Lower Limb Orthotics - Dr Rajendra Sharma

Lower Limb Orthotics - Dr Rajendra Sharma

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  GOVERNMENT OF INDIA MINISTRYOF HEALTH & FAMILY WELFARE
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  LOWER LIMB ORTHOTICS DR. RAJENDRASHARMA
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  An orthosis isdefined by the International Standards Organization as ‘‘an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system.’’ [International Organization for Standardization, ISO 8549-1:1989 Prosthetics and Orthotics - Vocabulary. General terms for external limb prostheses and orthoses. 1989, International Organization for Standardization: Geneva, Switzerland]
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  CLINICAL OBJECTIVES OF ORTHOTICTREATMENT • To relieve pain • To manage deformities • To prevent an Excessive ROM • To increase ROM • To compensate for abnormalities of segment length • To protect tissues • To promote healing • To provide other effects e.g. placebo, warmth.
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  According to ISO8549-3:1989 : • Foot Orthosis (FO) • Ankle-Foot Orthosis (AFO) • Knee Orthosis (KO) • Knee -Ankle-Foot Orthosis (KAFO) • Hip-Knee-Ankle-Foot Orthosis (HKAFO) • Hip Orthosis (HpO)
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  PRINCIPLE OF BRACING •Everyorthosis uses force applied to the limb to accomplish the goals of its design. An orthosis is most comfortable and effective when- 1. The forces are distributed over large surface areas to minimize pressure on skin and soft tissue. 2. The forces are applied in such a way that a large moment arm reduces the amount of force needed to control the joint. 3. The sum of the primary force and opposing counter forces of each control system equals zero.
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  Principles Underlying Control Systemsin Orthotic Design 1. Pressure = Force/Area 2. Torque = Force × distance 3. Control direction of primary force direction of counter-forces 4. Equilibrium Σforces = 0
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  Characteristics of an‘Ideal’ Orthosis FUNCTION • Meets the individuals mobility needs and goals. COMFORT • Can be worn for long periods without damaging skin or causing pain & can be easily donned and doffed COSMESIS • Meets the individual's need to fit in with peers FABRICATION • Can be made in the shortest period of time COST • Can be made with minimal initial cost and cost for maintenance
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  Shoes (FO) • Transferbody weight to the ground • Protection, weight bearing surface • Comfort, function, appearance • Decrease pressure • Base for orthotics and bracing
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  Anatomy of aShoe
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  TYPES • Blucher shoestyle open throat there is more room to don and doff the shoe and the orthosis. • Bal shoe style, The vamp is stitched over the quarters at the throat, thereby limiting the ability of the shoe to open and accommodate an orthosis.
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  CTEV BOOT
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  Shoe Modifications Conditions 1.Rocker sole : Traumatic/arthritis Painful conditions 2. Heel Flare : Providing wide heel for stability 3. ‘T’ or ankle strap : For varus & valgus tendency 4. C & E heel : Pes planovalgus (Thomas Heel) (Flat Foot & knock knees) 5. CTEV Shoe : Club Foot
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  Contd…. Shoe Modifications Conditions 6.Heel Wedge : Valgus/Varus heel (Medial-Lateral) 7. Medial Arch Support : To support medial longitudinal arch 8. Metatarsal Pad : Fall of M.T. head Metatarsal Bar Painful toe break 9. Lateral heel & sole : To keep the foot in eversion wedge 10. Excavated heel cushion : Calcaneal spur
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  Contd…. Shoe Modifications Conditions 11.Soft lining & Cushioning : Anaesthetic foot 12. Hallux Valgus pad : Hallux Valgus Foot 13. Shoe Filler : Partial Foot Amputation 14. Universal & Equinus shoe : For shortening Raise <3/8” - accom. inside shoe >3/8” - full length external lift to the sole 15. Ext. Orthoses or Prosthesis : If the shortening > 6”
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  SHOES CHECK OUT •A practical way of ensuring that a shoe is of adequate length is to determine whether the index finger can be placed between the tip of the great toe and the toe box. • The presence of calluses indicates areas of friction from poorly fitting (loose) shoes. • The presence of corns indicates areas of friction over bony prominences, most often caused by tight-fitting shoes. • Leather shoes are durable, allow ventilation, and mold to the feet with time.
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  PRINCIPLE IN FOOTORTHOSIS • For a custom foot orthosis to be made, the subtalar joint should be placed in a neutral position before casting. • The subtalar neutral position is used to treat conditions associated with hyperpronation including pes planus, patellofemoral pain, painful RA affecting the first MTP joint
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  UCBL Orthosis • Indication subtalarjoint instability. • Controls flexible rearfoot valgus or varus as well as forefoot abduction or adduction. • Holds the calcaneus & supports the midfoot with high medial and lateral trim lines. • It realigns the calcaneus, improving the angle of pull of the Achilles tendon. • Provides a more stable foundation for the articular surfaces of the talus, navicular & cuboid bones.
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  Supramalleolar AFO/ Dynamic AFO •By limiting movement of the midfoot & forefoot and holding the foot in functional position, it provides a stable base for postural control during standing and ambulation. • Redistributes plantar pressures of spastic equinovarus from the anterior foot to the heel by reducing overall stimulation of reflexes. • By providing a stable base during stance phase, it improves swing limb clearance, stride length, cadence, and self- selected walking speed in diplegic CP children. Its proximal trim lines are just superior to the ankle joint, and its distal trim lines encase more of the forefoot.
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  ANKLE FOOT ORTHOSIS •Short leg braces used effectively to control ankle motion. • Provide mediolateral stability as a safety feature. • Control the amount of dorsiflexion and plantar flexion. • Plantar flexion creates a knee extension moment and dorsiflexion creates a knee flexion moment. • Can also stabilize the knee during gait. • A cushioned heel move the ground reactive force anteriorly at the foot and subsequently at the knee and helps stabilize the knee. • A firm heel decreases knee stability via a knee flexion moment while moving the ground reaction force posterior to the knee joint e.g. used in genu recurvatum
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  Three transitional rockerperiods occur as the body moves forward over the foot during stance. A, During first rocker, the transition from swing into early stance, controlled lowering of the forefoot ccurs, with a fulcrum at the heel. B, During second rocker, controlled forward progression of the tibia over the foot occurs, with motion of the talocrural joint of the ankle. C, In the third rocker, transition from stance toward swing occurs as the heel rises, with dorsiflexion of the metatarsophalangeal joints.
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  FRO Control System A,When a patient walks in a “crouch gait” pattern, the GRF vector passes behind the knee at midstance, creating a flexion moment at the knee, which must be counteracted to maintain upright position. B, In normal gait, knee stability at midstance is assisted by a ground reaction moment as the body moves over the foot, and the GRF vector passes anterior to the knee. C, The solid ankle-foot orthosis and the floor reaction orthotic designs use a fixed ankle position to harness the GRF, creating a large extension moment at the knee.
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  Plastic ground reactionAFO The anterior tibial shell closing and 10 degrees of plantar flexion help create knee extension moments with weight bearing to add stability to the knees
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  PLASTIC AFO ADV • Costeffective. • Good cosmesis. • Light weight. • Interchangeability with shoes. • Ability to control varus & valgus deformities. • Provision of better foot support with the customized foot portion. TYPES • Solid Plastic Ankle-Foot Orthoses • Plastic Ankle-Foot Orthoses Varus-Valgus Control • Patellar Tendon Bearing Ankle-Foot Orthoses • Charcot Relief Orthotic Walker Boot • Pressure Relief AFO
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  • Holds theankle in as close to optimal static alignment as possible. • Mediolateral ankle stability is a result of trim lines at the midline of the malleoli. • The high medial border at the foot and the slight flaring just proximal to the medial malleolus is used to counteract an abnormal, flexible subtalar valgus. • The crossed Velcro strap anterior to the ankle helps position the rear foot appropriately within the heel section of the orthosis. Solid Plastic AFO
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  Posterior Leaf Spring AFO •The posterior position and arc of the trim lines at the ankle, as well as the thickness of thermoplastic material used, determine the degree of flexibility of the posterior leaf spring AFO. • Support the weight of the foot during swing phase as a means of enhancing swing limb clearance. • Assist with controlled lowering of the foot during loading response in stance as part of the first/heel rocker.
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  HINGED PLASTIC AFO CamberAxis Hinged ankle joint, allows forward motion of the tibia through the second/ankle rocker of stance phase. Oklahoma orthotic ankle joint, has a built-in plantarflexion stop & posterior strapping that can be adjusted to limit the amount of dorsiflexion available.
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  METAL AFO • Consistsof a proximal calf band, two uprights, ankle joints, and an attachment to the shoe to anchor the AFO. • The posterior metal portion of the calf band should be 1.5 to 3 inches wide to adequately distribute pressure. • The calf band should be 1 inch below the fibular neck to prevent a compressive common peroneal nerve palsy.
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  • The plantarstop is used to control plantar spasticity and is commonly set at 90 degrees. • An anterior stop (5 degrees dorsiflexion) is used to substitute for the function of the gastrocnemius/ soleus complex. • The posterior spring substitutes for concentric contraction of dorsiflexors to prevent flaccid foot drop after toe-off.
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  Patellar Tendon BearingAFO Indications: • Ulcerations of the heel of foot, • Tibial fractures, • Relief of the weight- bearing surface in painful calcaneal fractures, • Post op ankle fusions, • Charcot joint, and • AVN of the foot or ankle.
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  PTB AFO • Madeof plastic and are bivalved and fit snugly with the use of Velcro straps or buckles. • The solid plastic orthosis makes contact with the ground before the reactive force is absorbed significantly by the foot and then distributes this force more proximally along the leg. • 10% of the weight is transferred to the patellar tendon and tibial condyles. • 50% weight-bearing reduction is achieved by custom- fitted contact distributed throughout the leg. • Additional weight-bearing reduction is obtained by eliminating ankle movement via carbon graphite inserts and/or the use of a rocker bottom.
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  Charcot Relief OrthoticWalker Boot (CROW) • A custom-molded bivalve plastic AFO that is fully padded on the inside with total contact of the foot, ankle, and leg. • Purpose is to off-load a plantar ulcer or stabilize the progressive deformity from Charcot joint of the foot and ankle. • Has a rocker bottom and rubber sole for indoor and outdoor ambulation. • Often used instead of total contact casting of diabetic foot ulcers.
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  Prefabricated carbon graphite AFO Advantagesinclude • Lighter weight. • Lower profile footplate. • Ability to provide some dynamic response/propulsion to substitute for weak plantar flexors. • Fit easily into many shoe styles and come with anterior or posterior calf shells. Disadvantages include • Poor mediolateral control • Lack of adjustability
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  STATIC AFO Type of Orthosis ActionsIndications UCBL orthosis Stabilize subtalar & tarsal joints in stance Rearfoot valgus/varus Flexible pes planus Solid-ankle AFO Tone inhibiting AFO Control ankle position throughout stance Provide stance phase stability via ankle- knee coupling & assist limb clearance in swing Spasticity with poor motor control at ankle & knee
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  DYNAMIC AFO Type ofOrthosis Actions Indications Supramalleolar Stabilize subtalar & tarsal joints in stance Preposition foot for IC by heel Flexible pes planus Spastic diplegic or hemiplegic CP Hypotonic CP Posterior Leaf Spring Assist limb clearance in swing Preposition foot for IC by heel Dorsiflexion weakness, impaired motor control. Articulating ankle Apart from above it permits advancement of tibia in stance Potential for recovery of neuromotor function
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  AFO FOR ANKLECONDITIONS CONDITION AFO FOOT DROP Posterior leaf spring AFO FOOT DROP With Mediolateral Instability Hinged plastic AFO with metal double-action ankle joints or Hinged midline posterior stop AFO that is spring- loaded PLANTAR SPASTICITY Hinged AFOs with plantar stops at neutral (90 degrees) LUMBAR SPINAL CORD INJURY AFOs fixed in 10 degrees of plantar flexion
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  CHECK OUT FORAFO • The examination is carried with the patient standing, sitting, and walking and with the appliance removed. • The first and most obvious form of a checkout is to verify that the gait pattern is improved with the orthosis compared with the gait pattern without the orthosis. • The patient is to be checked for ease of donning and doffing the orthosis, and while it is off, observed for areas of skin breakdown. • Can the patient sit comfortably with his knee flexed approx. 105 degrees.
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  CHECK OUT FORAFO: STANDING • Is the shoe satisfactory and does it fit properly. • Are the sole and heel of shoe flat on the floor. • Are the mechanical ankle joints aligned so they coincide approximately with the anatomic ankle. • Is there adequate clearance for ankle joint and uprights. • Is sufficient force exerted by the correction T strap. • Do the uprights or plastic shell conform to the contour of the leg and are they at the midline of the leg. • Is the calf band or shell comfortable, of proper width and provide sufficient clearance for the head of the fibula. • If PTB brim is used, is there adequate reduction in wt. bearing at heel.
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  KNEE ANKLE FOOTORTHOSIS • Above knee braces and the components apart from those of an AFO also include knee joints, thigh uprights, and a proximal thigh band. • Indications: severe knee extensor & hamstring weakness, structural knee instability, and knee flexion spasticity. • There are three stabilizers to the knee: the quadriceps, the hamstrings (via eccentric activation at heel strike), and the plantar flexors (plantar flexion creates a knee extension moment). • These stabilizers should all be evaluated carefully by physical examination before a KAFO is prescribed.
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  CONVENTIONAL KAFO INDICATIONS • Whenmaximum strength & durability are needed • Significant obesity • Uncontrolled or fluctuating edema ADV: Strong, durable & easily adjusted DISADV: • Heavy, less cosmetic • Must be attached to shoe or shoe insert • Fewer contact points reduce control CONTRAINDICATIONS •Energy expenditure as weight of the orthosis is a more • When control of transverse plane motion is needed THERMOPLASTIC KAFO INDICATIONS • For maximum limb control • For less energy expenditure • For control of transverse plane motion ADV: • Lightweight & greater cosmesis • Interchangeability of shoes DISADV: Can be hot to wear CONTRAINDICATIONS • In obese and fluctating edema intimacy of fit is difficult.
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  THERMOPLASTIC KAFO
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  Knee Ankle Foot Orthoses(KAFO)
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  ISCHIAL WEIGHT BEARING(UNWEIGHTING) KAFO The quadrilateral or ischial containment thigh section is designed to permit partial transfer of the patient’s weight through the KAFO during stance phase. This weight sift, however small, permits the patient to extend the stance side period on the involved side.
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  ORTHOTIC KNEE JOINT StraightSet Knee Joint - Allows free flexion but prevents hyperextension - Used in combination with a drop lock, which keeps the knee in extension throughout all phases of gait . Polycentric Knee Joint - Uses a double-axis system to simulate the flexion-extension movements of the femur and tibia at the knee joint. - No proved advantage, adds bulk & used in sports knee orthosis. Posterior Offset Knee Joint - For patients with weak knee extensors. - Allows free flexion & extension of the knee during the swing phase of gait - Helps keep the orthotic GRF in front of the knee axis for stability.
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  A. The kneejoint remains extended if the GRF is anterior to the knee. B. A knee flexion moment is created if the GRF is posterior to the knee. C. Orthotic GRF at heel strike with posterior offset orthotic
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  KNEE LOCKS The ratchetlock Has a catching mechanism that operates in 12-degree increments. Useful in rising from seated to standing & prevents buckling of knee. The Bail Lock Lifting up the bail posteriorly releases the knee joint to permit flexion, allowing the patient to sit down. The Dial lock Used to stabilize the knee In varying amounts of flexion Adjusted in 6-degree increments and is more precise for the management of a knee flexion contracture.
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  Scott-Craig Orthosis • Indications:complete lesion at L1 or higher SCI for ambulation. • It consists of - An ankle joint with a dorsiflexion and posterior stop. - A rigid anterior tibial band & a rigid posterior thigh band for three point pressure. - A sole plate extending to the metatarsal heads, - A crossbar added to the metatarsal head area for mediolateral stabilization, and - An offset knee joint with a bail lock.
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  Stance-control Knee-Ankle- Foot Orthosis • Mechanicalstance-control knee-ankle-foot orthosis. • It has lightweight lateral upright, medial cable, anterior padded cuffs, and Velcro-closing posterior straps. • The knee unit contains a cable-driven ratchet that locks the knee as it extends in terminal swing in preparation for stance phase, and unlocks it at terminal stance to allow knee flexion necessary for limb clearance during swing phase.
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  E-Knee KAFO • Itis a microchip-controlled and battery-powered SC- KAFO. • A pressure-sensing footplate signals the microprocessor to lock the knee joint when the limb is loaded(regardless of knee position), and unlock the unit when unloaded in late stance.
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  Load Response SC-KAFO • It containsa torsional spring that mimics controlled knee flexion for shock absorption in loading response.
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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 AnkleFoot Orthoses (HKAFO)
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  KAFO & HKAFOCHECK OUT • Should include points mentioned in AFO check out. • Are the mechanical knee joints aligned so they coincide approx with anatomic knee and is there adequate clearance. • Is the knee lock secure & easy to operate. • Do the uprights provide adequate clearance & are they at the midlines of leg and thigh. • Is there satisfactory clearance between the medial upright & perineum. • Is the lateral upright below the head of the trochanter but at least 1” higher than medial upright. • Does the ischial tuberosity rest properly on the ischial seat. • Is the patient free from vertical pressure in the area of the perineum. • Is the centre of hip joint slightly above & ahead of the greater trochanter. • Does the pelvic band fit the contours of the body accurately.
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  Specialized Knee Orthoses (KO) •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
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  Osteoarthritis Knee Orthoses Sport KneeOrthoses Uses the standard orthotic three-point distribution system in a mediolateral distribution Designed to prevent hyperextension and offers mediolateral stability at the knee
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  Specialised Knee Orthoses (KO) Unloaderknee braces apply a gentle force to separate the affected bone joint surfaces, unloading the affected area of the knee to minimise wear and tear They are proven to relieve pain and increase mobility, even amongst those with moderate and severe knee ligament injuries and OA.
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  VALGUS (UNLOADING) ORTHOSES •It unloads the medial compartment of the knee through use of adjustable tension straps crossing the lateral aspect of the knee joint, lateral condylar pads, or lateral hinge systems, which are fixed to a brace shell at the calf and thigh. • A study by Katsuragawa demonstrated an increase in BMD more in the lateral tibial condyle than the medial condyle due to the transfer of forces across the knee joint from the medial to the lateral side after use of a valgus orthosis. Change of bone density with valgus knee bracing. Int Orthop.1999;23(3):164–167. • A research by Horlick demonstrated a significant reduction of pain when wearing a valgus brace. Valgus knee bracing for medial gonarthrosis.Clin J Sports Med. 1993;3(4):251–255.
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  Standing Frame • Theage range for initial use is usually 8 to 15 months. • It helps balance the body in space and allows free use of the upper limbs for participation in activities.
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  Parapodium • Swivel orthosis. •It is an appropriate for children (2.5 – 5years) who are unlikely to become functional walkers. • The hip and knee joints remain locked in extension to permit ambulation in the upright position but can be unlocked to permit sitting. • Difficulties include donning and doffing and rising from a seated position to a standing position
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  The reciprocal gaitorthosis uses a dual cable system to couple flexion of one hip with extension of the other. This coupling assists forward progression of the swing limb while ensuring stability of the stance limb.
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  Specialized THKAFOs HG0 RGOARGO
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  SUMMARY • Lower limborthoses are among the most commonly prescribed biomechanical devices. • They are intended to assist individuals with neuromuscular deficits. • Orthoses can be rationally prescribed by specifying the functional outcome desired in biomechanical terms. • Ankle–foot orthoses can be designed with sufficient mechanical lever arms to effectively control the ankle complex and to influence the knee joint indirectly
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  • The recentdevelopment of stance control knee joints has eliminated several drawbacks associated with knee-ankle-foot orthoses . • An appropriate lower limb orthotic prescription requires a thorough biomechanical analysis of gait and knowledge of the available orthotic components .
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  REFERENCES • Braddom's PhysicalMedicine and Rehabilitation – 5th Edition • Orthotics & Prosthetics in Rehabilitation – 3rd Edition by Michelle Lusardi • AAOS Atlas of orthoses and assistive devices - 4th edition by John D Hsu