Lower limb orthosis by

Marwa abo el Hawa Assist. Lect. Rheum. & Rehab. Dep.

Faculty of Medicine Tanta University

DefDef. .

Exoskeleton devices applied to lower Exoskeleton devices applied to lower body segments in pt. with body segments in pt. with neuromuscular or skeletalneuromuscular or skeletal disorders to disorders to enhance normal movement and enhance normal movement and increase walking efficiency.increase walking efficiency.

indication

1-Assist motion .

2-Correct flexible deformity.

3-Prevent progression of fixed deformity.

4 -Stabilize gait .

5-Decrease pain.

6-Decrease energy expenditure.

7-Transferring weight.

Characters of device

SimpleLightStrong Durable

Cosmetically acceptableLow coastTemporarily [during recovery from injury or illness]Definitive [ with permanent disabilities]

1-3 point pressure

2-Circumferential pressure

3-Axial unloading

4 -Translation control

5 -Serial correction

6 -GRF( ground reaction force) control

BIOMECHANICAL PRINCIPLE

MATERIALSMETALS

PLASTIC -Thermosetting (molded by heat –permanent figure -not

return to consistency by reheating) - Thermoplastic ( soften when heated hardened when cooling -

Types low temp & high temp(

LEATHER RUBBERSynthetic materials

COMBINATIONS

FO foot orthosis

AFO ankle foot orthosis

KO knee orthosis

KAFO knee ankle foot orthosis

HKAFO hip knee ankle foot orthosis

HO hip orthosis

Lower Extremity Orthosis:

SHOES

STIRRUP

UPRIGHTS

ANKLE JOINTS

KNEE JOINTS

HIP JOINTS

CALF BAND

THIGH BAND

PELVIC BAND

STANDARD METAL DOUBLE UPRIGHT

Function - Protect foot - Warm foot

- Modified to transfer body weight during walking from sensitive area to pain free area

CharactersComfortableFit : correspond shape of foot

proper room for foot expanding during wt bearing longer 1cm than longest toe

SHOES

Copyright © 2005 Pearson Education, Inc., publishing as Benjamin Cummings

Arches of the Foot

Foot has three important archesMedial and lateral longitudinal arch

Transverse arch

Arches are maintained by: Interlocking shapes of tarsal

Ligaments and tendons

Copyright © 2005 Pearson Education, Inc., publishing as Benjamin Cummings

Arches of the Foot

Figure 8.12

Copyright © 2005 Pearson Education, Inc., publishing as Benjamin Cummings

Bones of the Foot

Figure 8.11b

Copyright © 2005 Pearson Education, Inc., publishing as Benjamin Cummings

Bones of the Foot

Figure 8.11c

modificationsA- medial longitudinal arch support

-Deformity:

Pes planus , pes cavus ,pes valgus

-Modification:

Internal

Steel shank(0.5 inch back to planter apex of calcaneus to 0.25 inch post to break of shoes)

Cookie insert or insole ( rigid leather 1.25 inch behind heel breast line to 0.5 inch behind 1st metatarsal head)

Navicular pad (scaphoid pad) as cookie insert but made of sponge material used when patient cannot tolerate rigid cookie insert

Longitudinal arch support ( for broader area of support to shift body weight laterally) ( plastic ,metal, leather)

Long counter (leather sandwiched between shoes layers form rigid wall medially to 0.5 inch forward to heel breast line

External

Thomas heel ( orthopedic heel , key stone heel or s-shaped heel) anterior projection of medial breast line 0.5 inch

Thomas heel wedge ,wedge sandwiched between base of Thomas heel &outsole

Medial wedging (for medial arch support & shift body weight laterally) (height of wedging is height need to place calcaneus in near vertical position)

Sole wedgingTarsal & metatarsalMidway between medial breast line &break of shoes

To front end of sole

Heel wedgingTalocalcaneal & talonavicular joint

Heel layer

Sole& heel wedgingSevere valgus deformity

Cross wedgingFlat feet

Weak foot

medial heel wedging& lateral sole wedging

Medial shank filler: from medial breast line to head of 1st metatarsal

Valgus strap: in spasticity & valgus contracture applied medially to prevent foot & ankle from assuming a valgus attitude

B-Lateral longitudinal arch support

Deformity:

Pes varus, pes planus

Modification:

Internal

Long counter laterally

Lateral heel wedge insert

External

Reverse Thomas heel: anterior projection of lateral breast line 0.5 inch

Lateral wedging: (heel, sole, sole &heel wedging)

Medial shank filler: from Lateral breast line to head of 5th metatarsal

Lateral flaring of shoes : to discourage varus deformityHeel flaring, sole flaring (1.5 inch post to 5th metatarsal base to end of out sole), Heel &sole flaring.

Varus strap : applied laterallyC- Metatarsal arch supportIndication:

Bursitis,metatarsalgia ,fracture of metatarsal bone, planter warts, hallux valgus & hallux rigidus, Morton's toe (short 1st MT& phalanges or amputated ).Modification:

InternalMetatarsal pad:( elevate inner sole just behind Metatarsal head)Dancer pad:( feathered edge under surface of Metatarsal head) Metatarsal corset:( removable arch support, above types with elastic strap over dorsum of foot)Levy inlay: wedge shaped pad made of foam or rubber placed between hallux & 2nd toe to realign 1st MTP jointMorton's toe extension: extend from heel to tip of toe supporting medial longitudinal arch to restore 3point wt distribution.

External

Metatarsal bar: behind & parallel to line from 1st to 5th MT head, in out sole so after heel strike wt borne to behind Metatarsal head.

Rocker bar: as Metatarsal bar but extend to toe end.

Denver bar: directly beneath transverse arch of foot at tarsometatarsal joints

NB: all above as same height of heel

D-Heel modification

Heel elevation: to compensate for fixed equinus deformity or any leg discrepancy of 1.5 to 3 cm (if > 3cm so elevate heel & sole)

Heel cushion relief: soft pad may filled with compressible material placed under painful part of heel.

FO (foot orthosis)

When foot cannot attain neutral, FO may shim the gap to that fixed position-Accommodative FOMay help the foot attain a neutral position-Corrective FOEither may unload compromised tissue; or may provide total contactMay be full custom or Off The Shelf (OTS)

HEEL CUP: rigid plastic insert, cover planter surface of heel ,extend post, med, lat up the side of heel, to prevent lateral calcaneal shift in flexible flat foot.

SESAMOID INSERT:0.75 inch length insert ,under hallux to transfer pressure off the short 1st MT head onto its shaft.

LONGITUDINAL ARCH SUPPORT: applied med or lat.

UCBL

University of California at Berkeley Laboratory (UCBL)

Rigid plastic total contact design formed over cast of foot held in maximal manual correction.

Hind foot / mid foot correction

Heel cup extends proximal to inframalleolar area and distally to the metatarsal heads

STIRRUP

SOLID

SPLIT

ROUND CALIPER

SOLID STIRRUP ATTATCHED WITH FOOT PLATE

UPRIGHTSsite:1 to t.5 cm from skinin short leg brace end at level of calf bandin long leg brace med1.5 inch below pubic tubercle& lat at lower end of GT

METALS OR PLASTIC

ROUNDED OR FLAT

Single (post or lat) OR

double (med &lat)

Fixed or telescoping

DISTALLY WITH ANKLE

AND PROXIMALLY TO CUFF BAND

1 -FREE MOTION

2-PLANTER FLEXION ANKLE STOP

3 -DORSIFLEXION ANKLE STOP

4-LIMITED MOTION ANKLE STOP

5-DORSIFLEXION ASSISTSPRING JOINT(klenzak)

6-Fixed ankle joint

ANKLE JOINTS site: opposite to malleoli upwards from medial to lateral(just below med malleolus & 0.5 inch above tip of lat malleolus)

LEATHER LEVEL calf 1-2 inch below fibular head

Lower thigh band 4inch from calf band

upper thigh band 1.5 inch below ischium

WIDE TO DISTRIBUTE FORCE

CALF BAND WITH PLANTER FLEXION STOP INCREASE KNEE FLEXION MOMENT SO USED IN GENU RECURVATUM

CALF AND THIGH BAND

KNEE JOINTS

SINGLE OR POLYCENTRIC

LEVEL at anatomical knee joint 0.5 inch above tibial plateau

SINGLE AXIS

1-FREE MOTION

2-OFFSET KNEE JOINT

3-DROP RING

4-SWISS LOCK

5-ADJUSTABLE KNEE LOCK (DIAL LOCK)

HIP JOINTS AND LOCKSopposite to GT

1 -MOVING HIP JOINT

2 -SINGLE AXIS

3 -TWO POSITION LOCK

4 -DOUBLE AXIS

PELVIC BAND site midway between iliac crest &GT

CONTROL ROTATION AND ADDUCTION

1-BILATERAL PELVIC BAND

Ant: ASIS, Post: middle of sacrum

In unilateral: from ASIS to PSIS

2-PELVIC GIRDLE

3-SILESIAN BELT

AFO (ankle foot orthosis)

Most common orthosis

Metal bars

Total Contact

Floor reaction

Unweighting

ImmobilizingMost AFO’s can be articulating or non-articulating

SMO Supra Maleolar Orthosis

Supra Maleolar Orthosis

Low profile design that crosses the ankle

Less invasive trim lines than a standard AFO

Total Contact AFO’s

provide intimate fit with total contact to provide better control

light weight (150-200gms) ;

more common today

Floor Reaction AFO-

Uses floor reaction force through toe aspect of foot plate to prevent forward tibial progression &

subsequent knee collapse ;

May be articulated

Unweighting AFO

May be patella tendon bearing (PTB), specific weight bearing or total surface bearing, TSB (inverted cone with lace closure) to unweight the ankle foot using prosthetic principles

Immobilizing AFO

Commonly used with a lower extremity deficiency when ankle immobilization is desireddistal tibia/ fibula fracturefoot bone fracturestendocalcaneus ruptureDiabetic Foot (Charcot Foot)

Articulated or Non-articulated May be designed for progressive increases or decreases in sagittal plane ROM and control

An articulating option may be available in many designs of AFO’s

Non-Articulating (Solid Ankle) Articulating

KO (knee orthosis)

Useful for malalignmentgenu varum ,

valgum ,

recurvatum,

to protect knee structures from undue loading/stress

may be preventative or corrective

may be permanent treatment for repaired/compromised knee structures

Athletic KO-

Non-articulated KO-

Custom or OTS KO-

Several Types of KO’s:

Athletic KO-Preventative .

Controversial as short lever arms may not be sufficient to diminish realistic damaging forces.

Proprioception thought to play a role.

non-articulated KO-

usually for short term use

difficult to transfer with

Off-the-Shelf KO-

Offers limited control of the knee .

Restricts gross motion

KAFO Knee Ankle Foot Orthosis

Indicated when lesser devices are biomechanical insufficient ;

Combines KO & AFO

Subtypes:

Single/Double bar (upright) KAFO-

Total contact KAFO-

Ischial Weight Bearing (unweighting) KAFO-

Single/Double Bar KAFO-

Accommodates volume fluctuation ,

Cooler than total contact ,

Highest material strength .

Several lock options .Lock for ambulation, unlock for sitting .

May incorporate hyperextension stops.

Various knee joints are availablee.g. Weight activated stance control,

locking ,

Total Contact KAFO-

More customizable .

Better load distribution.

Ischial Weight Bearing (unweighting) KAFO-

Ischial containment or Quadrilateral style brims with high trimlines .

Generally used with paralytic limbs .

Not as effective with larger or obese individuals.

HKAFO Hip Knee Ankle Foot Orthosis

Very restrictive and laborious to swing-to or through in gait

causing high rejection rates

Includes Reciprocating Gait Orthoses (RGO), total contact, leather and metal upright

Specific HKAFO: Reciprocating Gait Orthosis (RGO)

Used in spinal cord injury.

Combines flexion of one hip with extension of the opposite hip .

The flexion power of one hip is utilized to extend the opposite hip.

Hip Abduction Orthosis

Commonly used post-operatively to position the femoral head optimally within the acetabulum

Hip Abduction orthoses can be an HO only or can have a KAFO extension.

Specific Case Hip Orthosis (HO):S.W.A.S.H Orthosis

Standing Walking And Sitting Hip Orthosis

Maintains femoral abduction in standing, walking and sitting

Thank you