3. Orthotics
• Derived from the greek worth ORTHO meaning straight,
upright or correct.
• It refers to a static or dynamic device and is preferable to
splint or brace which refers only to a static device.
• Three point pressure principle: forms the mechanical
basis for orthotic correction; a single force is placed at the
area of deformity or angulation; two additional counter
forces act in the opposing direction
4. Functions of Orthotics
• Prevent Deformity
• Assist function of a weak limb
• Maintain proper alignment of joints
• Inhibit tone
• Protect against injury of a weak joint
• Allow for maximal functional independence
• Facilitate Motion
5. Orthotic Consideration
• Cost
• Energy efficiency
• Cosmesis
• Temporary versus permanent
• Dynamic versus static
• Encourage normal Movement
6. Orthotic Intervention
• Ensure continued proper fit
• Donning/doffing orthosis
• Implement progressive wearing schedule
• Patient/caregiver teaching:
• Skin Inspection
• Care of orthosis
• Mobility training with orthosis
7. Orthotic Goals
• Maximize functional mobility skills with orthosis
• Maximize independence with donning/doffing
• Maximize independence with wearing schedule
• Maximize independence with skin inspection
• Maximize competence with care of orthosis
8. Alignment
• Correct alignment permits effective function
• a. minimizes movement between limb and orthoses (pistoning)
• b. minimizes compression on pressure sensitive tissues
10. SHOES
The foundation for an orthosis; shoes can reduce areas
of concentrated pressure on pressure sensitive feet.
11. Shoes
• A. Traditional leather orthopedic shoes or
athletic sneakers can be worn with orthoses;
attachments can be external or internal
• B. Blucher opening has vamps (flaps contain
the lace stays) that open wide apart from the
anterior margin of the shoe for ease of
application
• C. Bal (balmoral) opening: has stiched down
vamps not suitable for orthotic wear
13. FOOT ORTHOSES (FO)
A semirigid or rigid insert worn inside a shoe that corrects
foot alignment and improves function may also be used to
relieve pain. Foot orthotics are custom molded and are often
designed for a specific level of functioning
14. Foot Orthoses (FO)
• May be attached to the interior of the shoe (an inserted
pad) or exterior to the shoe (thomas heel)
• Soft inserts (viscoelastic plastic or rubber pads or relief
cut-outs) reduce areas of high loading, restrict forces, and
protect painful or sensitive areas of the feet.
• Metatarsal pad: located posterior to the metatarsal heads;
takes pressure off the metatarsal heads and onto the
metatarsal shafts; allows more push off in weak or
inflexible feet
• Cushion heel: cushions and absorbs forces at heel
contact; used to relieve strain on plantar fascia in plantar
fasciitis
• Heel-Spur pad.
15. Cushion Heel
Foot Orthoses
Metatarsal Pad: Neuroma Pad
Heel Spur Pad
placed between the metatarsal
shafts to relieve nerve pain ans is
most commonly placed between
the 3rd and 4th met shafts
commonly this is also used with a
wider shoe to achieve relief
17. Longitudinal Arch Supports
• UCBL (university of California biomechanics
laboratory) insert: a semi rigid plastic molded
insert to correct for flexible pes planus
• Scaphoid Pad: used to support the longitudinal
arch
• Thomas heel: a wedge with an extended
anterior medial border used to support the
longitudinal arch and correct for flexible pes
valgus (pronated foot)
19. Posting
• Rearfoot posting alters the position of the subtalar joint or
rearfoot from heel strike to foot flat. Must be dynamic,
control but not eliminate STJ function.
• Varus Post (medial wedge): limits or controls eversion of the
calcaneus and internal rotation of the tibia after heelstrike. Reduces
calcaneal eversion during running
• Valgus Post (lateral wedge): controls calcaneus and subtalar joint
that are excessively inverted and supinated at heelstrike.
20. Posting
• Forefoot posting: suports the forefoot
• Medial wedge prescribed for forefoot varus
• Lateral wedge prescribed for forefoot valgus
• Contraindicated for insensitive foot
22. Heel Lifts
• Accommodates for leg length discrepancy; can be placed
inside the shoe (up to 3/8 inch) or attached to the outer
sole.
• Accommodates for limitation in ankle joint dorsiflexion
24. Rocker bar & Rocker bottom
• Rocker bar: located proximal to metatarsal heads;
improves weight shift onto metatarsals
• Rocket bottom: builds up the sole over the metatarsal
heads and improves push off in weak or inflexible feet.
May also be used with insensitive feet
26. Shoe attachments & Stirrups
• Foot Plate: a molded plastic shoe insert; allows
application of the brace before insertion into the shoe,
ease of changing shoes of same heel height.
• Stirrup: a metal attachment riveted to the sole of the shoe;
split stirrups allow for shoe interchange solid stirrups are
fixed permanently to the shoe and provide maximum
stability
28. Ankle Controls
• Free motion: provides mediolateral stability that allows
free motion in dosiflexion and plantarflexion
• Solid ankle: allows no movement indicated with sever
pain or instability
• Limited motion: allows motion to be restricted in one or
both directions
31. Limited Motion Ankle Control
• Bichannel adjustable ankle lock (BiCAAL): an ankle joint with the
anterior and posterior channels that can be fit with pins to reduce
motion or springs to assist motion
• Anterior Stop (dorsiflexion stop): determines the limits of ankle
dorsiflexion. In an AFO, if the stop is set to allow slight
dorsiflexion (~5degrees), knee flexion results; can be used to
control for knee hyperextension; if the stop is set to allow too
much dorsiflexion, knee buckling could result
• Posterior stop (plantarflexion stop): determines the limits of ankle
plantar flexion. In an AFO if the stop is set to allow slight plantar
flexion (~5degrees), knee extension results; can be used to
control for an unstable knee that buckles; if the stop is set to
allow too much plantar flexion, recurvatum or knee
hyperextension could result
34. Spring Assist & Posterior Leaf Spring
• Spring assist (Klenzak housing): double upright metal
AFO with a single anterior channel for a spring assist to
aid dorsiflexion
• Posterior leaf spring (PLS): a plastic AFO that inserts into
the shoe; widely used to prevent foot drop.
37. T Straps
• Control for varus or valgus forces at the ankle.
• Medial strap buckles around the lateral upright and
correct for valgus
• Lateral strap buckles around the medial upright and
corrects for varus
39. Uprights and attachments
• Conventional AFOs have metal uprights
(aluminum, carbon graphite or steel) and a
hinged ankle joint allowing plantarflexion and
dorsiflexion. Provides maximum support if the
patients condition is changing (e.g. peripheral
edema), conventional metal AFOs may be easier
to alter to accommodate changes than molded
AFOs.
40. Uprights and attachments
• Double metal uprights extend upwards from the ankle on
both sides of the leg and attach to a calf band.
• Conventional AFO, calf band (metal with leather lining or
plastic); provides proximal stabilization on leg; anterior
opening and buckle or velcro closure.
41. Uprights and attachments
• Molded AFOs are made of molded plastic and are lighter
in weight and cosmetically more appealing;
contraindicated for individuals with changing leg volume.
• Posterior leaf spring (PLS): has a flexible narrow posterior shell;
functions as dorsiflexion assist; holds foot at 90degree angle during
swing; displaced during stance; provides no medial-lateral stability.
• Modified AFO: has a wider posterior shell with trimlines just
posterior to malleoli; foot plate includes more medial-lateral stability
(control of calcaneal and forefoot inversion and eversion)
• Solid AFO: has widest posterior shell with trimlines extending
forward to malleoli; controls (prevents) dorsiflexion, plantarflexion,
inversion and eversion.
• Spiral AFO: a molded plastic AFO that winds (spirals) around the
calf; provides limited control of motion in all planes
44. Specialized AFOs
• Patellar-tendon-bearing brim: allows for weight distribution
on the patellar shelf similar to patellar-tendon-bearing
prosthetic socket; reduces weight bearing forces through
the foot
• Tone-reducing orthosis: molded plastic AFO that applies
constant pressure on spastic or hypertonic muscles
(plantarflexors and invertors); snug fit is essential to
achieve the benefits of reciprocal inhibition
47. Knee-ankle-foot orthosis (KAFO)
• Knee Controls
• Hinge joint: provides mediolateral and hyperextension control while
allowing for flexion and extension.
• Offset: the hinge is placed posterior to the weight bearing line
(trochanter-knee-ankle TKA line); assists extension, stabilizes knee
during early stance patients may have difficulty on ramps where knee
may flex inadvertently
• Locks
• Drop ring lock: rings drops over joint when knee is in full extension
to provide maximum stability; a retention button may be added to
hold the ring lock up, permit gait training with the knee unlocked
• Pawl lock with bail release: the pawl is a spring loaded posterior
projection that allows the patient to unlock the knee by pulling up or
hooking the pawl on the back of a chair and pushing it up adds bulk
and may unlock inadvertently with posterior knee pressure
49. Knee-ankle-foot orthosis (KAFO)
• Knee stability
• Sagittal stability achieved by bands or straps used to provide a
posteriorly directed force.
• Anterior band or strap (knee cap): attaches by four buckles to metal
uprights; may restrict sitting, increases difficulty in putting on KAFO
• Anterior bands: pretibial or suprapatellar or both
• Frontal plane controls: for control of genu varum or valgum
• Posterior plastic shell
• Older braces utilize valgum (medial) or varum (lateral) correction straps
which buckle around the opposite metal upright; less effective as
controls than plastic shell
50. Knee-ankle-foot orthosis (KAFO)
• Thigh bands
• Proximal thigh band
• Quadrilateral or ischeal weight bearing brim: reduces weight
bearing through the limb
• Pattern bottom: a distal attachment added to keep the foot off the floorl
provides 100% unweighting of the limb; a life is required on the opposite
leg.
• Specialized KAFOs
• Craig-Scott KAFO: commonly used appliance for individuals with
paraplegia; consists of shoe attachments with reinforced foot plates
BiCAAL ankle joints set in slight dorsiflexion, pretibial band, pawl
knee locks with bail release, and single thigh bands
• Oregon orthotic system: a combination of plastic and metal
components allows for triplanar control in three plans of
motion(sagittal, frontal, and transverse)
52. Knee-ankle-foot orthosis (KAFO)
• Fracture braces: a KAFO device with a calf or thigh shell that
encompasses the fracture site and provides support.
• Functional electrical stimulation (FES) orthosis: orthotic use and
functional ambulation is facilitated by the addition of electrical
stimulation to specific muscles; the pattern and sequence of muscle
activation by portable stimulators is controlled by an externally
worn miniaturized computer pack; requires full passive range of
motion good functional
• Standing frames
• Allows standing without crutch support may be stationary or
attached to a wheeled mobility base
• Parapodium
• allows for standing without crutch support; also allows for ease in
sitting with the addition of hip and knee joints that can be unlocked
can be used on children with myelodysplasia
56. Specialized Knee Orthoses (KO)
• Articulated KOs: control knee motion and provide added
stability.
• Post surgery KO protects repaired ligaments from overload
• Functional KO is worn long-term in lieu of surgery or during
selected activities
• Examples include: Lenox Hill, Pro-Am, Can-Am, Don Joy
• Swedish knee cage
• provides mild control for excessive hyperextension of the knee
• Patellar stabilizing braces
• Improve patellar tracking; maintain alignment
• Lateral buttress or strap positions patella medially
• A Central Patellar cutout may help positioning and minimizes
compression
59. Specialized Knee Orthoses (KO)
• Neoprene sleeves
• Nylon coated rubber material
• Provide compression, protection
and proprioceptive feedback
• Provide little stabilization unless
metal or plastic hinges are
added
• Retains body heat which may
increase local circulation
• A central cutout minimizes
patellar compression
• Can be used in other areas of
the body such as the elbow and
thigh etc
61. Hip-Knee-Ankle-Foot orthoses
• Hip joint: typically a metal
hinge joint
• Controls for abduction,
adduction and rotation
• Controls for hip flexion when
locked, typically with a drop
ring lock; a locked hip restricts
gait pattern to either a swing to
or swing through gait
• Pelvic attachments
• A leather covered, metal pelvic
band; attaches the HKAFO to
the pelvis between the greater
trochanter and iliac crest; adds
to difficulty in donning and
doffing; adds weight and
increases overall energy
expenditure during ambulation.
63. Specialized THKAFO
• Reciprocating gait orthosis
(RGO):
• utilizes plastic molded solid ankle
orthoses with locked knees,
plastic thigh shell, a hip joint with
pelvic and trunk bands; the hips
are connected by steel cables
which allow for a reciprocal gait
pattern (either 4point or 2point);
when the patient leans on the
supporting hip, it forces it into
extension while the opposite leg is
pushed into flexion allowing limb
advancement
65. Specialized lower limb devices
• Denis Browne splint: a bar that connects two shoes that
can swivel; used for correction of club foot or pes
equinovarus in young children
• Frejka pillow: keeps hips abducted used for hip dysplasia
or other conditions with tight adductors in young children
• Toronto hip abduction orthosis: abducts the hip; used in
treating LCPD
68. Spinal (trunk) orthoses:
Components/Terminology
• Corset
• Provides abdominal compression, increases intraabdominal
pressure; assists in respiration in individuals with SCI; relieves pain
in low back disorders; sacroiliac support
• Lumbosacral orthoses (LSO): control or limit lumbosacral
motions
• Lumbosacral flexion, extension, lateral control orthes (LS FEL)
(Knight Spinal): includes pelvic and thoracic bands to anchor the
orthosis with two posterior uprights, two lateral uprights and an
anterior corset
• Plastic lumbosacral jacket: provides maximum support by
spreading the forces over a larger areal more cosmetic but hotter
69. Spinal (trunk) orthoses:
Components/Terminology
• Thoracolumbosacral orthoses (TLSO): control or limit
thoracic and lumbosacral motions
• Thoracolumbosacral flexion, extension control orthoses (TLS FE)
(Taylor brace): includes components of a LS FEL with the addition
of axillary shoulder straps to limit upper trunk flexion
• Plastic thoracolumbosacral jacket: provides maximum support and
control of all motions; used in individuals recovering from SCI;
allows for early mobilization out of bed and functional training
• Jewett (TLSO): limits flexion but encourages hyperextension
(lordosis); used for compression fractures of the spine
72. Spinal (trunk) orthoses:
Components/Terminology
• Cervical orthoses (CO): control or limit cervical motion
• Soft Collar: provides minimal levels of control of cervical motions;
for cervical pain or whiplash
• Four-poster orthosis: has two plates (occipital and thoracic) with
two anterior and two posterior posts to stabilize the head; used for
moderate levels of control in individuals with cervical fracture/SCI
• Halo orthosis: attaches to the skull by screws, four uprights connect
from the halo to a thoracic band or plastic jacket; provides maximal
control for individuals with cervical fracture or SCI; allows for early
mobilization out of bed and functional training
• Minerva orthosis: a rigid plastic appliance that provides maximum
control of cervical motions; uses a forehead band without screws
76. Specialized trunk orthoses
• Milwaukee orthosis
• a cervical, thoracic, lumbosacral orthosis (CTLSO) used to control
scoliosis; it has a molded plastic pelvic jacket and one anterior and
two posterior uprights extended to a superior neck or chest ring;
pads and straps are used to apply pressure to the areas of
convexity of spinal curves; bulky, less cosmetic and may be used
for all kyphotic and scoliotic curves less than 40 degrees
• Boston orthosis (TLSO)
• A low profile molded plastic orthosis for scoliosis; more cosmetic,
can be worn under clothing; used for midthoracic or lower scoliosis
curves of less than 40degrees; also used to treat spondylolisthesis
and conditions of severe trunk weakness
79. Upper limb orthoses
• Passive (static) positioning devices: generally made out of
a variety of low temperature plastic; ie orthoplast, hexalite
• Resting splint (cock-up splint): an anterior or palmar splint that
positions the wris and hand in a functional position
• Dorsal splint: frees the palm for feeling and grasping by the use of
grips that curve around over the second and fifth metacarpal
heads; allows for the attachment of dorsal devices ie rubber bands
to make it a dynamic device
• Airplane splint: positions the patients arm out to the side at
90degrees of abduction the elbow is also flexed to the same
degrees; the weight of the outstretched arm is borne on a padded
lateral trunk bar and iliac crest band; a strap holds the device
across the trunk; used to immobilize the shoulder following fracture
of injury when trapping to the chest is not desirable or with burns
82. Upper limb orthoses
• Dynamic devices
• Wrist driven prehension orthosis (flexor hinge orthosis): assists the
patient in use of wrist extensors to approximate the thumb and
forefingers (grip) in the absence of active finger flexion; eg
facilitates tenodesis grasp in the patient with quadriplegia
• Motor driven flexor hinge orthosis: complex control systems that
allow for grasp not generally in widespread use
85. Physical Therapy Intervention
• Assessment
• Pre-orthotic assessment and prescription evaluate:
• Joint mobility
• Sensation
• Strenth and motor function
• Functional level
• Psychological status
• Orthotic prescription
• Consider the patients abilities and needs
• Level of impairments, functional limitations, disability
• Status: consider if the patient’s condition is permanent or changing
86. Physical Therapy Intervention
• Consider level of function, current lifestyle
• Consider if the patient is going to be a community ambulator versus a
household ambulator
• Consider recreational and work related needs
• Consider overall weight of orthotic devices, energy capabilities of
the patient. Some individuals abandon their orthoses quickly in
favor of wheelchairs because of the high energy demands of
ambulating with orthosis
• Consider manual dexterity, mental capacity of the individual. The
donning and use of devices may be too difficult or complicated for
some individuals
• Consider the pressure tolerance of the skin and tissues
• Consider use of a temporary orthosis to assess likelihood of
functional independence, reduce costs
87. Physical Therapy Intervention
• Orthotic Assessment check out
• Ensure proper fit and function; construction of the orthosis
• Static assessment
• Check alignments for lower limb orthosis:
• In midstance foot should be flat on the floor
• Orthotic hip joint: 0.8 cm anterior and superior to the greater trochanter
• Medial knee joint: ~2 cm above joint space, vertically midway between
medial joint space and adductor tubercle
• Ankle joint: at tip of malleolus
• Plastic shells or metal uprights, thigh and calf bands conform to
contours of the limb
• No undue tissue pressure or restriction of function
88. Physical Therapy Intervention
• Dynamic assessment
• Fit and function during activities of daily living, functional mobility skills
• Fit and function during gait
• Orthotic training
• Instruct the patient in procedures for orthotic maintenance: routing
skin inspection and care
• Ensure orthotic acceptance
• Patients should clearly understand the functions, limitations of an
orthosis
• Can use support groups to assist
• Teach proper application (donning-doffing) of the orthosis
• Teach proper use of the orthosis
• Balance, gait and functional activities training
• Reasses fitm function and construction of the orthosis at periodic
intervals; assess habitual use of the orthosis
90. Selected orthotic gait deviations
• Lateral trunk bending: patient leans toward the orthotic
side during stance. Possible causes: KAFO medial upright
too high; insufficient shoe lift; hip pain, weak or tight
abductors on the orthotic side; short leg; poor balance
• Circumduction during swing, leg swings out to the side in
an arc. Possible causes: locked knee; excessive plantar
flexion; weak flexors or dorsiflexors. All of these could
also cause vaulting
• Anterior trunk bending: patient leans forward during
stance. Possible causes: inadequate knee lock; weak
quadriceps; hip or knee flexion contracture
91. Selected orthotic gait deviations
• Posterior trunk bending: patient leans backward during
stance. Possible causes: inadequate hip lock; weak
gluteus maximus; knee ankylosis
• Hyperextended knee: excessive extension during stance.
Possible causes: inadequate plantar flexion stop;
inadequate knee lock; poor fit of calf band; weak
quadriceps; loose knee ligaments or extensor spasticity;
pes equinus
• Knee instability: excessive knee flexion during stance.
Possible causes: inadequate dorsiflexion stop,
indadequate knee lock, knee and/or hip flexion
contracture; weak quadriceps or insufficient knee lock;
knee pain
92. Selected orthotic gait deviations
• Foot Slap: foot hits the ground during early stance.
Possible causes: inadequate dorsiflexor assist;
inadequate plantarflexor stop; weak dorsiflexors
• Toes first: on toes posture during stance. Possible causes:
inadequate dorsiflexor assist; inadequate plantarflexor
stop; inadequate heel lift; heel pain, extensor spasticity;
pes equinus; short leg
• Flat foot: contact with entire foot. Possible causes:
inadequate longitudinal arch support: pes planus
• Pronation: excessive medial foot contact during stance,
valgus position of calcaneus. Possible causes: transverse
plan malalignment; weak invertors; pes valgus; spasticity;
genu valgum
93. Selected orthotic gait deviations
• Supination: excessive lateral foot contact during stance,
varus position of the calcaneus. Possible causes:
transverse plan malalignment; weak evertors; pes varus;
genu varum
• Excessive stance width: patient stands or walks with a
wide base of support. Possible causes: KAFO height of
medial upright too high; HKAFO hip joint aligned in
excessive abduction; knee is locked; abduction
contracture; poor balance; sound limb is too short
