LOWER LIMB

ORTHOTICS
 ORTHOTICS
Terminology:
 Splint: an orthosis used for a short time. It’s a device for immobilization or
support of a body part.
 Brace: used as synonym for orthosis, used to strengthen, tighten or support a
body part.
 Orthotist: a health professional who designs, fabricates, and fits orthoses.
 Orthotic: adjective of orthosis, may be used as noun.

Abbreviations (and types)

 FOs: foot orthosis: appliance applied to the foot inside or outside the shoe.
 AFOs: ankle foot orthosis: show and terminate below the knee
 KAFOs: knee ankle foot arthosis: extends from the foot to the thigh.
 HKAFOs: hip knee ankle foot orthosis: a KAFO with a pelvic band
 THKAFO: trunk hip ankle foot orthosis: covers part of the thorax
 HO: hip orthosis
 KO: knee orthosis
 WHO: wrist hand orthoses
 EWHO: elbow wrist hand orthosis
 SEWHO: shoulder elbow wrist hand orthoses.
 TLSO: thoracolumbosacarl orthosis
 LSO: lumbosacral orthosist,
 TLSO: thoracolumbosacarl orthosis
 CTLSO: cervicothoracolumbosacral orthosis

Types of orthotics according to function

 Static splint.

o For immoblization , pain relief, support…

 Dynamic splint

o To assist or resist movements.

1
  Functional orthosis:

o Help patient to use his limb.

Mechanical principles for orthotics

Three point fixation is the basic requirement for fixation or immobilization for any
region. Splints function as first class lever system with 3 point pressure.

Examples:

Cock up splint to prevent wrist flexion

KAO to prevent genuvarum

Milwalkee brace to control scoliosis

2
 LOWER LIMB ORTHOSES
General considerations
1. A lower limb orthosis is used only for managing a specific disorder.
2. The orthotic joints should be aligned at the approximate anatomic joint.
3. Most orthoses use a 3 point system to ensure proper positioning of the lower
limb
4. The orthosis should be simple, lightweight, durable, and cosmetically
acceptable.

Uses of lower limb orthoses

1. Control motion (prevent or limit motion)
2. Correction of deformities
3. Compensation of weakness (assist motion)

Components of lower limb orthotics

4. Foundation: consists of the shoe or metal or plastic shoe insert (foot plate) +
stirrup.
5. Foot control
6. Ankle control
7. Suprastructure (uprights or calf shell)
8. Knee control: added in KAFOs
9. Hip joint: in HKAFOs
10.Pelveic band

A. foundation

 Stirrup: may be attached to the shoe or the footplate

3
 o Split stirrup allows using the splint with many shoes

B. Ankle joint
 Attached to the stirrup
 May control or assist ankle motion (dorsiflexion and planterflexion) by “pins”
or “springs”
 Types:

1. Free motion ankle joint: permits free ankle motion and provides only
mediolateral stability.

2. Planterflexion ankle joint stop: restricts planterflexion while permitting

unlimited dorsiflexion. Used with patients with weakness of dorsiflexors and
flexible pes equines.

3. Dorsiflexion ankle joint stop: restricts dorsiflexion while permitting

unlimited planterflexion. Indicated for patients with weakness of
planterflexion.

4. Limited motion ankle joint stop: restricts both dorsiflexion and

planterflexion. Used when there’s generalized weakness of ankle muscles.

5. Dorsiflexion assist spring joint: a spring loaded dorsiflexion assist is

indicated when there’s weakness of dorsiflexors, but there’s adequate range.

4
 6. Varus or valgus correction straps (T strap): a T strap attached medially and
circling the ankle to buckle on the outside of the lateral upright is used to
correct valgus position. While lateral strap is used for varus correction.

C. Knee joint:

May be polycentric or single axis according to amount of movement.

Single axis knee joint has many types

1. Free motion knee joint. Allows unrestricted knee flexion and extension.
Used for patients with good quadriceps strength, but have recurvatum for
example.
2. Offset knee joint: the hinge is located posterior to the knee joint to facilitate
knee extension and provide knee stability. It permits free knee flexion.
3. Drop ring lock knee joint: the most commonly used knee lock. When the
ring is slipped in place the knee is held in extension (both medial and lateral
rings should be locked for maximum stability).
4. Spring loaded pull rod: provides automatic locking when the limb is not
bearing weight.
5. Pawl lock with bail release (cam lock): the knee could be unlocked by
pulling up the bail.
6. Adjustable knee lock joint (dial lock): allows knee joint locking at different
degrees of flexion. Can be used for patients with knee flexion contracture
that improves gradually.

5
Free motion Offset Knee Drop Ring pawl lock with Spring Loaded Adjustable Knee

bail release

D. Knee cap and strap

The knee cap can be placed

In front of the knee to prevent flexion of the knee

Medial strap is used for genuvalgum

6
Lateral strap for genuvarum.

E. Hip joints and locks

F. Pelvic band and locks
G. Side bars

7
 FOOT ORHTOSES
A. Shoes
 Parts of the shoe

A shoe is composed of three main parts; sole, heel, and upper

1. Upper

The upper is the portion of the shoe above the sole.

2. sole

Outer and inner soles are separated by compressible filler

3. The heel

Modifications of the shoe

Shoe modifications may be:

1. External modifications: attached to the sole and heel, as flares and wedges

2. Internal modifications: shoe inserts, that are fixed inside the shoe

Both types enhance function by:

1. Transferring body weight stresses

2. Protecting painful area from connecting with the shoe

3. Correcting alignment of flexible segments.

4. Assisting transition during stance phase.

8
5. Equalizing leg length

A. External modifications
1. Heel elevation: to compensate for fixed equinus deformity and leg length
discrepancy.
2. Heel flare: a flare is made by addition of material in a progressive manner
to the heel (and/ or sole)

 Lateral flare is used to resist inversion (and assist eversion)

 Medial flare is used to resist eversion (and assist inversion)
 Flares increase the stability of the ankle and subtalar joints
 Uses: medial flare can be used in cases of:

(1) Mobile calcaneovalgus to aid to correct the deformity.

(2) Fixed calcaneovarus to accommodate (compensate) for the fixed

deformity.

3. Heel wedge

9
Medial wedge is used to promote inversion and lateral wedge is used to

The heel counter should be strong to prevent hind foot form sliding down.

Uses:

Medial heel wedge is used to:

(1) Mobile calcaneovalgus to aid to correct the deformity.

(2) Fixed calcaneovarus to accommodate (compensate) for the fixed

deformity.

4. Metatarsal bar:

Is a flat strip of leather or other firm material placed posterior to the metatarsal
head

It transfers the stress from the metatarsophalangeal joint to the metatarsal shaft

5. Rocker bar:

A convex structure placed posterior to the metatarsal head.

10
 Used to shift the rollover (fulcrum) point form the metatarsal head to the
metatarsal shaft.

Used to avoid irritation of ulcers along the metatarsal heads in patients with DM

6. Sole wedge: A medial wedge is used to promote supination, and lateral sole
wedge is used is used to promote
7. Sole flare: a medial flare is used to resist eversion and a lateral flare is used
to resist inversion.
B. Internal modifications
1. Heel cushion relief:

Used to relive pain under the heel, e.g. in cases of

planter fasciitis.

2. Heel wedge

A medial wedge is used to rotate the hind foot into inversion and vice versa

3. Metatarsal pads:

Designed to reduce the stress from the metatarsal heads by transferring the load to
the metatarsal shafts, e.g in metatarsalgia.

11
 ANKLE FOOT ORTHOSIS
A. Thermoplastic AFO

Consists of

Calf shell

Calf strap

Shoe insert

1. Spiral and hemispiral AFO

Descripion

Spiral AFO consists of a shoe insert, a spiral that originates from the medial side of
the footplate, passes around the leg posteriorly, then passes anteriorly to terminate
at the medial tibial flare where a horizontal calf band is attached.

Hemispiral AFO consists of a shoe insert, a spiral that originates from the lateral
side of the footplate, passes around the leg posteriorly in a direction opposite from
that of the full spiral AFO covering only half a turn of 180⁰ to terminate at the
medial tibial flare where a horizontal calf band is attached.

Indications:

1) Motor weakness of all components of the

ankle foot complex
2) Mediolateral instability
3) Decreased power of the knee
4) Loss of proprioception of the ankle.

12
 2. Posterior solid AFO

Description

It extends medially to the tibial flare, provides support behind the head of the first
metatarsal and the medial portion of the calcaneus.

Indications:

1) Weakness of absence of ankle strength with loss of sensation and

proprioception (as in Charcot's joint).
2) Severe spasticity.
3) Pain on movement of the ankle.

3. AFO with flange

Has an external extension (flange) that projects from the

calf shell medially for maximum valgus control and
laterally for maximum varus control.

13
 4. Hinged AFO

The adjustable ankle hinge can be set to the desired range of ankle dorsiflexion or
planterflexion

B. Metal and plastic AFOs

This type of AFO consists of a shoe or foot attachment, ankle joint, two metal
uprights (medial and lateral), with a calf band connected proximally.

14
 KNEE ANKLE FOOT ORTHOSIS (KAFOs)

Consists of an AFO with metal uprights, knee joint, and two thigh bands.

Uses:

1) Quadriceps paralysis or weakness.

2) Correct mobile genuvarum or genuvalgum.

15
 3) Limit weight bearing on the thigh, leg, and foot with quadrilateral or ischeal
containment.

KAFO may be made from:

Metal and leather

Metal and plastic

Straps may be used not only for fixation but

also for correction of defomities as
genuvarm, genuvalgum or flextion.

16
EXAMPLES OF KAFOs

1. Double upright metal KAFO

 2 uprights extending to thighs
 Mechanical knee joint
 Two thigh bands

2. Scott-Craig orthosis

Used for standing and walking for paraplegic patients due to spinal cord lesion.

Allows swing-to and swing-through gait with crutches.

Components of Scott Craig orthosis

 Cushioned heel with T-shaped foot plate for

mediolaterla stability.
 Ankle joint with anterior and posterior
adjustable stops.
 Double uprights.
 Knee joint with pawl locks and bail control
 Pretibial band.
 Posterior thigh band.

3. Plastic shell and metal upright orthosis

 Posterior leaf spring AFO
 Double metal uprights extending up to a
plastic shell
 Knee joint.

17
 KNEE ORTHOSIS (KO)

Provides support only to support the knee (not ankle or foot).

Examples of KO

 Supracondylar knee orthosis: to prevent genuvarum, genuvalgum or

genurecurvatum.
 Knee orthosis for patellofemoral disorders.
 Knee orthosis for knee control

HIP KNEE ANKLE FOOT ORTHOSIS (HKAFO)

Consists of KAFO in addition to hip joint and pelvic band

18
 TRUNK HIP KNEE ANKLE FOOT ORTHOSIS (THKAFO)

 Consists of spinal orthosis in addition to HKAFO

 Controls spinal movement and alignment.
 Indicated for paraplegia patines.

Examples:

at
1) Reciprocating gain orthosis (RGO)
2) Parawaker
3) parapodium

Reciprocating gain orthosis (RGO)

RGO consists of bilateral KAFOs with posterior offset

locking knee joints, hip joints and a custom-molded
pelvic girdle with a thoracic extension.

The hip joints are coupled with cables preventing

bilateral hip flexion simultaneously. The hip extension
on one side coupling hip flexion on the other side
through the cables produces reciprocal walking gait
pattern.

Can be combined with FES to simulate 2 or 4 point gait

in ambulatory paraplegics or tetraplegic patients. Using
FES can also doubles the patient’s gait speed, lower
blood pressure and heart rate, and increase oxygen
uptake as compared to ambulating with the RGO
without FES.

Parawalker

Consists of bilateral KAFOs and a body brace.

Ambulation is performed through trunk motion
transmitted to the lower limbs with hip flexion and
extension via the brace.

19
Parapodium

This device is developed to allow pediatric patients to

stand without crutches and use their upper limbs. It
allows converting side to side rocking into forward
propulsion.

Externally Powered Orthoses

 Orthoses may be modified to enable selected patients to achieve household,
or, in rare cases, community ambulation.
 Orthoses may be combined with Functional elecrrical stimularioll (FES)
 Muscles needed for walking (as quadriceps, glutei, and dorsiflexors) are
stimulated via surface electordes on their motor nerves
 The patient should have passively movable joints to be able to benefit from
FES

20