Lower limb orthosis contains foot, ankle , knee ,hip orthosis

Lower limb orthosis contains foot, ankle , knee ,hip orthosis

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  Lower limb orthotics MRJALIL SK Prosthetist &Orthotist
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  Orthotic Basics  Derivedfrom 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.
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  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
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  Orthotic Consideration  Cost Energy efficiency  Cosmesis  Temporary versus permanent  Dynamic versus static  Encourage normal Movement
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  Orthotic Intervention  Ensurecontinued proper fit  Donning/doffing orthosis  Implement progressive wearing schedule  Patient/caregiver teaching:  Skin Inspection  Care of orthosis  Mobility training with orthosis
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  Orthotic Goals  Maximizefunctional 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
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  Alignment  Correct alignmentpermits effective function  a. minimizes movement between limb and orthoses (pistoning)  b. minimizes compression on pressure sensitive tissues
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  Foot Orthoses (FO)
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  Common pathological condition offoot  Flat feet / Pes planus  Calcaneal spur  Planter fascitis  Metatarsalgia  Forefoot adduction  Foot pain  Ulcer  Charcot foot
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  FO  A semi-rigidor 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.  May be attached to the interior of the shoe (an inserted pad) or exterior to the shoe.  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.
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  Metatarsal pad:  Metatarsalpad: located posterior to the metatarsal heads; takes pressure off the metatarsal heads and onto the metatarsal shafts.  Indication: metatarsalgia
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  TOE-SPREADER TOE-SPREADER WITH HALLUX CORRECTION correct alignmentand increase foot strength.
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  Bunion orthosis  Usesto correct hallux valgus deformity  Common in RA
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  Cushion heel • Cushionsand absorbs forces at heel contact; used to relieve strain on plantar fascia. • Indication :plantar fasciitis.
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  Heel-Spur pad  Heelspur pad used to relieve weight for tip of calcaneum.  A heel spur, also known as a calcaneal spur or bone spur, is a bony growth that can develop on the bottom of the calcaneum bone.  Indication: painfull heel
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  Longitudinal Arch Supports Prevent depressionof the subtalar joint and correct for pes planus (flat foot)
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  Pes planus  Pesplanus is a common condition in which the medial longitudinal arches have been lost.  It is formed by the calcaneus, talus, navicular, three cuneiforms and first three metatarsal bones.  Arches do not develop until about 2-3 years of age, meaning flat feet during infancy is normal.  This shape allows them to act in the same way as a spring, bearing the weight of the body and absorbing the shock produced during locomotion.
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  UCBL  UCBL (universityof California biomechanics laboratory) insert: a semi rigid plastic molded insert to correct for flexible pes planus.  Indication : Subtalar joint instability & Pes planus  UCBL foot orthosis are used to support, distribute pressure and help maintain proper alignment of the foot, especially the heel and arch.
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  Scaphoid Pad:  usedto support the medium longitudinal arch.  A scaphoid pad is a Myolite padding added to the medial side of the superior frame and runs along its medial longitudinal arch.
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  Thomas heel:  awedge with an extended anterior medial border used to support the longitudinal arch and correct for flexible pes valgus (pronated foot).
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  Calcaneus valgus  Calcaneusvalgus, also known as calcaneovalgus foot, is a postural deformity of the foot in which the heel is turned outward.
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  Medial wedge  Rearfootposting 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
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  Lateral wedge  ValgusPost (lateral wedge): controls calcaneus and subtalar joint that are excessively inverted and supinated at heelstrike.
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  Forefoot Posting  Forefootposting: suports the forefoot  Medial wedge prescribed for forefoot varus  Lateral wedge prescribed for forefoot valgus  Contraindicated for insensitive foot
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  Heel raise/ HeelLifts
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  Heel Raise  Accommodatesfor 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
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  Rocker bar &rocker bottom
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  Rocker bar  Rockerbar: located proximal to metatarsal heads; improves weight shift onto metatarsals
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  Rocker bottom  Rocketbottom: builds up the sole over the metatarsal heads and improves push off in weak or inflexible feet. May also be used with insensitive feet.
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  Supramalleolar orthosis
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  SMO  It supportsthe foot up to just above the ankle bone, otherwise known as the malleolus.  SMOs are typically prescribed to children who have foot and ankle instability which cannot be controlled by insoles or footwear.  The SMO allows dorsiflexion and plantarflexion whilst stopping mediolateral (side to side) movements.  It is designed to maintain a neutral heel alignment, whilst supporting the arch of the foot. The SMO is proven to help ambulation by helping to improve standing and walking balance.
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  SMO indication: Ankle instability
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  Ankle-foot orthosis (AFO)
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  ANKLE-FOOT ORTHOSES  Usedto control the lower extremity during each phase of the gait cycle for individuals with neuromuscular or musculoskeletal impairments.  Categories 1. Static 2. Dynamic
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  AFO Conventional Molded
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  AFO COMPONENTS  Foundation- Consistsof shoe and plastic/ metal component  Ankle control  Foot control  Superstructure
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  PARTS OF conventionalANKLE- FOOT ORTHOSIS  Consist of a shoe attachment, ankle control, uprights and a proximal leg band
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  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
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  Uprights and attachments ConventionalAFOs 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.
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  Uprights and attachments (bandsor shells)
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  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.
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  Varus or valguscorrection straps (T Straps)
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  T Straps Control forvarus 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
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  TYPES OF MOULDEDAFO  Static AFO  Dynamic AFO  Supramalleolar Orthosis  Tone reducing Orthosis  Floor reaction Orthosis  Posterior leaf spring Orthosis
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  STATIC ANKLE FOOTORTHOSIS
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  Biomechanics of AFO
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  SAFO ACTIONS  Controlankle position throughout stance  Provide stance phase Stability via ankle-knee coupling  Assist limb clearance in swing  Pre-position foot for IC by heel  Distal trim line behind metatarsal heads or extended toe-plate INDICATIONS Significant hypertonicity with seriously impaired motor control at ankle and knee. CONTRA- INDICATIONS LMN paralysis ( flaccidity) Hypotonicity as primary problem
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  Dynamic AFO
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  DAFO ACTIONS  Stabilize sub-talarand tarsal joints in stance INDICATIONS •FLEXIBLE PES PLANUS •MILD TO MODERATE SPASTIC DIPLEGIC •HEMIPLEGIC CP •HYPOTONIC CP CONTRAINDICATIONS •RIGID FOOT DEFROMITY
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  Ankle Controls  Freemotion: 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
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  Ankle Controls Free MotionLimited Motion
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  Limited Motion AnkleControl  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
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  Limited Motion AnkleControl BiCAAL
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  Dorsiflexion assistance
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  Spring Assist Spring Assist Spring assist: double upright metal AFO with a single anterior channel for a spring assist to aid dorsiflexion
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  Posterior Leaf Spring 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.  a plastic AFO that inserts into the shoe; widely used to prevent foot drop.
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  Specialized AFOs
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  Floor reaction orthosis An orthosis that has evolved from the basic SAFO design to better address impaired motor control of the knee and weakness of the quadriceps is the anterior floor reaction orthosis (FRO)  The FRO is fabricated to hold the ankle in a few degrees of plantarflexion. This restricts the ability of the tibia to roll forward over the foot in the second/ankle rocker of gait, creating an extensor moment that stabilizes the knee during stance.
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  Biomechanics of FRO
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   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
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  Patellar-tendon-bearing AFO  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
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  Tone-reducing orthosis  Tone-reducingorthosis: 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
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  Knee-ankle-foot orthosis (KAFO)
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  KAFO KNEE-ANKLE-FOOT ORTHOSIS PARTS  Shoe Foundation  Ankle control  Knee control  Superstructure
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  KAFO Knee, ankle, footorthosis, custom may include knee joints. Joints may be locking or adjustable in flexion and extension. Indications: Polio, MS, paresis, knee instability/buckling. Contraindications: Morbid obesity, dependent patient with poor cognition and upper extremity weakness combined with poor support system.
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  Knee Control  Hingejoint  Offset joint  Provide medial-lateral and hyperextension restriction while permitting knee flexion  Hinge placed posterior to midline of leg. Weight falls anterior to offset joints, stabilizing knee in extension during early stance phase.
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   Drop ringlock  Pawl lock with bail release  When client sands with full knee extension, the ring drops, preventing knee from bending.  Provides simultaneous locking of both uprights. The pawl is a spring- loaded projection that fits into a notched disk. The patient unlocks the brace by pulling upward on the posterior bail.
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  Types of OrthoticKnee Joints
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  Functions of 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
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   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 floor provides 100% unweighting of the limb; a life is required on the opposite leg.
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  Craig-Scot KAFO PARTS  Shoereinforced with transverse an longitudinal plates  BiCAAL ankle joints set in 10 degree dorsiflexion  Pretibial band  Pawl lock with bail release  Single thigh band
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  CRAIG SCOTT KAFO INDICATIONS Paraplegics  Thoracic spinal cord injury GAIT PATTERN  Swing-to or swing- through with aid of crutches or a walker ADVANTAGES  Medio-lateral foot stability provided by metatarsal bar  Enable a patient to stand with sufficient backward lean so as to prevent untoward hip or trunk flexion.  Functional  Easy to don and doff  Light weight as compared to standard KAFO
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  Knee-ankle-foot orthosis (KAFO)  Fracturebraces: a KAFO device with a calf or thigh shell that encompasses the fracture site and provides support.  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
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  KAFO Fracture Brace
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  Parapodium Standing Frame
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  Standing frame  Standingframe orthosis developed at Gillette Children's Hospital.  The tubular frame has hip and knee joints, allowing the child to transfer into the device and then raise into standing.  The fulcrum of the three-force system used to ensure hip extension is the broad posterior pelvic pad (at the center, without Velcro straps), with counterforces delivered by the anterior thoracic corset and the anterior knee pads.
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  Standing frame  Thesimplest in this group of orthoses are standing frames, Prone standers primarily support the anterior surface of the  Body and can be positioned against a counter or table work surface so that the child can use the upper extremities for functional activities  prescribed to allow children with significant mobility impairment to participate in activities typically done in standing position in school and home settings.  Also developed for adults with neuromuscular impairments such as SCI, severe stroke, traumatic brain injury, and other diseases that compromise motor control
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   Constraints ofStanding Frame  getting into and out of a standing frame may require considerable assistance;  the frame may not be easily mobile such that it should be pre-positioned before donning,  the frame may need adjustment or replacement as the child grows, and  the frame may require maintenance, mechanical hydraulic components, or replacement of worn straps and locking mechanisms.
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  Specialized Knee Orthoses (ko)
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  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.
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  Swedish knee cage: providesmild control for excessive hyperextension of the knee
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  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
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  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
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  Hip-knee-ankle-foot orthoses (hkafo) Contain ahip joint and pelvic band added to a KAFO
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  Hip-Knee-Ankle-Foot orthoses  Hipjoint: 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.
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  Specialized THKAFO Contains atrunk band added to a HKAFO
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  Reciprocating gait orthosis (RGO) Parts:  plastic molded solid ankle orthoses  locked knees,  plastic thigh shell,  a hip joint with pelvic and trunk bands;  the hips are connected by steel cables  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
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  RGO  Bilateral HKAFO PRINCIPLE-ipsilateral hip flexion leads to contra- lateral hip extension and vice versa. It consists of hip joints that transfer forces from one hip to other by Bowden cables INDICATIONS  Active hip flexion but no hip extension  Paraplegic L1 level DISADVANTAGES  High energy cost requirement  Slow speed
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  Specialized lower limb devices
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  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
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  Specialized lower limb devices DenisBrowne Splint Frejka Pillow
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  Selected orthotic gait deviations
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  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
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  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
• 97.
  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
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  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
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  Thank You foryour Attention!