , rubbers .
LEATHER : It is the most important material in footwear . It is
easy to work , has a soft feel & slightly stretchable , friendly to
the human skin & can breathe .
Commonly used animal skins are Buffalo , Cow , Calf , Sheep ,
Goat , Deer , Horse , Pig & Camel .
Animal skin is first Tanned , Dried ,Stained , Oiled , Polished &
then used for making footwear .
Cow leather is most preferable material for footwear .

FELT : It is a non woven woolen ,cotton or synthetic
fabric used as a reinforcing material & also for making
various shoe modifications .
METALS : provides rigidity to the footwear.
CORK : is generally used for height built up .
RUBBERS : it is generally used for outer sole , heel, wedge ,
arch support & lining .
MAN MADE MATERIAL OR SYNTHETICS :
Different types of thermoplastics like PVC, Urethane, Nylon
can be used for making sole , heels etc .
Their disadvantages are :
1 . Poor breathability causes skin rashes .
2 . Inability to mold to the shape of foot .

FOOT ORTHOSIS :
Foot orthosis is a mechanical device used to
1 . Maintain the alignment of foot .
2 . Support the foot .
3 . Prevent , Correct or Accommodate the deformity
4 . Improve the function of foot .
FUNCTION OF FOOT ORTHOSIS :
1 . Evenly distribute the weight bearing stresses over the
entire plantar surface of the foot .
2 . Reduce the stress & strain on the ankle , knee , hip & spine
indirectly .
3 . Alleviate the pain from painful & sensitive areas of the sole
of the foot .
4 . Support the foot arches .
5 . Provide relief for tender areas i.e. corn , fissures

6 . Decrease degree of foot movements which are beyond
normal limits .
7 . Improve foot alignment .
8 . Accommodate congenital or developmental foot
anomalies .
9 . Equalize the foot length discrepancy & compensate for leg
length discrepancy .
10 . Minimize the pressure & irritation from external (shoe) or
internal (bony prominences) sources .
11 . Serve as an addition to AFO , KAFO & HKAFO

DIFFERENCE BETWEEN CUSTOM MADE FO & MARKETED FO
CUSTOM MADE FO
• Gives anatomical fit &
comfort
• Unlimited sizes
• Easy to modify
• More effective
• High patient acceptance
• High cost
• Time consuming process
• Limited supply
MARKETED FO
• Does not give good fitting &
comfort
• Limited sizes
• Not easy to modify
• Less effective
• Acceptance poor
• Low cost
• Prefabricated so less time
• Abundant supply

Based on the length of FO it is classified as :
1 . Metatarsal Length : extending up to MT heads .
2 . Sulcus Length : extending up to web space of toe
3 . Morton’s Extension : full extension under greater toe &
remaining end at the web .
4 . Full Length : extends up to tip of toes
Foot orthosis confined to the foot only & primarily covers the
plantar surface of the foot . They do not encompass the ankle .
Foot orthosis benefits only up on weight bearing .
There fore evaluation should include observation of foot
function during weight bearing & walking .

Basically foot orthosis are of three types :
1 . Accommodative or soft device
2 . Intermediate or semi rigid
3 . Corrective or rigid
SOFT DEVICES OR SHOE MODIFICATIONS :
1 .MEDIAL LONGITUDINAL ARCH SUPPORT :
It is given on the medial aspect of foot under medial arch .It
prevent excessive pronation of the foot & controls flat foot &
helps in proper weight distribution on the foot . Generally
given for flexible foot deformities .
2 .LATERAL LONGITUDINAL ARCH SUPPORT :
Not commonly used in treatment .

3 .METATARSAL PADS :
Given proximal to MT heads to support anterior transverse
arch & decrease pressure from MT head

4 .WEDGES :
are used to correct flexible deformities of hind foot or
forefoot e.g. medial wedge has more material on medial
border than lateral border .
It helps to shift the weight .
It is contraindicated for fixed deformities .
Medial wedge:
Decreased rear foot pronation
Increased lateral ground reaction
Force.
Lateral wedge:
Increased rear foot pronation
Decreased lateral ground
reaction force .

5 . FLARES OR FLOATS :
•It is an extension either medially or laterally of the sole
provided for stabilization .
•It can be added on the sole or heel .
•It is not given to correct the deformity ,only to control
side to side motion & give wider base of support .

PATHOLOGICAL FOOT :
Foot is most frequently affected by Neurological , Vascular ,
Congenital & Degenerative disorders .
1 . PES PLANUS : commonly called as FLAT FOOT .
There is a flattening of longitudinal arches .
2 . PES PLANOVALGUS :
It is a congenital flat foot
associated with
abnormality of subtalar
joint & muscle imbalance
Sole is convex & shows
Rocker bottom , heel is in
Equinus & valgus ,
Forefoot abducted & DF

Orthotic Management :
1 . Heel Adaptation = THOMAS HEEL , MEDIAL WEDGE either
on sole or on heel
2. MEDIAL ARCH SUPPORT :
3 .MEDIAL T – Strap for orthosis :

THOMAS HEEL OR CROOED & ELONGATED HEEL :
• Heel on the medial side is extended up to navicular bone .
• Extend ¼”
to ½” on the inner side of the shoe & ½” ahead
than normal breast line of the shoe .
• It gives an additional upward thrust which prevents the
inward rolling of the foot & heel .
• Along with the arch support it helps in inversion of the foot .
• It also helps to transfer weight on the lateral border of the
foot .

3 . FOOT DROP :
Unable to lift the foot actively but passively it can be
dorsiflexed . No change in shape of bone & deformity can be
corrected .
4 . PES EQUINUS :
Here deformity is fixed can not be corrected .
There is change in normal foot alignment .
Dorsal aspect of bone increases in size compared to ventral
aspect .

OTHOTIC MANAGENENT :
1.Reduction in heel height
2. Ankle foot orthosis
3. Metatarsal bar or pad &
arch support to redistribute
the weight
5 . CALCANEUS :
•In this toes are elevated & weight is borne on the heel .
•This deformity is reverse of equinus .
•There may be contracture of dorsiflexors or paralysis of
gastro-soleus .
•Orthosis is given to maintain the foot in neutral or in slight
equinus .
•High heel footwear can be use .

6 . PES CAVUS (HOLLOW FOOT ) :
•It is characterized by high longitudinal arch .
•Length of the arch is decreased & height is increased due to
dropping of tarsal bones .
•This gives fatigue ,discomfort ,pain in the sole under MT heads
• The size of the foot decreases .
•Foot modifications are required for proper weight distribution
& relieve the weight from MT heads .

• Cavus foots are usually less flexible resulting in decreased
shock absorbing capacity .
• Because of this excessive pressure comes on the ball of
the foot & heel .
• Severe cavus deformity also result in pressure on the
base of the head of the fifth MT .

WINDLASS ACTION :
•Contracture of the soft tissues draws the foot in to the cavus
deformity .
•As the angulations on the dorsum of the foot increases distance
between the origin & insertion of the toe muscles increases which
pulls the toes into hyperextension at MTP joint .
•DF of toes at MTP joints by means of WINDLASS ACTION
increases tension on the palmar aponeurosis which increases
cavus deformity & vicious cycle continues .

ORTHOTIC MANAGEMENT :
1 . Lateral heel & sole wedge for foot eversion .
2 . MT pad or bar to elevate MT heads .
3 . Arch support for better weight distribution .
4 . Increased heel height
5 . Special shoe with molded insole & high toe box .

7. CONGENITAL TALIPES EQUINOVARUS :
Called as CTEV or CLUB FOOT .
Five components of deformity are :
1 . Planter flexion of ankle & forefoot
2 . Forefoot adduction
3 . Supination
4 . High longitudinal arch
5 . Internal rotation of tibia ( tibial torsion )

Causes :
1 . Raised intrauterine pressure forces the foot in deformity .
2 . Ischemia of calf muscles during intrauterine life results into
contracture of foot muscles .
3 . Genetically related disturbance develop foot deformity
4 . Secondary to paralytic disorder like POLIO , MMC , AGMC .
Correction of deformity can be done non operatively or by
operative method .
Serial casting is first option for small children's .
In the night time Dennis Brown splint can be given .

1 . Flexible Deformity :
Modified footwear to keep the foot in corrected position &
night splints along with foot exercises .
D.B . Splint is given for children's below 1yr of age
2 . Rigid deformities :
Surgical correction followed by modified footwear & night
splints .
If deformity is not correctable then molded boots are given
to accommodate the deformity .
General shoe modifications for CTEV :
1 . Straight & stiff or out flared boots
2 . Reverse Thomas heel
3 . Lateral heel & sole wedge
4 . Spring loaded AFO for correcting equinus .

8 .CALCANEUM BURSAE & SPURS :
•It is a osseous prolongation in the form of spur in the plantar
musculo-fascial origin .
•The central & thickest part of plantar fascia is attached to
medial process of the calcaneum tuberosity .
•Tension in these structure causes bursae also known as
Planter Fascities .

• Pain at the most anterior
portion of the heel pad .
• pain at the medial part of
Calcaneum .
• Pain increases with active
dorsiflexion of great toes .
• Pain is more with first
Step or after inactivity i.e.
In the morning

1 . Soft cushioned heel :
Used in early stage or in mild complaint .
U shaped heel cushion or excavated heel cushion helps in
relieving weight from painful bony area & distribute it on the
surrounding fat .
2 . Longitudinal arch support :
Helps in reducing weight from painful area .

9 . DEPRESSED TRANSVERSE ARCH :
It is due to laxity of inferior metatarsal ligament ,
weakening of muscles or due to over weight .
Also called as SPLAY FOOT .
Abnormal pressure on MT heads result in metatarsalgia &
may cause inflammation .
Orthotic management :
1.Adequate width of the footwear to accommodate wide
forefoot .
2. Lower heel height to reduce weight from MT heads .
3. MT pad or MT bar to relieve pressure from MT heads .

10 . HAMMER , MALLET & CLAW TOES :
Hammer : Flexion deformity of PIP joints .
Mallet : Flexion contracture of DIP joints .
Claw Toes : PIP & DIP joints are hyper flexed & MTP joints are
hyper extended .

1 . Aim of orthosis is to support depressed arch , reduce toe
deformity & improve push off .
2 . Cushion insoles can be given in sensitive corns
3 . MT support reduces pressure on MT heads .
4 . Steel sole bar helps in restricting painful motion
5 . Wide & long vamp & high toe box shoe is required to
accommodate deformed toes .

11 . HALLUX VALGUS OR BUNION :
Deviation of great toe towards lateral or fibular border of foot
First MT head becomes prominent & bursa over it.
Two types are seen :
1 . Hallux valgus interphalangeous
2 . Hallux valgus metatarso-phalangeous .
1 . Low heel height to prevent forward sliding of foot .
2 . Medial arch support to shift weight towards outer side .
3 .Broad toe box footwear .
4 . Overcorrected molded splint

12 . HALLUX RIGIDUS :
•It is a painful problem of great toe .
•Due inflexibility of MTP joint of big toe it is unable to dorsiflex
which interfere with push off .
•In attempt to prevent motion patient try to shift the weight
on lateral border which gives adduction & inversion of the
foot & pain in lateral MT head .
1 . Long rocker sole
2 . Medial arch support
3 . Steel sole bar .

13 . METATARSALGIA :
Any disturbance in circulatory , metabolic , neurogenic ,
traumatic & infectious, first manifest in planter or dorsal
metatarsal region .
Common cause of metatarsalgia is pain in the short muscles &
compression of the nerves in between the metatarsals .
14 . HALLUX VARUS :
It is a rare condition in which great toe is angulated medially
at MTP joint i.e. reverse of hallux valgus .

VASCULAR DISORDERS & DIABETES :
In vascular insufficiency there is osteoporosis of the foot due to
poor nutrition .
NEUROGENIC DISORDERS:
CHARCOT’S JOINT (neurotrophic arthropathy ) :
•It is a chronic progressive degenerative arthropathy which
involve any joint & the weight bearing articulations .
•Usual initial complaint is painless swelling of foot or ankle .
•Instability becomes a problem when joint destruction
progresses .
•Common in uncontrolled & chronic diabetic patient .
•Usually seen between ages 35 to 65 years .

INSENSITIVE FOOT :
•Ulceration is the basic problem of insensitive foot due to
excessive pressure & inability to protect the foot due to lack
of sensation .
•Mechanical stress is responsible for tissue breakdown .
LEPROSY (HANSEN’S FOOT )
•In this Rolling away of fingers & toes are seen .
•It is due to rarefaction of cancellous part of the bone .
•If stress is placed the bone may collapse .
•Nerve damage is also common in leprosy .
•Keratin of the skin looses all flexibility , elasticity & results in
dry skin predisposing the cracks .

ORTHOTIC MANAGEMENT OF INSENSITIVE FOOT :
•Main aim of orthosis is to take away weight from high
pressure zones like heel & MT heads .
•This is done by using soft insoles & arch support .
•Usually footwear with outer rubber sole & inner leather sole
& no nails are preferred .
•Once the ulceration takes place it becomes essential to take
off total weight from ulcer area by redistributing it to other
areas of foot .

MOULDED INSOLES
•Fit in shoe to stabilize foot
deformity .
•Allows foot to compensate
abnormality .
•Transfer weight from painful
area .
•Improves shock absorption .
•Control ground reaction forces
around a specific location .
Example:
Diabetic foot, Neuropathy,
PVD, congenital malformations

• Redistribution is done by providing arch support &
special heel pads which feet inside the shoes .
• It takes the weight of the ulcer area , lifts the ulcer from
the contact with the insole & take the thrust to the sides .

FOOT PATHOLOGY
• Claw Toes
• Grade 0 foot with
protective sensation
• Grade 0 foot without
protective sensation
superficial ulcers
deep ulcers
• Grade 3 – 5 foot
with Chronic heel ulcer
ORTHOSIS
• Accommodative Insoles
• Cushion Insoles
• Accommodative insoles
with relief for calluses
• Accommodative insoles
with relief for ulcer area
• Same as above
• Surgical intervention like
calcanectomy
CROW orthosis
Lace shoes gives best stability & protection than sandals .

DERMATOLOGICAL DISORDERS :
1 . CALLUS :
•It is a thickening of the skin area exposed to persistent
abnormal friction .
•It forms due to abnormal foot mechanics .
•In case of depressed transverse arch weight bearing by the
MT head will lead to the formation of plantar callus .
•There may be translucent core but no blood vessels .

CORN :
•It is a hyperkeratic lesion appears over bony prominences & is
sharply demarcated .
• Small blood vessels lies parallel to the surface .
•Corn can be very tender & painful .
PLANTAR WART :
•It is a deep rooted growth giving needle sticking type of
sensation .
•Warts are seem to grow between & under MT heads .
•Blood vessels are visible & distinct margin appear after
paring .

ATHRITIES :
It is a painful condition where bones get deformed , may get
bend or have extra bony growth as in rheumatoid arthritis .
ARTHRODESIS :
In this bone shape specially tarsal's is altered & fused by
surgeon to correct the deformity .
MORTON’S TOE :
It is an acute anterior metatarsalgia or severe neuralgia
involving 3rd
& 4th
toes arising from a neuroma .
OSTEOCHONDRITIES :
Most commonly due to trauma of 2nd
MT head known as
Freiberg’s disease or infraction of 2nd
metatarsal head .

FOOT & LEG LENGTH DISCREPANCY :
Generally due to polio or developmental anomaly .
There may be generalized shortening or absence of bones
causing shortening .
Shortening may take place due to trauma ,cold injury or due
to leprosy .
Internal heel elevation or external heel elevation can be
given to compensate height .

ROCKER SOLE :
•Basic function of rocker sole is to rock the foot from heel
strike to toe off without requiring the shoe to bend .
• It is used to enhance & ease forward propulsion .
• It can also be used to offload areas of high plantar pressure
& replace or restore lost of motion due to injury or deformity .
SIX BASIC TYPES OF ROCKER SOLES ARE :
A . MILD ROCKER SOLE :
•Basic & commonly use in all footwear .
•It effectively reduces pressure under MT head .
•Assist gait by easing & increasing forward propulsion .

B . HEEL TO TOE ROCKER SOLE :
•It is thicker than mild sole .
•It has more severe rocker angle at heel & toe .
•It is basically used for patients with ankle arthrodesis &
triple arthrodesis using AFO
C . TOE –ONLY ROCKER SOLE :
•It has severe rocker angle at toe & very mild angle at heel
•It is used to increase weight bearing proximal to MT head .
•It provides stable midstance & reduces the toe dorsiflexion
on toe off .

D . SEVERE ANGLE ROCKER SOLE :
•It has severe angle at toe but not on heel .
•It eliminate weight bearing forces on the forefoot .
E . NEGATIVE HEEL ROCKER SOLE :
•This has mild heel rocker & significant toe rocker angle .
•Heel is placed at lower height than ball of the foot .
•This helps in reducing the body weight from toe area .
F . DOUBLE ROCKER SOLE :
•It is same as mild rocker sole but middle section of sole is
removed giving appearance of two rocker sole .
•one at the forefoot & another at the hind foot .

INTERMEDIATED OR SEMIRIGID FOOT ORTHOSIS :
•Depending on the material used for fabrication of shoe
modification they gives semi rigid or rigid support .
• Either plastic or thicker soft material can be used to make
insoles with various modifications which can be inserted
inside the marketed footwear .
• Depending on the thickness of the material effectiveness of
modifications will change .
• H.D.P.E. sheet of 2mm or 3 mm can be used to make insoles
with various modifications .

Supra Malleolar Orthosis (SMO ) :
•Low profile design that crosses the ankle .
•Less invasive trim lines than a standard AFO .

UCBL INSERTS :
• This is a rigid plastic molded foot orthosis .
• It encompasses the heel & extends forward terminating just
posterior to the MT heads .
• Posterior wall of the insert covers the heel & medio-laterally
it covers the foot just below the malleoli .
• Possible to wear inside the marketed footwear .
• It is effective in severe flat foot to support longitudinal arch
• mainly given in C.P. cases to support navicular bone .
• Can be made up of H.D.P.E. or P.P.

UCBL support with sustentaculum tali pad :
FUNCTION :
1 . To position entire foot in neutral position .
2 . Control motion of subtalar joint .
3 . Affects rotational forces applied to the entire leg during
Stance phase .
Two three point force systems
First affects the transverse
Plane in stance phase & limit
Forefoot adduction :
1 . Medially directed force on
The shaft of 5th
MT .
2 . Laterally directed force on
Navicular bone .
3 . Medially directed force on
the lateral side of calcaneus.

Second force system affects the coronal plane & control
calcaneovalgus , midfoot collapsing & pronation .
1 . Medially directed force at the lateral base of calcaneus .
2 . Laterally directed force on navicular .
3 . Laterally directed force by body’s center of gravity .

ANKLE FOOT ORTHOSIS :
• When orthosis extends above ankle joint but below knee
joint then it is called as AFO .
• AFO can be designed with sufficient mechanical lever arm to
effectively control ankle complex & to influence knee joint
indirectly .
• AFO can also be used for foot problems where only foot
orthosis are not effective .
Basic function of AFO is
1 . To provide mediolateral stability at ankle joint during
stance phase &
2 . Toe pick up during swing phase .
In short to give gait closer to normal gait with less energy
consumption .

• Angular motion of the joint is corrected by applying linear
forces by orthosis .
• Orthosis must apply a system of forces to balance each
other creating state of equilibrium .
• Minimum three forces are required to control angular
motion so it is called as Three Point Force System .
• A force acting at a distance from a joint center creates a
turning effect known as a MOMENT calculated by
• M (moment ) = F (force ) x D ( distance )
• D = lever arm i.e. perpendicular distance from the joint
center to the line of action of forces .
• Hence orthosis that applies oblique forces are less effective
in generating moment than one which applies
perpendicular forces because lever arm is small .
• Increasing lever arm is very essential for great effect .
• But lever arm is limited by length of anatomical segment .

THREE POINT FORCE SYSTEM :
1.It reduces unwanted angular rotation .
2.Helps to stabilize joint , bone or skeletal segment .
F 1
F 2
F 3
D

• In case of AFO forces are not parallel to each other .
• They act in a same plane to form equilibrium .
• This mechanical principle is known as Triangle of Forces .
• Oblique axis of subtalar joint links axial rotation of leg &
hind foot .
• During walking foot is converted from flexible shock
absorber to a rigid lever .
• When this mechanism of foot is fail to function properly
relationship of the foot to the ground is altered .
• This increases stress on one or more joint of the foot ,
ankle , knee or pelvis .
• AFO can be designed with sufficient mechanical lever arm
to effectively control ankle complex & to influence knee
joint indirectly .

Orthosis may modify systems of moments & external
forces acting about a joint in four different ways :
1 . Restricting the rotation .
2 . Reducing shear forces .
3 . Reducing axial displacement .
4 . Controlling line of action of ground reaction force .
Axis of rotation

Heel Lever
Toe LeverCenter of Gravity
(Body Weight)
CG
Axis of
rotation
CG
LEVER SYSTEM & ROTATION :
Momentum is generated by push off of contralateral limb .
Forward motion is generated by rotation of the lever system .

Indications of AFO :
1 . Substitute for weak or absent dorsiflexors or planter flexors .
2 . Stabilize foot & ankle in coronal & sagittal plane .
3 . Provide some knee stability in sagittal plane .

AFO are differentiated depending on the component :
1 . Molded supramalleolar orthosis
2 . Single upright orthosis with shoes
3 . Double upright orthosis with shoes
4 . Plastic rigid AFO
5 . Plastic articulated AFO
6 . Molded spiral orthosis
7 . Plastic AP shell orthosis
8 . PTB AP shell orthosis
9 . CROW orthosis
Orthosis with shoe are called as Conventional Orthosis .

METAL AFO WITH SHOES :
Indications :
1 . Wide fluctuation of edema
2 . High risk foot i.e. Foot having absent
or diminished sensation , visual impairment
Uprights :
Aluminum : for light weight
Stainless steel : for durability
Main components of conventional
orthosis are :
1 . Stirrup
2 . Spur
3 . Ankle joints
4 . Uprights

STIRRUP :
It is riveted directly to the anterior section of the heel of the
shoe & it is the permanent attachment
between the upright of ankle joint & shoe .
Stirrups are of two types
Solid Stirrup – stability is more but cannot change the shoe .
Split Stirrup – shoe change
1 . ROUND STIRRUPS :
•It is a split type of stirrup .
•It has one hollow pipe in which spur pins goes .
•Ankle movement can be given by modifying stopper of the
stirrup .
•Main disadvantage is here movement takes place at heel .
•Axis of orthotic ankle joint & anatomical ankle joint does not
coincide causing undue stress between the brace & leg

1 . U – Stirrup
2 . Rectangular Stirrup
3 . Round Stirrup

2 . U – SHAPED STIRRUP :
•It is a solid type of stirrup & is in U shape in one piece .
•It start from one side of shoe , goes under the heel & comes
to the other side of the shoe coinciding with both ankle joint
level .
•Here ankle joint movements are coinciding with anatomical
ankle joint but shoes cannot be change .
3 . RECTANGULAR STIRRUP :
• It is a split type of stirrup which does not allow movement at
the heel .
•It coincide with the anatomical ankle joint hence gait is near
to normal gait .
•Additional strap connecting two upright may required .

Footplate Type Stirrup
4 . FOOTPLATE TYPE ATTACHMENT :
In this ankle joints are attached to the footplate so that any
marketed footwear can be used on it .

ANKLE JOINT :
• Medial malleolus is 15mm anterior to lateral malleolus due
to tibial torsion.
• Ankle DF & PF takes place through the axis passing 1.5cm
anterior to the tip of medial malleolus & bisection of lateral
malleolus .
• Normally ankle joint axis is placed at the tip of medial
malleolus .
• Ankle joint motion can be control as per the patients need
1 . FREE MOTION ANKLE JOINT :
It provides free movement of
Dorsiflexion & planter flexion &
generally given for mediolateral
Stability of ankle .

2 . Ankle Joints with Dorsi-flexion Assist :
It allows only dorsiflexion & stop at 90 degree .
Hence does not allow planter flexion .
Given in case of weak dorsi flexors .
3 . Ankle Joint with Planter – flexion Assist :
It is done in the same manner as above but
in opposite direction .
It allows only planter flexion & given in case
of weak planter flexors .
4 . Double Action or Limited Action Ankle Joint :
It is modified in such a way that it provide
limited range of planter flexion as well as
dorsiflexion .
Given for the patients having weakness of
Planter flexion & dorsiflexion muscles .

5 . Spring Loaded Dorsiflexion Assist :

FITTING CRITERIA FOR METAL AFO :
Height : top of the calf band should be 1 1/8th
inch below the
Head of fibula to avoid pressure on peroneal nerve .
Width :
Calf band should have sufficient width to
control tibia in frontal plane without
causing any discomfort to the calf muscle
Uprights :
They should follow medio – lateral contour
of the body & should have 1/4th
inch
clearance from skin .
Ankle Joints :
They should coincide with anatomical
ankle joint & should have 1/4th
inch
clearance from medial & lateral malleolus

Auxillary Controls :
Varus/Valgus Control Strap
Controls varus or valgus of
rear foot during weight-
bearing .
For valgus control T – strap is
given on the medial side of the
brace , in between the ankle
joint & shoe .
It is called as inside T-strap .
For varus control it is given on
lateral side of the brace .
It is called as outside T- strap .

Laminated footplate can be added to
The metal AFO instead of shoe so that
Patient can use any marketed footwear .

Plastic pretibial shell can be added to
the metal AFO when it is required to
relieve the weight from distal part i.e.
foot .
In this body weight is partly transfer
on the patella tendon & hence it is
called as Partial Weight Relieving
Orthosis .
Given in case of nonunited fractures ,
patients having Charcot type of joints ,
having ulcers on the foot etc.

Check out of Metal AFO with Shoe :
1 . Shoe should be properly fitted & lies flat on the ground .
2 . If the orthosis is articulated then orthotic ankle joint axis
should be aligned with the anatomical ankle joints .
3 . Plantar and/or dorsiflexion stops should be adjusted
equally within medial and lateral ankle joints.
4 . Uprights should be situated along mid-line on M&L sides
of lower leg .
5 . Calf band should be deep enough to allow complete
flexion of the knee .
6 . If patient supplies own shoes insure that they fit well
before attaching orthosis .
7 . Check skin integrity (esp. at calf band, ankle joints and
shoe) after 1/2 hr. of use.
8 . If there are no problems resume use, checking every 4
hours for the first few days .

VAPC Shoe Clasp : (Veteran’s Administrative Prosthetic Clinic )
•It consist of a shoe & single upright which is attached to the
center of heel on posterior side & calf band is attached to it
•Sliding attachment of calf band over the posterior upright is
made .
•Posterior bar is made up of fiberglass .
•Shoe clasp is made up of stainless steel .
•It is a light duty , light weight , inexpensive device which
allows interchangeability of shoe with same heel height .
•Center of rotation of ankle & orthosis is different .
•It only provides dorsiflexion assistance during swing phase
•It does not provide any mediolateral stability .
•Undue stresses can lead to collapse of orthosis into maximum
dorsiflexion .
•Not efficient to provide knee stability .

SPIRAL ORTHOSIS :
It is designed to absorb & use the torques that are in normal
walking .
It has limited stability at the ankle & subtalar joint .
Carbon fiber provides dorsiflexion assist & allows limited
planter flexion .

PLASTIC MOULDED AFO :
Advantage of plastic AFO over metal AFO are :
1 . Total contact hence comfort level is high .
2 . Patient can use any marketed footwear .
3 . Comparatively light in weight .
4 . Cosmetically good .
This can be made in two types :
Solid AFO :
It is one-piece with no separate components .
Does not allow any movement at the ankle level .
Rigidity determined by thickness and trimlines of orthosis.
Articulated AFO :
They are made up of two parts which are joined together by
incorporating ankle joints to allow controlled ROM .
As ankle movements are not restricted gives more natural
gait pattern .

SOLID AFO REINFORCEMENT ARTICULATED AFO

SOLID OR RIGID PLASTIC AFO :
Thickness :
Typically between 3 mm to 5 mm
Depending on the age & physical
build of the patient .
Angle :
Generally it is made in 90 degree
But angle can be change to enhance
knee function .
Increase dorsiflexion allows knee
flexion .
Increase plantar flexion allows knee
extension .

Functions :
1 . Limits foot drop .
2 . Control inversion or eversion of foot .
3 . Control dorsiflexion of ankle in stance phase .

C . Varus or inversion control force system .
D . Valgus or eversion control force system .
E . Dorsiflexion control force system .

POSTERIOR LEAF SPRING AFO :
•It is same as solid AFO only difference
is a trim line .
•In this after calf level trim line goes
much posterior & does not cover ankle
in the orthosis .
•It is good in giving toe pick up effect
but does not provide M - L control .
•Can be easily fitted in normal
footwear .
•It limits the foot drop in swing phase
of gait preventing toe drag .

One three point force system is present :
1.Superiorly directed force on the sole of the foot .
2.Posteriorly directed force on the dorsum of the foot .
3.Anteriorly directed force on the back of the calf .

CUSTOM MOLDED BIVALVED A-P SHELL ORTHOSIS :
Functions :
1.Provides total contact support of the foot & ankle joint which
can stabilize fracture part .
2.Immobilize the joint & aid in wound healing through
compression .
3.Distribute pressure equally over entire surface of the foot ,
ankle , lower leg thus avoiding concentrated areas of pressure

Pre-tibial shell :
Enhances knee extension
PTB modifications can
reduce weight bearing
from distal part .

FRO ( FLOOR REACTION ORTHOSIS ) :
Principle :
•Control tendency of knee flexion by shifting weight line
anterior to knee joint .
•Encourage knee extension by locking ankle in PF .
Indication : 1 . Poor quadriceps
2 . Knee instability
Design :
Consist of PSI having
ankle in 3-5 degree
of planter flexion &
anterior shell or
pretibial shell which
Covers patella .

Disadvantages :
1 . Heel to toe gait not possible .
2 . Hip extensor power should be good .
3 . Can not be use in case of contracture .
Modification :
Design can be
modify by
incorporating
footplate joined
by upright &
Pretibial shell

PLASTIC AFO WITH ANKLE JOINTS :
Depending on the type of ankle joint used it provides either
Dorsiflexion or Planter flexion or Limited Range of Motion at
ankle joint .

DF Assist Neutral
Tamarack
OKLAHOMA
JOINT

FRIDDEL VARIABLE
MOTION ANKLE JOINT CAMBER ANGLE VARIABLE
MOTION ANKLE JOINT

FLEXIBLE AFO :
May be patella tendon bearing (PTB)
Specific weight bearing or total surface bearing (TSB )
(inverted cone with lace closure)
Unweight the ankle foot using prosthetic principles .

IMMOBILIZER AFO ( FRACTURE BRACE ) :
Commonly used with a lower extremity deficiency when
ankle immobilization is desired .
Mainly given in case of distal tibia or fibula fracture or foot
bone fractures .
Tendocalcaneus rupture or any ligament rupture .
Diabetic Foot (Charcot Foot)

FRACTURE BRACING :
Main objectives of fracture bracing are :
•Support the site of lesion
•Relieve the weight from site of lesion
•Maintain normal alignment of fractured part
•Maintain surgical correction
•Prevent further malalignment
Immobilization was consider as a basis to increase the rate of
calcification .
But too much of immobilization obstruct the blood supply &
may result into TAO ( Thrombo Angitis Obliterance )
Another problem is that due to constant nerve pressure some
neurological problems may occur .
Hence there was a need to mobilize the part to certain extent
with proper protection of the part .
For this purpose concept of functional bracing has come up .

Functional bracing encourages union & prevents joint stiffness
by continuous use of affected limb while the fracture is kept
adequately supported by modified braces .
Closed Compartment Theory :
When part of fracture is closely protected from all sides &
supported with a snug fit appliance to resemble the natural
contours of the body to maintain the natural alignment of the
body then early ambulation is possible .
Principles of Fabrication of Fracture Orthosis :
•Fracture site should not come in weight bearing line .
•Weight should be transfer proximal to the site of lesion .
•Ground reaction should be eliminated by keeping foot hanging
& not touching the ground .
•Orthosis should provide snug fit & proper support .
•Donning & doffing should be easy .
•Light weight orthosis is preferred .

TIBIAL FRACTURE BRACING :
•It is the first long bone treated by orthotic device .
•Initially it is treated by below knee PTB casting .
•Same principle is used in orthosis .
•Soft tissues of the extremity are responsible for maintenance
of alignment of the bone .
•Viscoelastic nature of soft tissue exerts lateral & oblique
forces that offset the vertical load in ambulation .
•Early ambulation with orthosis helps in early union & also
reduces the complications due to non ambulation .
•Ankle joint with plastic foot insert can be incorporated which
prevents orthosis from sliding down & also avoid rotation of
orthosis .
•Tibial fracture brace are available in various sizes or it can be
custom made for individual patient .

Functions :
1.Stabilize the fracture of tibia or fibula while allowing ambulation.
2.Articulation of ankle & knee joint minimize the loss of ROM .
3.Minimize the muscle atrophy following healing of the fracture .
4.Compression of soft tissues creates hydrostatic pressure which
provides stabilization of fracture .

CROW ( Charcot Restraint Orthotic Walker ) :
• In Charcot joint there is disassociation & destruction of
joint surfaces .
• This is the beginning of a painless & degenerative collapse
of the foot structure .
• Foot is swollen , red , hot , has increased & abnormal
blood supply .
• In the acute stage bone & joints begin to break down due
to increased osteoelastic activity that absorbs bone .
• Many times minor fracture or soft tissue injury may
happen .
• Reconstruction phase is an attempt to restore joint
architecture by immobilizing the lower limb .

• Initially plaster casting is used for immobilization .
• Then total contact AFO are designed but as it has to be
fitted inside the footwear which makes donning complicated
• Advance technique is CROW .
• CROW is a custom made total contact AP shell AFO .
• It is a shoe less design with rocker bottom .
• It helps to distribute the weight bearing forces over the
entire lower limb & minimize the peak pressure on the
planter surface .
• It locks the ankle & reduces forces acting on the ankle joint
• Removable insoles can be added to accommodate changes
in pressure area .

CHECKOUT OF BELOW KNEE ORTHOSIS :
Checkout procedure provides for the systematic evaluation of
the orthosis .
Main purpose of checkout is to ascertain that orthosis is
satisfactory & to attend any modifications or adjustment that
may be required .
It consist of series of questions designed regarding fit ,
comfort function , appearance & durability of the orthosis .
It also provides convenient means of recording results of
evaluation .
Orthosis should be checked in all position in which patient
going to use it i.e. Standing , sitting & walking .
Once all above checking is done then orthosis is removed &
body part is checked to rule out any excessive pressure .

1 . Is the orthosis & shoes as per the prescription ?
2 . Can patient don the orthosis without any difficulty ?
CHECK WITH THE PATIENT STANDING :
SHOE :
3 . Is the shoe fitting satisfactory & comfortable ?
Shoe should be long enough & wide to permit natural movement of
toes at the same time should not allow shifting of foot inside .
4 . Are the sole & heel of the shoe flat on the floor ?
So that body weight should be distributed on complete foot .
ANKLE :
5 . Are the mechanical ankle joint are coinciding with anatomical
ankle joints i.e. Tip of medial malleolus .
6 . Does the movement of both ankle joint is same ?
7 . Is there sufficient clearance between joint surface & body ?
8 . If varus – valgus correction strap is given then does it provide
sufficient force to correct deformity without causing any discomfort
9 . Is there minimal friction between shoe insert & shoe ?

10 . Does the foot is properly placed inside the shoe insert
11 . If patient is providing marketed footwear then does it have
proper rocker action ?
12 . Does proper 5 to 7degree of toe out is provided .
UPRIGHTS :
13 . Does the uprights conform to the body contour ?
14 . Are the uprights placed along the midline of body ?
15 . Is there adequate clearance between uprights & body surface ?
16 . In case of children's is there adequate provision for lengthening
BANDS / SHELLS :
17 . Is the calf band is placed 1” below the head of fibula to avoid
pressure on peroneal nerve .
18 . Is the band is wide so that there will not be any localized
pressure on the leg .
19 . Does the band conform to the contour of the leg ?
20 . If pretibial shell is given is it able to take weight on patella
tendon & reducing weight from heel ?

STABILITY :
21 . Is the patient is stable in standing ?
Malalingment of orthosis causes instability .
CHECK WITH PATIENT WALKING :
22 . Is there adequate clearance between malleoli & mechanical
ankle joints in weight bearing ?
23 . Does varus – valgus strap or shoe insert provides desired support
24 . Is there any gait deviation that require attention ?
25 . Does patient walking is improved with orthosis ?
CHECK WITH PATIENT SITTING :
26 . Can patient sit comfortably with knee flexion approx. 105 degree
27 . Does there any pressure on calf muscle in sitting ?
CHECK WITH ORTHOSIS OFF THE PATIENT :
28 . Does there any irritation on skin after removal of orthosis ?
29 . Does there any pressure points because of orthosis ?
30 . Does general workmanship of the orthosis satisfactory ?
31 . Does patient consider orthosis satisfactory as to weight , comfort
function & appearance .

FYBPO - Orthotics - AIIPMR Lectures.

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