OP Compiled.pdf

Nomenclature of Orthotics & prosthetics
apart from ISO terminologies; general terms used all over the world suggested by
American board of certification in orthotics and prosthetics
• ABC – American Board for Certification in Orthotics & Prosthetics
• Abduction – The act of moving the hip/shoulder (and residual limb) away from the midline of the body.
• Adduction – The act of moving the hip/shoulder (and residual limb) toward the midline of the body.
• Extension – The act of moving the hip (and residual limb) backward
• Flexion – The act of moving the hip (and residual limb) forward or to the front of the body.
• Orthosis – Custom-fabricated or custom-fitted brace or support designed to align, correct, or prevent
neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.
• Prosthesis – Artificial medical device that is not surgically implanted which is used to replace a missing
limb or appendage such as artificial limbs, hands, fingers, feet or toes.
• Residual Limb – Remaining portion of the limb after amputation.
• Sound side leg – Non-amputated limb.
• Fabrication – Procedure of mechanically creating a device.

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• Amputation – taking away of a body extremity by surgery or trauma.
• Bulbous – Refers to the residual limb being larger in circumference at the end than at the top.
• Functional Level – Degree of function a disabled patient still achieves.
• Gait – Walking.
• Thoracic – Related to the trunk/rib cage.
• Hemipelvectomy – A high-level pelvic amputation.
• Hip Disarticulation – Amputation of the entire leg from the hip.
• Syme’s amputation – An amputation performed at the ankle joint
• Transfemoral – A type of amputation that occurs above the knee.
• Transhumeral – A type of amputation that occurs above the elbow.
• Transradial – A type of amputation that occurs at the forearm.
• Transtibial – A type of amputation that occurs below the knee.

Hemipelvectomy/ hip disarticulation

Syme’s amputation, transfemoral ,transtibial

• Socket – The portion of the prosthesis that is in contact with the residual limb.
• CO (Certified Orthotist) – Orthotist who has passed the certification standards of
The American Board of Certification in Orthotics & Prosthetics, and maintains
certification through mandatory continuing education program and adherence to the
Canons of Ethical Conduct.
• CP (Certified Prosthetist) – Prosthetist who has passed the certification standards of
The American Board of Certification in Orthotics & Prosthetics, and maintains
certification through mandatory continuing education program and adherence to the
Canons of Ethical Conduct.
• CPO (Certified Prosthetist-Orthotist)
• Corset – Lumbar brace made from
textile material.

Continue……………………
• Cervical – Pertaining to the neck.
• Custom Fabricated Orthosis – Orthosis, which is individually made for a specific
patient. Created using an impression generally by means of plaster or fiber cast, a
digital image using computer-aided design-computer aided manufacture (CAD-CAM)
systems software, or direct form to patient.

• Orthopaedics – Medical specialty dealing with the locomotor system.
• Orthopaedist – Surgeon who corrects congenital or functional abnormalities of
the bones with surgery, casting, and bracing.
• Orthotics – The science and practice of evaluating, measuring, designing,
fabricating, assembling, fitting, adjusting, or servicing an orthosis under a
prescription from a licensed physician, physical therapist, chiropractor, or
podiatrist to correct or alleviate neuromuscular or musculoskeletal dysfunction,
disease, injury, or deformity.
• Orthotist – Person who measures, designs, fabricates, fits, or services orthoses
as prescribed by a licensed physician, and who assists in the formulation of an
orthosis to support or correct disabilities.
• Pedorthics – Design, manufacture, fit and/or modification of shoe and foot
orthoses to alleviate foot problems caused by disease, congenital condition,
overuse or injury.

• Prosthetics – Science and practice of evaluating, measuring, designing, fabricating,
assembling, fitting, adjusting, or servicing prosthesis under an order from a licensed
physician/physical therapist.
• Prosthetic Components – The parts that make up the artificial limb. For example, foot,
ankle, socket, pylon, etc.
• Prosthetist – Person who measures, designs, fabricates, fits, or services prosthesis as
prescribed by a licensed physician, and who assists in the formulation of the prosthesis
prescription for the replacement of external parts of the human body lost due to
amputation or congenital deformities or absences.
• Pylon – Pipe-like structure used to connect the prosthetic socket to the foot/ankle
components.

• Definitive Prosthesis – The permanent prosthesis (usually provided after a
preparatory/temporary) that is designed to last for several years.
• Alignment – The relationship of the prosthetic foot to the socket.
• Doffing – Taking the orthosis or prosthesis off.
• Donning – Putting the orthosis or prosthesis on.
• Dystrophy – Pathologic loss of muscle mass.
• Edema – Swelling of the tissue.
• Endoskeletal Design of prosthesis– A construction technique that uses a pipe or
pylon as the support structure. This design allows for the exchange of components
and adjustment. An endoskeletal system can be covered with a cosmetic foam that is
shaped to match the sound side limb.
• Exoskeletal Design of prosthesis– A construction technique that uses wood or hard
foam as the support structure. This prosthesis is identified by its hard external finish.

• Physical Therapist (PT) – A trained professional who performs and teaches exercises
and other physical activities to aid in rehabilitation and maximize physical ability with
less pain. PTs teach the amputee exercise techniques, gait training and ways to navigate
physical barriers with a prosthesis.
• Plaster Impression – The plaster cast that is applied to the residual limb in order to
obtain an accurate model during the fabrication process.
• Prefabricated Orthosis – which is manufactured in quantity without a specific patient
in mind, which may be trimmed, bent, molded, or otherwise modified for use by a
specific patient.
• A preformed orthosis is considered prefabricated even if it requires the attachment of
straps and/or the addition of a lining and/or other finishing work
• Any orthosis that does not meet the definition of a custom fabricated orthosis is
considered prefabricated.,

• Soft Orthosis – Orthotic device made from fabric or elastic components (e.g.,
pressure gradient hose, corset, cervical collars, ).
• Rehabilitation – Process of restoring a person who has been debilitated by a disease
or injury to a functional life.
• Rehabilitation Team – Group of allied health care professionals that frequently
includes physician, surgeon, orthotist/prosthetists, physical and occupational
therapist, social worker and counselor who serve the needs of a patient.

Physical therapy
• Use of prostheses and orthoses to improve human function. Physical therapists (PTs)
examine patients/clients, evaluate data to make clinical judgments, diagnose to
determine the impact of the problems on function, and then select and implement
appropriate interventions.
• Determining the need for prostheses or orthoses, working closely with prosthetists
and orthotists in selecting appropriate components, and teaching patients and families
the proper use and care of the devices are integral parts of these functions. Physical
therapists’ assistants (PTAs) work with the physical therapists in carrying out selected
interventions and must also understand the fit and function of such devices.
• To fulfill these functions, the student must learn the different types of devices, their
biomechanical principles, how they should be properly fitted, and how to teach clients
the proper use and care of all devices. Today’s growing technological advances have led
to a great variety of currently available simple and complex devices, and continued
research and development lead to new components and capabilities.

HISTORY OF ORTHOTICS
• People have been wearing shoes for many centuries. Early shoe designs
dating back thousands of years suggest that appearance has always
been as important as comfort; in early times, wearing shoes was a
status symbol as only the rich could afford them.
• As materials and artisans became more plentiful and shoes became more
affordable, people started to consider comfort as well as style.
• Early innkeepers provided travelers with matted animal hair for foot covering, and eventually,
artisans began to specialize in making shoes. These early cobblers added leather and felt.
Responding to customers’ need for adaptations, they began to make pads and inserts to provide
more comfort.
• A variety of shoes and shoe adaptations followed with the advent of electricity and new
equipment.
• New materials were developed and universal lasts for different sizes became available for mass
production. Cobblers continued to be in demand to make adaptations for comfort and
accommodation of deformities

HISTORY OF ORTHOTICS
• Concomitant with the development of more sophisticated and adapted shoes came the
development of splints and braces to support damaged limbs. Skilled metal workers,
not only made prosthetic devices for those who had lost a limb but also made
supportive devices for people with fractures and other injuries.
• Brace makers eventually became the orthotists of today.
• In the 18th century, the French physician Nicolas Andry suggested that a body’s
misshape did not have to be permanent, particularly in children. He suggested that,
much like a gardener who ties a misshapen tree to correct the shape, devices could be
developed to correct a misshapen spine or limb so that, with growth, the deformity
could be corrected.
• As in prosthetics, the greatest improvements in the orthotics came in the 20th century
after both world wars and the polio epidemics of the late 1940s and early 1950s.
Manufacturers, orthotists, orthopedists, and others involved in the rehabilitation of the
severely disabled began to use and adapt the now wide array of prefabricated parts
into functional orthoses for specific purposes.

AMPUTATION SURGERY THROUGH THE AGES
• Early amputations were only performed because of trauma or gangrene.
Hippocrates (450–377 BCE) advocated performing amputation because of gangrene
and cutting through “dead” tissue.
• Bleeding was controlled with cauterization. The emphasis was on surgical speed
rather than shaping the residual limb. Many did not survive the shock of the
amputation or the postoperative infections that frequently followed. Over the next
decades, surgical techniques continued to improve and amputations were performed
for chronic ulcers, tumors, and congenital deformities.
• Ambroise Pare (1510–1590), a French army surgeon, reintroduced the use of ligatures,
originally set forth by Hippocrates. This technique was more successful than crushing
the amputation limb, dipping it in boiling oil, or other means of cautery that had been
used during the Dark Ages to stop bleeding. Pare was the first to describe phantom
sensation.
• General improvements and development in surgical techniques which continued
through the centuries contributed to improvements in amputations, survival, and
eventually residual limb preparation.

AMPUTATION SURGERY THROUGH THE AGES
• The relationship between the residual limb and the prosthetic socket is critically
important in the person’s eventual ability to functionally use a prosthetic device.
• With improved control of bleeding followed by the introduction of anesthesia,
surgeons could begin to look at other surgical techniques rather than the standard
cutting of the limb at one level, usually above the knee.
• James Syme of Edinburgh performed the first successful amputation at the ankle joint
in 1842; the procedure carries his name. He also advocated thigh amputations through
the cortical bone of the condyles or the trochanters.
• In 1867, Joseph Lister published his principles of antiseptic surgery that markedly
reduced mortality during and after surgery.
• Lister also experimented with catgut as a ligature (1880) rather than silk or hemp
that were not absorbed by body tissues and often caused inflammation and
hemorrhage.
• These developments were all precursors to the improved surgical approaches to
amputation that came in the 20th century.

The 20th Century
• In the early 1900s, surgeons attempted to build bone bridges at the ends of transtibial
(below-knee) amputations to allow for greater end bearing and to reduce breakdowns at
the end of the residual limb. Traditionally, severed muscles were allowed to retract, and
eventually, bone ends pushing against the distal skin of the residual limb in the open-
ended sockets of the times caused pain and ulcerations.
• World War I with its 4200 U.S. amputations and almost 100,000 amputations in all
armies led to improved skin flaps and greater consideration for levels of amputation.
• It was generally agreed that the middle third of the lower leg and lower to middle third
of the thigh were the most ideal length for a residual limb.
• World War II led to further improvements in surgical techniques and greater
consideration for the shape of the residual limb.
• Myoplasty, the suturing of the ends of severed muscles over the end of the bone, was first
advocated in 1942 but did not gain in popularity until the 1950s when it was adopted by
Dederich and popularized by Burgess.

The 20th Century
• Myodesis,: the suturing of severed muscles to distal bone, was advocated by Weiss in the 1960s.
Both myodesis and myoplasty are designed to provide muscle fixation for improved function and
shape of the residual limb.
• In 1958, Michael Berlemont, in France, demonstrated immediate postsurgical fitting of
prostheses.
• The technique that involves placing the residual limb in a rigid postsurgical dressing fabricated
using prosthetic principles was also advocated by Weiss and was brought to the United States by
Sarmiento and Burgess.
• In the l960s and 1970s, a number of factors combined to lead surgeons to reconsider the
transfemoral amputation as the level of choice for severely Ischemic limbs.
• Immediate postoperative fitting reduced postoperative edema, allowing healing at transtibial
levels, even for individuals with severe ischemia. Improved circulatory evaluation techniques
provided accurate information on the presence of collateral circulation.
• The use of the long posterior flap with its increased blood supply also contributed to the healing
capabilities of transtibial amputations.
• All of these factors contributed to a reversal in the number of transtibial and transfemoral
amputations performed for severe limb ischemia and concomitantly increased the number of
individuals becoming successful prosthetic ambulators.

The Development of Prostheses Through the Ages
• Early prostheses were usually made by local artisans or the individual who had sustained the
loss. Most lower extremity limbs employed a simple peg with some straps for suspension.
Upper extremity limbs were fabricated to hold a weapon or shield.
• Prostheses were made of wood or metal as dictated by availability and the preference of the
fabricator. In 1561, Pare designed an artificial limb of iron that employed an articulated joint
for the first time (Fig. 1.1). In 1696, Pieter Andriannszoon Verfuyn (Verduin’), a Dutch
surgeon, introduced the first known transtibial prosthesis with an unlocked knee joint.
• In concept, it resembled the thigh-corset prosthesis used in more recent times. A thigh cuff
bore part of the weight and was connected by external hinges to a leg piece whose socket was
made of copper and lined with leather. The leg piece terminated in a wooden foot.
• In 1843, James Potts of London introduced a transfemoral (above-knee) prosthesis with a
wooden shank and socket, a steel knee joint, and an articulated foot with leather thongs
connecting the knee to the ankle. This enabled dorsiflexion (toe lift)
• whenever the wearer flexed the knee. The device was known as the “Anglesey (Anglesea) leg”
because it was used by the Marquis of Anglesey following the loss of his leg in the Battle of
Waterloo((Fig. 1.2).

FIGURE 1.1. An above-knee artificial leg
invented by Ambroise Paré
FIGURE 1.2. The Anglesey (Anglesea) leg
(1816) with articulated knee, ankle, and foot.
(Left) Below knee. (Right) Above knee.

THE WORLD WARS
• During the American Civil War (1861–1865), interest in artificial limbs and amputation
surgery increased because of the number of individuals surviving amputations (30,000
in the Union army) and the commitment of federal and state governments to pay for
artificial limbs for veterans. J. E. Hanger, who lost a leg during the Civil War, replaced the
cords of his prosthesis with rubber bumpers at the ankle to control plantar flexion and
dorsiflexion.
• The J. E. Hanger Company opened in Richmond, Virginia, in 1861, and in 1862 the first
law providing free prostheses to people who lost limbs in warfare was enacted by the
U.S. Congress.
• In 1863, the suction socket (Fig. 1.3) that employed the concept of using pressure to
suspend an artificial limb was patented by an American, Dubois D. Parmelee, who also
invented a polycentric knee unit and a multiarticulated foot.
• In 1870 Congress passed a law that not only supplied artificial limbs to all honorably
discharged persons from the military or naval service who had lost a limb while in the
U.S. service, but also entitled them to receive one every 5 years.

FIGURE 1.3. The D. D. Parmelee
prosthesis with suction socket,
patented in 1863.

THE WORLD WARS
• Fewer Americans (4403) lost a limb during World War I (1914–1918) compared to the
British (42,000) or to the total number of amputations (approximately 100,000) in all
of the armies of Europe.
• However, the war was an impetus for improvements in artificial limb developments.
Collaboration between prosthetists and surgeons in the care of veterans with
amputations led to the formation of the Artificial Limb Manufacturers Association in
1917.
• Little progress was made in the field of prosthetics and amputation surgery in the
period between the two wars, but World War II again spurred developments.
• The American Orthotic and Prosthetic Association (AOPA) was established in 1949 and
developed educational criteria and examinations to certify prosthetists and orthotists.
• In 1945, in response to the demands of veterans for more functional prostheses, the
National Academy of Sciences (NAS) initiated a study to develop design criteria for
artificial limbs that would improve function.

THE WORLD WARS
• The Committee on Artificial Limbs (CAL) contracted with universities, industrial
laboratories, health providers, and others to spearhead majorchanges in all facets of
prosthetics and orthotics.
• From 1947 to 1976 under NAS sponsorship and Veterans Administration (VA) support,
the CAL, the Committee on Prosthetic Research and Development (CPRD), and the
Committee on Prosthetic-Orthotic Education (CPOE) influenced the development of
modern prosthetics and orthotics.
• Plastics replaced wood as the material of choice, socket designs followed physiological
principles of function, lighter weight components were developed, and more cosmetic
alternatives were fabricated.
• Most modern prosthetic principles had their inception in the work of these committees.
• Since the 1970s, prosthetic developments have grown at an exponential rate.
Computer-assisted socket designs, new materials spawned by the space age, better
research into human function, miniaturization, and computer chips all have contributed
to vastly improve general and specialized prosthetic components.

THE WORLD WARS
• Prosthetics and orthotics have emerged as sciences as well as art. The consumer is also
making greater demands on the prosthesis, seeking limbs that will enable him or her to
participate in all aspects of life, including sports and leisure activities. The Iraq and
Afghanistan wars have brought many young people into the world of the amputee; they
seek prostheses that will enable them to stay in the military if desired and perform all
the physical activities needed for their jobs.
• Flexible intimate fit sockets suspended by suction were developed for transfemoral
and transtibial amputations. Gel-filled liners provide a shock-absorbing interface
between the residual limb and the hard socket. Gel liners insure an intimate fit
suspending the prosthesis with virtually no pistoning, making the artificial limb an
integral part of the lower extremity.
• There are a wide variety of prosthetic feet designed to respond dynamically and
incorporating multiple axes of motion similar to the human foot.
• Research highlighted the importance of swing phase as well as stance phase in normal
walking, leading to multiaxis and computer-assisted knee mechanisms.

THE WORLD WARS
• Initial development of prototype active feet and knee components are
currently in use and close to reaching the marketplace. Researchers are
attempting to find a method to bring sensation into the prosthetic limb.
• The upper extremity has always posed a major challenge for prosthetists.
The great complexity of hand function is difficult to duplicate mechanically.
• The loss of sensation limits the function of the hand or hook, and
researchers have yet to develop replacement for sensory function. Research
in this area is continuing.
• Developments in external power and virtual reality are probably the
highlight of modern upper extremity prostheses. Myoelectric controls are
now used fairly routinely for transhumeral and transradial amputations.

THE 21ST CENTURY
• The 21st century is bringing many changes in the field of prosthetics and orthotics and in the
care of individuals in need of prostheses and orthoses.
• Robotics are moving from the realm of science fiction to practical applications. Fairley reported
on the development of a lower extremity exoskeleton suit developed at the University of
California Berkeley.
• The suit weighs about 31 lbs with a battery pack, and a computer allows the wearer to perform
activities such as carrying a heavy weight without feeling the weight or tiring. Another suit
developed in Japan allows the disabled wearer to perform activities of daily living the person
cannot otherwise perform.
• This suit detects biosignals generated on the surface of the skin when the person attempts to
make selected movements.
• Robotic developments in prosthetics seek to create active rather than responsive movements.
• The 21st century will likely bring changes in surgery and reconstruction. Work being done on
nerve transplants is already beginning to salvage limbs that otherwise would be nonfunctional
and often require amputation.
• Virtual reality is increasingly being used for both upper and lower extremity rehabilitation.
• .

History: The American Academy of Orthotists and Prosthetists
• The American Academy of Orthotists and Prosthetists is dedicated to promoting
professionalism and advancing the standards of patient care through education,
literature, research, advocacy, and collaboration.
• The Formative Years
• The American Academy of Orthotists and Prosthetists (the Academy) was founded in
November 1970 to expand the scientific and educational attainments of professional
practitioners in the disciplines of orthotics and prosthetics.
• The leadership of the American Orthotic and Prosthetic Association (AOPA), a trade
association serving the interests of orthotic and prosthetic facilities, manufacturers,
and suppliers, and the American Board for Certification in Orthotics, Prosthetics &
Pedorthics (ABC), the sole U.S. credentialing agency at that time, agreed that there was
a need for an organization focused on continuing education.

History: The American Academy of Orthotists and Prosthetists
• The Academy is dedicated to:
• (1) attainment of the highest standards of technical competence and ethical conduct
by its members;
• (2) the professional recognition of qualified practitioners;
• (3) the assurances that practitioners maintain high standards of professional
conduct; and
• (4) collaboration with other educational, research, and related organizations in
developing technical and ethical standards for orthotics and prosthetics.
• In order to fulfill these objectives, Active, voting, membership in the Academy is
restricted to individuals who have been certified in orthotics or prosthetics by and
who remain in good standing with ABC.

BASIC TERMINOLOGY used for ORTHOTICS AND
PROSTHETICS
• International terminology standards have been established to facilitate
communication and research regarding orthoses and their uses.
• The method of describing orthoses by reference to the body segments they
encompass is widely accepted
• worldwide and now has been complemented by proposals for the classification and
description of orthotic components.
• A recently approved international standard describing the methods and the
terminology to be used to define the clinical objectives and functional requirements
of orthoses fosters the development of evidence-based practice worldwide.

Historical background: (International organization for
standardization)
• The International Organization for Standardization (ISO) is a worldwide
federation of national standards organizations, known as ISO member bodies, that
has its headquarters in Geneva, Switzerland.
• Founded on 23 February 1947, the organization promotes worldwide proprietary,
industrial and commercial standards.
• ISO has 164 national members out of the 206 total countries in the world
• The organization is involved in a wide range of standardization activities
embracing virtually every aspect of manufacturing, scientific, and commercial
activity.
• ISO derives its income from two sources: the fees paid by member bodies and the
sales of documents, primarily standards, that it publishes.
• Because of this latter funding stream, all ISO documents are protected by
copyright, and no part of them can be reproduced without the permission of the
publisher.

(International organization for standardization)
• Before describing the content of the current ISO standards, it is perhaps appropriate
both to pose and to attempt to answer the question, ‘‘Why do we need international
terminology standards in orthotics?’’ An answer might be provided by citing the
sentiments expressed in the introductions to some of the more recently published
standards.
• In the absence of an internationally accepted method of describing either patients being
treated (orthotically) or the orthoses and their components being employed, the
members of the clinic teams in different countries have tended to develop their own
terminology for this purpose.
• This situation creates difficulties for practitioners prescribing orthoses and for
manufacturers describing their products and has made the reporting of the treatment
of particular patient groups and in particular the comparison of the outcomes of
orthotic treatment in different centres almost impossible.
• The standards described in this chapter permit the systematic and unambiguous
description of the patient being treated with an orthosis, the objectives of the
treatment, and both the functional characteristics and the

Technical committees and working Groups
• The task of developing ISO standards is performed by Technical Committees (TCs) and
their Working Groups (WGs). Every member body that expresses an interest in the work
of a TC is entitled to be represented on that TC and its WGs.
• The process whereby a new international standard is developed and eventually
published is complex and lengthy.
• A proposal must go through a series of stages, first as a New Work Item Proposal
(NWIP), then as a Committee Draft (CD), then as Draft International Standards (DIS),
and finally as Final Draft International Standards (FDIS), with opportunities for
comment or revision at all stages by the participating member bodies.
• The complete process, from the adoption of a new work item until publication, typically
takes a minimum of 5 years.
• The purpose of describing the ISO committee structure and its method of operation is to
make clear that ISO standards development is a closely regulated and controlled
process.
• The resulting standards genuinely reflect the consensual view of the relevant
professional groups.

The standards
• One of the first tasks undertaken by WGs at their inaugural meeting in St. Andrews, Scotland,
in 1980 was an attempt to define the scope of their future work.
• The initial work program of the WGs included two standards of relevance to the field of
orthotics:
• ISO 8549-1:1989 Prosthetics and Orthotics—Vocabulary (General terms for external limb
prostheses and external orthoses)
• ISO 8549-3:1989 Prosthetics and Orthotics—Vocabulary (Terms relating to external
orthoses)
• The majority of the work performed by the WGs in the succeeding 10 years of the TC’s
existence was directed at the field of prosthetics; however, the past 5 years has seen the focus
of theWG program shift in the direction of orthotics, with the resulting publication of two
further important standards:
• Description of the person to be treated with an orthosis, clinical objectives of
treatment, and functional requirements of the orthosis.”
• ISO :2005: Prosthetics and Orthotics (Classification and description of external orthoses
and orthotic Components)

ISO;1989: Prosthetics and Orthotics—Vocabulary
• General terms for external limb prostheses and external orthoses
• This first basic step into the world of ISO standardization attempts to define the fields
of prosthetics and orthotics, the general terms used to describe prostheses and
orthoses, the anatomy of those parts of the body most commonly fitted with these
devices, and the personnel and procedures involved in their supply.
• The orthotic terms included in this standard are listed in Box 1-1. An orthosis is
defined as ‘‘an externally applied device used to modify the structural and functional
characteristics of the neuromuscular and skeletal systems.’’
• Orthotics is defined as ‘‘the science and art involved in treating patients by the use of
an orthosis.’’
• An orthotist is defined as ‘‘a person who, having completed an approved course of
education and training, is authorised by an appropriate national authority to design
measure and fit orthoses.’’

ISO :1989 Prosthetics and Orthotics—Vocabulary
• Terms relating to external orthoses This important standard, based on the
pioneering work of Dr. E.E. Harris while working for the Committee for Prosthetic
Research and Development (CPRD) in Washington, DC, under the direction of A.
Bennett Wilson, categorizes orthoses by reference to the anatomical segments and
joints they encompass and establishes a system of abbreviations derived from the
initial letters of the English terms for each category. For example,
• an ankle–foot orthosis is defined as ‘an orthosis which encompasses the ankle
joint and the whole or part of the foot’’ and is referred to by the abbreviation ‘‘AFO.’’
• A wrist–hand–finger orthosis is defined as ‘‘an orthosis that encompasses the
wrist joint, the hand, and one or more fingers’’ and is referred to by the abbreviation
‘‘WHFO.’’
• A lumbosacral orthosis is defined as ‘‘an orthosis that encompasses the whole or
part of the lumbar and sacro-iliac regions of the trunk’’ and is referred to by the
abbreviation ‘‘LSO.’’
• The degree of acceptance of the system of abbreviations internationally.

The full range of devices defined in this manner is listed in Box 1-2.

Definition of orthosis
• The simplest definition of an orthosis is any externally applied device to an existing body
part that improves function.
• Common goals for orthotic devices include the following:
• 1. Stabilize weak or paralyzed segments or joints
• 2. Support damaged or diseased segments or joints
• 3. Limit or augment motion across joints
• 4. Control abnormal or spastic movements
• 5. Unload distal segments
• To achieve these fundamental goals, special attention must be given to issues such as the
biomechanics of the device, durability of the materials used, and, most importantly,
tissue tolerance to pressures exerted by the device.

(ISO) 2003: Prosthetics and Orthotics—Functional Deficiencies
Description of the person to be treated with an orthosis, clinical objectives of
treatment, and functional requirements of the orthosis
• This ambitious standard, published in 2003, is intended to provide clinicians with a
method of describing in a consistent and unambiguous manner the persons they are
treating orthotically, their reasons for doing so, and the conditions the orthosis must
create.
• The first of the three defined objectives of the standard— the description of the
person being treated—is achieved by specifying the method and the terminology to be
used to describe the clinical characteristics listed in Box 1-3.
• It should be emphasized that the clinician using this standard would not routinely
record all this information, but rather would select those items considered relevant to
the particular type of patient and the intended use of the information.

(ISO)2003: CONTINUE………………
• The second goal of the standard is to establish a consistent method of defining what
are referred to in the standard as ‘‘the clinical objectives’’ of the orthotic treatment.
• Nine basic objectives are identified in Box 1-4.
• For each of these objectives, the information that it recommended to be recorded is
specified.
• For example, if the objective is to relieve pain, the clinician should record which
joints or segments are involved and what induces the pain.
• If the objective is to manage a deformity, the information required includes the joints
or segments involved and whether the deformity is ‘‘preventable,’’ ‘‘reducible,’’ or
‘‘irreducible.’’
• Where terms like these, which do not already have a generally accepted meaning, are
used in the standard, definitions are included that make their meaning absolutely
clear.

(ISO)2003: CONTINUE……………………
• The final segment of the standard describes the method and the terms to be used to
describe the ‘‘functional requirements of the orthosis’’ necessary to achieve the
previously defined clinical objectives.
• The five categories identified are listed in Box 1-5.
• The reason adoption of this two-stage approach was considered necessary to the
development of what is in effect the orthotic prescription is best illustrated by
looking at an example of the use of the standard.
• One of the clinical objectives of the orthotic treatment of a person who suffers from a
degenerative joint disease might be to relieve pain.
• Depending on the location and severity of the condition, the functional requirements
of the orthosis used to achieve this objective might be to prevent, reduce, or stabilize
a deformity; to limit the range of a joint; or to reduce or redistribute the load on
particular tissues.

(ISO)2003 Continue…………………………….
• A second clinical objective for treatment of this person might be to manage a
deformity. Again depending on the severity of the condition, the functional
requirements for the orthosis to achieve this objective might be simply to stabilize the
deformity (i.e., prevent it from increasing) or alternatively to reduce the external
loading on the involved joint.
• As with the previous section of this standard, for each of the categories of functional
requirement, the information recommended to be recorded is specified.
• Thus for the first clinical objective just discussed, the information regarding the
functional requirements of the orthosis would include (in addition to defining the joint
or segment it is to affect)
• (1) the way in which the deformity is to be controlled, that is, prevented, reduced, or
stabilized; (2) the range of joint motion to be imposed; and (3) the type of loading to
be reduced.
• This standard also contains as an appendix some details of the different
‘‘biomechanical effects’’ that orthoses use to achieve their functional requirements.

ISO: 2005: Classification and description of orthoses and orthotic
components
• This final element of the existing body of ISO orthotic terminology standards is designed to
complement by providing a means of actually describing the functions and construction of
the orthosis used to achieve a particular set of clinical objectives and functional
requirements.
• The first section of the standard describes the method to be used to classify and describe
the complete orthosis. This in turn comprises three elements.
• The first element is termed the general description and recommends the use of the
terminology contained in the previously published, that is, AFO, WHO, SO, and so on,
• whereas the second element is termed the function of the orthosis and logically uses the
same terminology as used to describe functional requirements—
for example, to prevent, reduce, or stabilize a deformity; to reduce or
redistribute the load on tissues; and so on.
• The final element of this section simply requires the description of the ‘‘type of
fabrication’’ as being either custom fabricated or prefabricated.

ISO: 2005: Classification and description of
orthoses and orthotic components
• The second section of the standard specifies the method to be used to
classify and describe the components used in the construction of an
orthosis.
• Four categories of component are identified:
1. Interface components
2. Articulating components
3. Structural components
4. Cosmetic components

ISO: 2005: Classification and description of orthoses
and orthotic components
• The standard proceeds to define each category, list the range of components that
belong in each category, and specify what information is required to describe them.
• 1: interface components are defined as ‘‘those components which are in direct
contact with the user and are responsible for transmitting the forces which result in
its function and may retain it in place’’ and are considered as including the following:
• Shells
• Pads
• Straps
• Foot orthoses
• Shoes (used with an orthosis)

ISO: 2005: Classification and description of orthoses and
orthotic components
• 2: Articulating components, which are defined as ‘‘components of orthoses used to
allow or control the motion of anatomical joints,’’ are to be described by specifying the
following:
The anatomical joint whose motions they are intended to allow or control .
The permissible motions of the joint when assembled in the finished orthosis
 The form of articulation, either motion between parts of the joint or deformation of a
part of the joint
 The axis of rotation, either monocentric or polycentric. The type of controls that the
joint incorporates (e.g., locks, limiting mechanisms, assist/resist mechanisms)
• 3: Structural components are defined as ‘‘components which connect the interface
and articulating components and maintain the alignment of the orthosis’’ and include
both uprights and shells.
• 4: cosmetic components are defined as ‘‘the means of providing shape, colour and
texture to orthoses’’ and include fillers, covers, and sleeves

The orthotic prescription
• Writing a prescription for an orthosis is one element of the larger process of rehabilitation to
improve patient function. It includes evaluation, assessment, and formulation of the specific
treatment plan described in the prescription.
• Optimal communication and transdisciplinary education occur when the patient, physician,
orthotist, and therapist all are present for both patient evaluation and long-term follow-up.
Maintaining this level of collaboration outside of the formal clinic team setting is difficult.
• The certified orthotist functions as a consultant to the clinic team with regard to orthotic
management and provides fitting and follow-up of the indicated device.
• A clear understanding of the patient’s disease process, based on a comprehensive history and
physical examination, is the foundation for generating the appropriate prescription.
• An effective prescription for orthotic care summarizes the:
• medical issues related to the patient
• biomechanical functions
• specifies key technical attributes of the desired orthosis.

Orthotic team member roles
• The role of each individual team member can be precisely defined, but overlap occurs in several areas. These
areas of overlap should enhance discussion and communication among team members to generate the most
appropriate treatment plan.
• 1: Role of the physician:
• Perform the medical evaluation, including chart review, history, and physical examination
• Explain the diagnosis and prognosis to other team members
• Alert the team to special considerations, including skin issues, weight-bearing limitations, vascular
disease, and spasticity
• Establish restrictions of the treatment program to prevent complications or danger to the patient
• Assess and manage the patient’s pain control regimen
• Assess and manage the patient’s psychological status
• Justify the treatment program to the insurance carrier
• Write prescriptions for the orthotic device, therapy program, and medications
• Regular monitoring and long-term follow-up of all components of the treatment program
• Share knowledge with other team members

2: Role of the certified orthotist
• Participate in patient evaluation and generation of the orthotic
prescription
• Act in a consulting role to provide information on device design and
materials options
• Educate the patient regarding the device
• Fabricate the device to prescription specifications
• Deliver and check device fit and function
• Modify and repair the orthosis if, and when, appropriate
• Follow up with the patient and team members

3: Role of the physical therapist and/or occupational therapist
• Participate in patient evaluation, particularly as related to functional ability,
such as transfers, ambulation, stair climbing, and assistive devices, in
addition to assessment of other durable medical equipment, such as
wheelchairs and bathroom equipment
• Participate in generation of the therapy prescription
• Provide the therapy program, which may include strengthening, range of
motion, ambulation, wheelchair mobility, self-care activities,
• proper use of orthotic device, therapeutic modalities, and home program

4: Role of the certified pedorthist
• Participate in patient evaluation, with particular attention to the patient’s
feet and footwear
• Participate in generating the prescription for appropriate footwear
• Work cooperatively with the orthotist to provide the footwear and
appropriate modifications to the footwear
• Educate the patient, especially the diabetic patient, on footwear and foot
care

5: Role of the patient
• Convey appropriate information to the team members
• Listen, learn, and follow the team recommendations
• Comply with the treatment program and proper use of the orthotic device
• Follow up with the team, particularly if complications or problems related
to the orthosis or function occur through open discussion and mutual
respect, members of the orthotic team can function effectively and
efficiently to provide the appropriate services and improve the patient’s
functional outcome.
• Communication is the cornerstone of this process.

Biomechanical principles of orthotic design
• The biomechanical principles of orthotic design assist in promoting control,
correction, stabilization, or dynamic movement.
• All orthotic designs are based on three relatively simple principles: (1) pressure. (2)
equilibrium (3) the lever arm principle.
• These considerations include and are not limited to:
• the forces at the interface between the orthotic materials and the skin,
• the degrees-of-freedom of each joint,
• the number of joint segments,
• the neuromuscular control of a segment, including strength and tone,
• the material selected for orthotic fabrication,
• the activity level of the client.

• The following principles provide the foundation for all orthotic design keeping in
mind that the more complicated the orthotic application, the more confounded the
various principles become.
• 1: The pressure principle
• It states that:
• Pressure is equal to the total force per unit area.
• Clinically, what this means is that the greater the area of a pad or the plastic shell of an
orthosis, the less force will be placed on the skin. Therefore, any material that creates
a force against the skin should be of a dimension to minimize the forces on the tissues.
• P = force _
• Area of application

• 2: The equilibrium principle
• It states that:
• The sum of the forces and the bending moments created must be equal to zero.
• The practical application is best explained by the most commonly used loading
system in orthotics, the three-point pressure system (Fig. 1).
• The three-point pressure or loading system occurs when three forces are applied to a
segment in such a way that a single primary force is applied between two additional
counter forces with the sum of all three forces equaling zero.
• The primary force is of a magnitude and located at a point where movement is either
inhibited or facilitated, depending on the functional design of the orthosis.

• 3: The lever arm principle
• It states that:
• The farther the point of force from the joint, the greater the moment arm and the smaller the
magnitude of force required to produce a given torque at the joint.
• This is why most orthoses are designed with long metal bars or plastic shells that are the length of an
adjacent segment.
• The greater the length of the supporting orthotic structure, the greater the moment or torque that can be
placed on the joint or unstable segment.
• Collectively, these three principles rarely, if ever, act independently of each other. Ideally, when designing
or evaluating an orthotic appliance, the clinician should check that
• (1) There is adequate padding covering the greatest area possible for comfort;
• (2) The total forces acting on the involved segment is equal to zero or there is equal pressure throughout
the orthosis and no areas of irritation to the skin;
• (3) The length of the orthosis is suitable to provide an adequate force to create the desired effect and to
avoid increased transmission of shear forces against the anatomic tissues.
•

Goal of Orthotics
The goal of orthotic fitting is to meet the functional requirements of
the client with minimal restriction.
• To meet this goal, the rehabilitation team must evaluate each client
individually without preconceived ideas of routine orthotic
prescription based purely on the diagnosis.
• It must be determined whether the appliance will be:
• a temporary device to protect or assist the client until further
restorative therapies have been progressed, or
• a permanent orthosis fabricated for long-term use.

The functional considerations for an orthoses
• 1: Alignment: the correction of a deformity or maintenance of a body segment.
• Clinical examples:
• Musculoskeletal considerations
• Milwaukee brace for scoliosis
• Dynamic splint to prevent scar shortening in clients with burns
• Neurologic considerations
• Tone reducing AFOs in patient with cerebral palsy
• CTLSO to prevent motion of the cervical region
• 2: Movement: a joint requires assistance with motion or resistance to excessive motion.
Clinical examples:
• A) Assistance with joint motion
• a) Musculoskeletal considerations
• AFO with dorsiflexion assist for dorsiflexor weakness
• RGO assist clients with spinal cord injury with ambulation

• B. Resistance of joint motion
• a) Musculoskeletal considerations
• i. Shoe insert for a patient with foot deformity.
• ii. Finger splints for arthritic hands
• b) Neurologic considerations
• i. Swedish knee cage for unstable knee
• ii. Arm sling for neurologic shoulder
• 3: Weight-bearing: To reduce axial loading and reduce the forces placed on a joint.
• Clinical examples:
• Musculoskeletal considerations
• Shoe insert with metatarsal pad for a diabetic patient with foot deformity.
• Heel wedge for the pronated foot of a child with cerebral palsy

• 4: Protection: support or protect a segment against further injury or pain.
• Clinical samples:
• Musculoskeletal considerations(Functional knee brace)
• Neurologic considerations (Cock-up splints post spinal cord injury)
• Contraindications for orthotic application:
• (1) The orthosis cannot provide the required amount of motion,
• (2) When greater stabilization is required than can be provided,
• (3) The orthosis actually limits function, and the client is more functional without
the appliance, and
• (4) Abnormal pressures from the orthosis would result in injury to the skin and
other tissues.

Materials:
• The client is fitted with an orthotic appliance that is both functional and,
in most cases, cosmetically acceptable. Selecting the appropriate material
characteristics for the fabrication of an orthotic device requires careful
consideration of a number of factors
• Strength: the maximum external load that can be sustained by a material.
• Stiffness: the amount of bending or compression that occurs under stress.
Clinically, when greater support is required, a stiffer material is used;
when a more dynamic orthosis is desired, a more flexible material is used.
• Durability (fatigue resistance): the ability of a material to withstand
repeated cycles of loading and unloading. Selection of a material for
orthotic appliances is frequently based on the ability of the material to
withstand the day-to-day stresses of each individual client.

Materials:
• Density: the material’s weight per unit volume. Generally, the greater the
volume or thicker a material the more rigid and more durable it will be,
however, this usually increases the overall weight of the finished orthosis.
• Corrosion resistance: the vulnerability of the material to chemical
degradation. Most materials will exhibit corrosion over time, metals will
rust and plastics will become brittle. Contact with human perspiration
and environmental elements such as dirt, temperatures, and water
accelerate the wearing effect on materials. Knowing the client’s daily
environment can assist in material selection.
• Ease of fabrication: The equipments needed for fabrication of orthoses

MATERIALS
METALS
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
RUBBER
Synthetic materials
COMBINATIONS

Materials:
• Metals and plastics are the basic principal materials used in orthotics and prosthetics.
• To understand recommended design and fabrication procedures, a basic knowledge of
the properties of the various available materials is necessary. The practitioner must be
familiar with these materials in order to cope with both standard and difficult designs
and fabrication problems and have the ability to prevent structural or functional failures
of device due to the material.
• Selection of the correct material for a given design depends partially on understanding
the elementary principles of mechanics and materials, concepts of forces, deformation
and failure of structures under load, improvement in mechanical properties by heat
treatment, work (strain) hardening or other means, and design of structures.
• For example, the choices for a knee–ankle–foot orthosis (KAFO) may include several
types of steels, numerous alloys of aluminium, and titanium and its alloys.
• Important but minor uses of other metals include copper or brass rivets and successive
platings of copper, nickel, and chromium.
• Plastics, fabrics, rubbers, and leathers have wide indications, and composite structures
(plastic matrix with reinforcing fibers) are beginning to be used.

Materials:
• Often complex combinations of materials are used in manners that are not appropriate
from the material point of view but are appropriate for the particular clinical application.
• Understanding these properties not only assists with the selection, manufacture, and
management of the device but extends to the management of the patient and the
information that the practitioner will instill into patients.
• A simple example is the combination of flexible materials such as a strap and
thermoplastic, using an alloy rivet. Despite publicity for exotic materials, no single
material is a panacea. One reason is that a single design frequently requires divergent
mechanical properties (e.g., stiffness and flexibility required in an ankle–foot orthosis
[AFO] for dorsiflexion restraint and free plantar flexion).
• In addition, practitioners rarely are presented with situations where they will use only
one material or with single-design situations that will not require modification,
customization, or variation over time.

1: Metals
• A metal is defined as a chemical element that is lustrous, hard, malleable, heavy,
ductile, and tenacious and usually is a good conductor of heat and electricity. Of the 93
elements, 73 are classified as metals. The elements oxygen, chlorine, iodine, bromine,
and hydrogen and the inert gases helium, neon, argon, krypton, xenon, and radon are
considered nonmetallic.
• There is, however, a group of elements, such as carbon, sulfur, silicon, and phosphorus,
that is intermediate between the metals and nonmetals. These elements portray the
characteristics of metals under certain circumstances and the characteristics of
nonmetals under other circumstances. They are referred to as metalloids.
• The most widely used metallic elements include iron, copper, lead, zinc,
aluminum (or aluminium), tin, nickel, and magnesium. Some of these
elements are used extensively in the pure state, but by far the largest
amount is used in the form of alloys.

1: Metals:
• An alloy is a combination of elements that exhibits the properties of a metal.
The properties of alloys differ appreciably from those of the constituent
elements.
• Improvement of strength, ductility, hardness, wear resistance, and corrosion
resistance may be obtained in an alloy by combinations of various elements.
• Orthotics and prosthetics typically contain alloys of aluminum and carbon
steels, particularly stainless steel.
• Titanium also is frequently used, and, despite references to ‘‘pure titanium’’
(particularly in applications such as osseo-integration), it is the alloy that is
being referenced. Although these alloys (steel, aluminum, titanium) can be
categorized as similar depending on the base metal and some of the
contributing alloy metal, they are potentially infinitely variable.

Steel and aluminum alloys (Commercial name for metals
• It is necessary to discuss the types of steel and aluminum commercially
available and used in orthotic and prosthetic applications.
• The terms surgical steel, stainless steel, tool steel, and heat treated along
with other general designations are freely used by manufacturers of orthotic
and prosthetic components.
• The chemical content of these products is not identical from vendor to
vendor.
• For example, the term spring steel, used by many manufacturers, refers to a
group of steels ranging in chemical composition from medium- to high-
carbon steel and is used to designate some alloy steels.

Steel and aluminum alloys (Commercial name for metals
• The term tool steel also covers a wide variety of steels that are capable of
attaining a high degree of hardness after heat treatment. More care is
exercised in manufacturing tool steel to ensure maximum uniformity of
desirable properties.
• These general designations do not assure the orthotist or prosthetist of
obtaining the exact material that is needed. Because the mechanical
properties of a material and subsequent fabrication procedures depend on
the material’s chemical analysis and subsequent heat treatment or working,
the practice of using general descriptions for metals is seriously inadequate.
• In addition, reliance on these categories is not necessary because specific
designations already exist for each type of steel and processing treatment.

Strengthening aluminum and steel
• Although the yield stress and ultimate stress of the aluminum alloy below that of the
steel, but all aluminums are not weaker than all steels.
• By adding certain alloying elements, proper heat treatment, or cold working, some
aluminums can be increased in strength to an ultimate stress tolerance of 90,000 psi
(7178-T6), which is above the strength of some steels.
• However, the aluminum still will be more subject to fatigue failure than the steel.
• Increasing the strength of steel also is possible using similar processes.

2: Plastics and composites
• Plastics are the result of humankind’s ability to innovate, to create new materials by
combining organic building blocks—- carbon, oxygen, hydrogen, nitrogen, chlorine,
and other organic and inorganic elements—into new and useful forms. A plastic is a
solid in its finished state.
• However, at some stage in its manufacture, it approaches a liquid condition and is
formed into useful shapes. The name refers to the large plastic range of deformation
associated with these materials.
• Forming usually is done through the application of heat and pressure, either singly or
together.

 Examination is essential element
 Orthosis fits and function properly before attempting to train the
patient to use it
 Team should determine the adequacy of orthosis as pass,
provisional pass or fail.
 Pass indicates that orthosis is altogether satisfactory and patient is
ready for training
 Provisional pass:-
means that minor faults exist, generally having to
do with the cosmetic finishing of the appliance ; the patient can
wear the orthosis in training program without the harmful effects

 Failure:-
signifies that orthosis has major defect that would
interfere with training ; for example shoes that are too tight for the
patient.
Problem must resolve before training.
assure orthosis meets patients needs.

 Lower-Limb Orthotic Static Examination:-
examination of orthosis on
patient while standing and sitting, as well as examination of the
device off the individual.
Dynamic examination:- analysis of the wearer’s gait.

 Calf bands …….. Terminate below fibular head
 If patellar tendon bearing brim ……. Caoncave relief.
 Calf shell, bands and patellar tendon bearing brim…… should not
intrude on popliteal fossa
 Shoe and bands should be such that …… donning easy
 Knee lock should be function properly…….
 Medial uprights should terminate appr 1.5 in. below the perineum

 The calf and distal thigh shells or bands should be equidistant so
that when the orthosis is flexed, as in sitting, the plastic or metal
parts will contact one another, rather than pinch the back of the
wearer’s leg .
 KAFO’s …… quadrilateral brim to reduce weight bearing …….
Should provide a sufficient seat for ischial tuberosity..

 Pelvic joint:- set slightly above and ant to the greater trochanter to
compnsate for the usual angulation of the femoral neck
 Pelvic band:- conform to the contours of the wearer’s torso , without
edge pressure
 Brace is off….. Inspect pt skin
 Move joint slowly
 Binding….tilting distal portion of the joint……
 If Medial & lat stops not working at the same time…. Stop that
contact first erode rapidly and contribute to twisting of the orthosis..

Deviation in Early stance
Deviation Orthotic cause Anatomical
cause
Foot slap Inadequate dorsiflexion
assist
inadequate
plantarflexion stop
Weak
dorsiflexors
Toes first: tiptoe posture may
or may not be maintained
throughout stance
Inadequate heel lift
Inadequate dorsiflexion
assist
inadequate
plantarflexion stop
Inadequate relief of heel
pain
Short LE
Pes equinus
Extensor
spasticity
Heel pain
Flat foot contact: entire foot
contacts ground initially
Inadequate dorsiflexion
stop
Inadequate traction from
sole
Poor balance
Pes calcaneus
Excessive knee flexion: knee Inadequate knee locks Weak

deviation Orthotic cause Anatomical cause
Hyperextended knee: Genu recurvatum
inadequately controlled
by plantar flexion stop
Inadequate knee lock
Weak quadriceps
Lax knee ligaments
Wide walking base Excessive height of
medial uprights of
KAFO
Abduction contractures
Poor balance
Lateral trunk bending Excessive height of
medial uprights of
KAFO
Weak gluteus medius
Hip pain
Short leg
Poor balance
Abduction contracture

Difficulty in Late stance
 Delaying weight transfer or being unable to transfer weight over the
effected foot
 Problem can be mitigated with an anterior stop and a rocker bar.
 One should be certain that the stops on the stirrup function
properly.


During swing phase
 Pt must be able to clear the floor with the braced leg.
 Hip hicking occurs when hip flexors are weak, as well as when the
limb is functionally longer than the contralateral limb.
 Increased length may be produced by a faulty posterior stop that
no longer limits plantar flexion
 The problem should be anticipated and, for the unilateral KAFO
wearer can be prevented by adding a 1/2in. Lift to the contralateral
shoe.
 internal and external hip rotation may be caused by motor
imbalance b/w medial and lat musculature; the orthotic causes
relate to malalignment of the brace

 A walking base that is abnormally wide can be caused by a limb
that is longer than that on the opposite side
 Vaulting refers to exaggerated plantarflexion on the contralateral
limb during swing phase of the affected side.
 Vaulting occurs because the braced leg is functioanlly too long,
possibly because the posterior ankle stop has eroded .
 The less agile may obtain foot clearance by hip hiking

Ankle foot orthosis
• An ankle-foot orthosis (AFO) is an orthosis or brace that encumbers the ankle and foot. AFOs
are externally applied and intended to control position and motion of the ankle, compensate
for weakness, or correct deformities.
• AFOs can be used to support weak limbs, or to position a limb with contracted muscles into
a more normal position. They are also used to immobilize the ankle and lower leg in the
presence of arthritis or fracture, and to correct foot drop; an AFO is also known as a foot-
drop brace.
• Ankle-foot orthoses are the most commonly used orthoses, making up about 26% of all
orthoses provided in the United States.
• According to a review of Medicare payment data from 2001 to 2006, the base cost of an AFO
was about $500 to $700.
• An AFO is generally constructed of lightweight polypropylene-based plastic in the shape of
an "L", with the upright portion behind the calf and the lower portion running under the
foot. They are attached to the calf with a strap, and are made to fit inside accommodative
shoes. The unbroken "L" shape of some designs provides rigidity, while other designs (with a
jointed ankle) provide different types of control.
• OBTAINING A GOOD FIT WITH AN AFO INVOLVES ONE OF TWO APPROACHES:
• prefabricated AFO matched in size to the end user
• custom manufacture of an individualized AFO from a positive model, obtained from a
negative cast or the use of computer-aided imaging, design, and milling. The plastic used to
create a durable AFO must be heated to 400°F., making direct molding of the material on the
end user impossible.

uses /advantages of Ankle orthosis
• Ankle orthotics may potentially be useful after an acute
ankle injury (acute ankle sprain (ligament injury) or
fracture), for rehabilitation, to prevent ankle re-injury,
and for chronically unstable ankles. Whether a specific
ankle orthotic is effective depends on the particular
indication for its use.
• There are 4 potential uses for ankle supports: (i)
treatment of acute injury (i.e., beginning within 3 days
following injury); (ii) rehabilitation (for the first few
weeks following injury until full function is obtained);
(iii) prophylaxis and (iv) treatment of chronic
instability. The length of time that ankle supports need
to be used following injury varies depending largely on
the type and severity of the injury

Uses/advantages of Ankle orthosis
• 1: Treatment after acute injury: The ankle begins to swell
after injury, and swelling continues to increase for about 3
days following injury. Significant swelling persists for about 2
weeks following injury.
• 2: Rehabilitation: Ankle supports have been used for the first
few weeks following injury to prevent re-injury during early
return to activity.
• After the pain has subsided and the patient can walk without
a limp, use of the ankle support is only appropriate during
high-risk activities (i.e., especially racquetball, football, and
basketball). Leaving the ankle support on all the time only
serves to restrict functional range of motion and encourage
psychological dependence.
• 3: Prophylaxis: (used primarily in patients with a history of
ankle injury);

Uses/advantages of Ankle orthosis
• 4: Chronic instability :Ankle supports are used to
stabilize the ankle in patients with chronic instability. In
most instances, they are to be used only during high-
risk sports and activities. It is unusual for ankle
supports to be prescribed for use during normal daily
activities.
• Many types of ankle supports exist as an alternative to
ankle taping. In addition, shoes for some sports
(particularly basketball) are available with high tops and
built in straps for additional ankle protection.
• Recent studies have shown that use of ankle supports
during early rehabilitation of acute grade I or grade II
ankle sprains (partial ligament rupture) produced
results as good as cast immobilization, with more rapid
return to activity.

• Types of ankle-foot orthosis

1: Taping
• A number of studies have supported the use of tape in helping stabilize the
ankle and reducing sprains in persons with previous sprains.
• The goal of taping is to prevent the ankle ligaments from being stressed to
the point of injury. Taping should limit ankle inversion and eversion but
allow functional dorsiflexion and plantarflexion. There is evidence that
ankle taping also helps prevent injury by stimulating proprioceptive
(position-sense) nerve fibers, causing the peroneus brevis muscle to be
activated just before heel strike.
• For treatment of acute injury (beginning within about 3 days following
injury), taping may be used to provide support and to help reduce edema
(swelling). Felt or foam pads may be applied under the tape to help reduce
edema.
• Taping may be used for rehabilitation (i.e., to prevent re-injury during early
return to activity). About 3 days after the injury, swelling subsides, and tape
is re-applied to decrease the risk of re-injury.
• Using tape to prevent injury, however, is a time-consuming procedure, so it
is recommended for early stages of rehabilitation only. Tape may be applied
for the first few weeks after return to activity for rehabilitation of ankle
injuries.

1: Taping
• Taping may be used prophylactically in persons with or
without a prior ankle sprain, although it is not
recommended for routine use for this indication.
• Although taping probably reduces the rate of ankle
injuries, it loses support rapidly with movement and
sweating. This is not as much as a factor in acute sprains,
because in which tape is not stressed so much. For use
prophylactically, however, it is not a time- and cost-
effective option compared to the alternatives described
below.
• Taping has also been recommended as a possible
treatment for chronic instability, although it is not
recommended for routine use in this situation. With
movement and sweating, tape rapidly loses support. Also,
if used permanently, tape becomes expensive. This
approach is probably not as cost- and time-effective as
other options described below.

1: Taping
• One-inch wide standard tape is used for the foot, and 1½-inch
tape for the ankle. Areas sensitive to blistering must be
protected with lubricated gauze sponges. Special adherent
spray may be applied under the tape. If tape is to be re-
applied often, an under-wrap is used to prevent chronic skin
irritation.
• Tape should only be wrapped by a person well-trained in its
application, such as a trainer, physician, nurse, or physician
assistant. Improperly applied tape may cause further injury.
• Elastic tape has also been studied, and although it provides
more compression than non-elastic tape, it loses its restriction
of range of motion even more than standard tape.
• Tape and wrapping does not meet the durability requirement
for covered durable medical equipment, in that it is not
reusable and is not “made to withstand prolonged
use.” Although Aetna will cover taping or wrapping provided
by a healthcare provider in their office, take-home tape and
wrapping are not covered.

2: Elastic wrapping and sleeves
• Wrapping with elastic bandages is useful in the early
stages (about the first 3 days) of ankle sprain/soft tissue
injury to provide compression that reduces swelling. It
is used as an adjunct to ice and elevation.
• It needs to be changed often to monitor the
skin. Wrapping has not been proven to be useful for
other indications: prevention of re-injury, prophylactic
use, and use for chronic ankle instability. This is
because wrapping provides little or no support during
activity.
• Elastic ankle sleeves that are pulled over the foot like
open-ended socks offer no value as supports. They
may, however, enhance proprioception.

2: Elastic wrapping and sleeves
• They may also provide even compression to reduce
ankle edema. Thus, they have been shown to be useful
only in treating an acute ankle sprain (i.e., within
about 3 days after injury). Like elastic wrapping, elastic
ankle sleeves have not been proven to be useful for
rehabilitation, prophylaxis, or use in chronically
unstable ankles.
• Certain manufacturers, e.g., Stromgen, combine the
comfort of even compression by using Spandex, elastic,
and Velcro strap combinations to restrict eversion, and
inversion. They have been used primarily for
prophylaxis.

3: Bracing
• Like taping, bracing can be used in an acute injury, during
rehabilitation to prevent re-injury, prophylactically, and in
chronically unstable ankles. Braces come in 3 main types:
• casts, lace-up wraps, and plastic orthoses. Casts can be either
semi-rigid or rigid; lace-up braces and plastic orthoses are
considered semi-rigid.
• Braces have been shown to have several advantages over
taping. They can be used by persons who do not have access to a
person skilled in taping techniques. In some cases, they can be
more cost-effective than taping.
• But some braces may migrate during vigorous movement because
of the lack of adhesion to skin. This movement may cause the
brace to fail to provide support. But tape adhesion or straps to
reduce migration may help.
• During wear-and-tear, Velcro fasteners tend to fail and release,
straps or buckles break, and elastic stretches out. Off-the-shelf
braces may not fit persons who are too tall, are obese, or
deformed. Custom-made braces are available, but are generally
more expensive.

4: Air-stirrups:
• The air-stirrup is a pre-fabricated semi-rigid orthosis. The largest-selling
brand is the Aircast air-stirrup ankle brace (Aircast), which is composed
of a rigid outer plastic shell that fits up both sides of the leg and is
connected under the heel. It is lined with inner air bags and is attached
to the leg with Velcro. As with lace-up ankle supports, some clinicians
combine use of the air-stirrup with taping. The air-stirrup is an off-the-
shelf device that does not require custom fitting. It can be worn under
regular shoes.
• The air-stirrup decreases inversion and eversion, and protects the
already injured ligament and soft tissues from re-injury, thereby
decreasing rehabilitation time. The pressure in the air-stirrup increases
when weight-bearing, which is thought to provide intermittent
compression during walking that aids in the milking out of edematous
fluid. The air-stirrup can also be readjusted to allow total contact fitting
while swelling is fluctuating.
• The air-stirrup can be used after acute ankle sprains and in the early
stages of rehabilitation to prevent recurrent sprain. It can also be used
after rigid casting and for treatment of some fractures. There is
currently insufficient evidence for their use for prophylaxis or in chronic
instability, although some newer variations of the splint have been
designed for this purpose.

5: Orthoplast Stirrup:
• The orthoplast stirrup is a strip of thermoplastic material
custom-fitted to run under the heel and up both sides of the
leg. The ankle bones (malleoli) and other bony prominences
are covered with foam padding, and the stirrup is fitted with
an elastic bandage.
• Orthoplast is a low-temperature thermoplastic that becomes
pliable when submerged in hot water. It is applied directly to
the patient and molded evenly around the ankle. The
fabrication is simple enough to be carried out in the office or
clinic.
• The orthoplast stirrup has been successfully used to treat
ankle sprains, but because it is relatively hard, it does not
adapt to reduction in swelling. It has not been shown to
decrease inversion range of motion more than tape, and is
most commonly used in the acute or early rehabilitative
stages. Orthoplast deteriorates with long-term use, limiting
its usefulness in prophylaxis and for chronic ankle sprains.

6: stabilizing shoes
• Several shoe designs have been used for prevention
and treatment of ankle sprains.
• Acute injury, rehabilitation, and chronic instability: The
use of ankle-stabilizing shoes, such as the Kunzli line of
shoes (Swiss Balance, Santa Monica, CA), to treat ankle
sprain and to prevent re-injury have not been studied
adequately to date.
• Prophylaxis: High-topped shoes have been shown to
increase ankle stiffness in sports. However, the
advantage of high-topped shoes over low-topped shoes
in prophylaxis has been shown to be relatively
small. The prophylactic benefits of various shoe types
in sports have not been adequately investigated.

7: Ankle contraction splint:
• According to Medicare Durable Medical Equipment
Carrier Guidelines, an ankle contracture splint is a pre-
fabricated AFO that has all of the following
characteristics:
• Applies a dorsiflexion force to the ankle , and
• Designed to accommodate an ankle with a plantar
flexion contracture up to 45°, and Has a soft
interface, and Used by a patient who is non-
ambulatory.
• Ankle flexion contracture is a condition in which there
is shortening of the muscles and/or tendons that
plantarflex the ankle with the resulting inability to bring
the ankle to 0 degrees by passive range of motion. (0
degrees ankle position is when the foot is
perpendicular to the lower leg.)

8:Foot drop splint:
• A foot drop splint/recumbent positioning device is a
pre-fabricated AFO, which has all of the following
characteristics:
• Designed to maintain the foot at a fixed position of 0°
(i.e., perpendicular to the lower leg), and Has a soft
interface, and Not designed to accommodate an ankle
with a plantar flexion contracture, and
• Used by a patient who is non-ambulatory.
• Foot drop is a condition in which there is weakness
and/or lack of use of the muscles that dorsiflex the
ankle but there is the ability to bring the ankle to 0
degrees by passive range of motion.
• Foot and ankle orthoses for rheumatoid

Ankle Control
• Most AFO., are prescribed to control ankle motion by limiting
plantar flexion and/or dorsi-flexion or by assisting motion.
• The patient with dorsiflexor weakness or paralysis risks dragging
the toe during swing phase.
• Dorsiflexion assistance can be provided by a posterior leaf spring
that arises from plastic insert. (31-14). The upright is bent
backward slightly during early stance, when the patient progresses
into swing phase the plastic recoils to fit the foot. Thin ,narrow
plastic permits relatively greater motion.
• Motion assistance can also be achieved with a steel dorsiflexion
spring assist (klenzak joint 31-1) incorporated into each stirrup.
The coil spring is compressed in stance and rebounds during
swing.
• The tightness of coil can be adjusted but orthosis is noticeably
Bulkier than the posterior leaf spring model. Both types of spring
assist will slightly into planterflexion at heel contact, affording the
wearer protection against inadvertent knee flexion.

Toe off: AFO, ankle dorsiflexion
assistance(31-14)

Ankle control
• The alternate approach to prevent toe drag is planter flexion
resistance, which prevent the foot from planter flexion so that
patient with drop foot will not catch the toe and stumble
during swing phase.

Ankle control
• The solid ankle orthosis may be divided transversely at
ankle, with the two sections hinged, creating the
hinged solid ankle foot orthosis(lFig. 31.16). It provides
slight sagital motion. Fostering achievement of the
foot-flat position in early stance and enabling some
patients with hemiplegia to walk with increased stride
length and cadence.”
• Children with spastic-diplegia preferred the hinged
AFO, rather than the solid AFO, although gait velocity,
cadence and stride length were unaffected.
• An alternative to the plastic solid ankle AFO is metal
joint that resists both plantar ﬂexian and dorsi ﬂexion
known as limited motion joint. One type of limited
motion joint is a pair of Bichannel adjustment ankle
joint (BiCAALs) (Fig. 3l.l9) which consist of pair joint,
each of which has an anterior and a posterior spring.

Foot control
• Medial lateral motion can be controlled with solid
ankle AFO.
• The rigidity of the orhosis can be increased by
using thicker or stiffer plastic, corrugating the
plastic forming the edges with a rolled contour. or
embedding carbon ﬁber reinforecemnt.
• A solid ankle AFO (see Fig 3l.l8) or A hinged solid
ankle AFO (see Fig. 3 I. I6) also controls frontal and
transverse plane foot motion

31-18. plastic solid AFO. A plastic solid hinged AFO(31-16)

Knee-ankle-foot orthosis (KAFOs)
• A knee-ankle-foot orthosis (KAFO) is an orthosis that
encumbers the knee, ankle and foot.
• Motion at all three of these lower limb areas is affected by a
KAFO and can include stopping motion, limiting motion, or
assisting motion in any or all of the 3 planes of motion in a
human joint: saggital, coronal, and axial.
• Mechanical hinges, as well as electrically controlled hinges
have been used. Various materials for fabrication of a KAFO
include but are not limited to metals, plastics, fabrics, and
leather.
• Conditions that might benefit from the use of a KAFO include
paralysis, joint laxity or arthritis, fracture, and others.
• Although not as widely used as knee orthoses, KAFOs can
make a real difference in the life of a paralyzed person,
helping them to walk therapeutically or, in the case of polio
patients on a community level.

CONTINUE…….
• These devices are expensive and require maintenance.
Some research is being done to enhance the design.
• The term KAFO is an acronym that stands for Knee-
Ankle-Foot Orthosis and describes the part of the body
that this device encompasses.
• This device extends from the thigh to the foot and is
generally used to control instabilities in the lower limb
by maintaining alignment and controlling motion.
• Instabilities can be either due to skeletal problems:
broken bones, arthritic joints, bowleg, knock-knee,
knee hyperextension or muscular weakness and
paralysis. With this in mind, the indications for the use
of a KAFO are many and varied and any one particular
design is specific to the needs of the person it is made
for.

There are two very general categories of KAFOs/ knee
control
• Metal designs (See Figure 1) and plastic and metal designs (See
Figures 2 and 3).
• The metal design consists of a metal structure shaped to the limb
and upholstered with leather at the points where the device
makes contact with a person’s body.
• The plastic and metal design is the one most frequently
encountered today and is usually a plastic device custom molded
to the person’s body with metal components in key structural
areas only.
• The reason for the increased use of the plastic and metal design is
that it is lighter in weight and is considered to be more cosmetic.
• Some KAFOs may have drop locks at the knee joint (See Figure 4).
• A drop lock allows the knee to be kept in extension or straight
while walking (See Figure 5), and the joints can be unlocked for
sitting (See Figure 6).
• Drop locks would be used for someone with severe knee
instability.

Application:
• Since there are many different reasons to use a KAFO, there are
many different designs. Each design has its own special features
and its own specific way to be put on properly.
• The orthotist providing the device will instruct the patient on the
proper way to put the KAFO on at the fitting to make best use of
the design features of the device.
• The following instructions are for putting on a basic plastic KAFO
with metal uprights:
• 1. While sitting, position the thigh and the leg inside the KAFO
(Figure 4).
• 2. Position the heel completely back into the plastic of the KAFO
(Figure 5).
• 3. Secure the Velcro strap across the instep (See Figure 6).
• 4. Continue fastening the Velcro straps up the leg and the thigh
(Figure 7).
• The foot can then be inserted into the shoe. If necessary, the
insole of the shoe can be removed to allow for more room for the
foot portion of the KAFO.

Wearing Schedule:
• On the first day you receive the brace, begin by wearing for only 1
hour. After 1 hour, remove the brace and check your skin for red
marks. Some small, light red marks may be noticed on the skin
that should go away in 20 to 30 minutes after removing the brace.
• Slight redness is common over the instep and under the ball of the
foot. If the red marks do not go away in 20 to 30 minutes or if you
notice any scratching, bruising, or blistering, do not put the brace
back on.
• Call immediately to schedule an appointment with your orthotist.
• If the skin is ok, wait at least 1 hour and then put the brace back
on for 1 hour at a time for the rest of the first day, checking the
skin after each hour.
• On the second day, put the brace on for 2 hours. After 2 hours,
remove the brace and check the skin.
• If the skin is ok, put the brace back on for 2 hours at a time for the
rest of the day, checking the skin after every 2 hours. If your skin is
ok, gradually increase wearing time by 1 hour each day, checking
the skin after each wearing time.

Knee orthosis (KO)
• A knee orthosis (KO) or knee brace is a brace that extends above
and below the knee joint and is generally worn to support or align
the knee.
• In the case of diseases causing neurological or muscular
impairment of muscles surrounding the knee, a KO can prevent
flexion or extension instability of the knee.
• In the case of conditions affecting the ligaments or cartilage of the
knee, a KO can provide stabilization to the knee by replacing the
function of these injured or damaged parts.
• For instance, knee braces can be used to relieve pressure from the
part of the knee joint affected by diseases such
as arthritis or osteoarthritis by realigning the knee joint into valgus
or varus. In this way a KO may help reduce osteoarthritis pain.
• However, a knee brace is not meant to treat an injury or disease
on its own, but is used as a component of treatment along with
drugs, physical therapy and possibly surgery. When used properly,
a knee brace may help an individual to stay active by enhancing
the position and movement of the knee or reducing pain.

Cleaning and Maintenance:
• The best way to clean a KAFO is to spray the inside with rubbing alcohol and
wipe dry to remove body oils and residue. It can also be cleaned by wiping
it out with a damp towel and anti-bacterial soap or anti-bacterial moist
towelettes.
• Do not immerse the KAFO in water, as this will harm the instep strap and
metal fasteners.
• Keep the KAFO away from excessive heat to prevent damage to the plastic.
• Tips and Problem Solving:
• • KAFOs should always be worn with socks and shoes and also some type of
fabric
• comfort and wick perspiration.
• • The best type of shoe to use is a basic gym shoe with the laces or Velcro
extending well down the front of the shoe. This provides adjustability and
allows the shoe to accommodate the added dimension of the device in the
shoe without having an excessively large shoe on the opposite foot.
• • If you notice red marks, bruises, or blisters on your skin, discontinue
wearing the brace and call your orthotist to schedule an appointment

HIP-KNEE-ANKLE-FOOT ORTHOSIS (HKAFO with ,stirrup: steel
upright. Hinged anKle knee and hip-joints: drop ring lock at
the knee and hip and pelvic band.

HKAFO
• Hip joint:-
• Metal hinge that connects the lateral uprights to pelvic band
• Joint prevents abduction and adduction as well as hip rotation
• Only control of hip rotation , a simpler alternative to hip joint
and pelvic band is a webbing strap.

• To reduce internal rotation:-
• strap resembles a prosthetic
silesian bandage.
• To reduce external rotation:-
• the strap joins the lateral uprights
of KAFOs and passes anteriorly at the level of groin

• If flexion control is required, a drop ring lock is added to the joint.
• 2 position lock stabilizes pt in hip extension for standing and
walking and 90 degree hip flexion for sitting.
• Pelvic band
• Metal band anchor HKAFO to the trunk.
• Lodge between greater trochanter and iliac crest on each side
• More awkward to don, pelvic band uncomfortable when wearer
sits, restrict gait when joints are locked.

THKAFOs
• Pt who require more stability
• Incorporate a lumbosacral orthosis
• Very difficult to don
• Heavy
• Cumbersome
• Seldom worn after discharge

Orthotic options for patients with paraplegia
• Spina bifida
• SCI
• Other disorders
• Functional goals:-
standing to maintain
skeletal,renal,respiratory,circulatory,and gastrointestinal
function and some form of ambulations
Upright posture…….. Psychological benefits

Mass- produced orthoses
• Readily available for children
• Povide youngster with considerable functions
• Less expensive
• Easier to don

Standing frame and swivel walker
• Designed for children
• Consist of broad base, posterior nonarticulated uprights extending
from a flat base to midtorso chest band & post thoracolumbar
band
• Ant leg bands……. Stability
• Ordinary shoes
• Also available for adults
• swivel walker: child & adult size
• Base different …… two distal plates that rock slightly to enable a
swivel gait

Parapodium
• Permit to wear
• Base flat
• Stabilizing points….. Same
• Pick up objects from floor
• Less expensive
• Stand without crutch support
• Freeing tne hands for play
• Can move from place to place
• Worn outside
• School-age children …. Cosmetically objectionable

Rigid orthosis (LSFEL control orthosis)

soft foam four poster orthosis

Philadelphia collar(encompass chin & posterior head
for greater restrain

B:::Four post orthosis
A:::Minerva halo/Halo vest orthosis

Minerva halo/Halo vest orthosis

Scoliosis orthosis & Milwaukee brace

Scoliosis brace/plastic Bosten orthosis

WILMINGTEN ORTHOSIS(SCOLIOSIS)

• Appliances…. Apply forces to the foot
• May be An insert…… placed in the shoe
• An internal modification…..affixed inside the shoe
• External modification……… attached to sole or heel of the shoe

• Enhance function by relieving pain
• Mechanism:-
• Transferring weightbearing stresses to pressure-tolerant sites,
• Protecting painful areas from cantact with the shoe,
• Correcting alignment
• Accomodating a fixed deformity

Internal modifications
• Closer the modification to the foot…….more effective it is
• Widely used
• Insert permits the pt….. Transfer orthosis from shoe to shoe.
• Terminates just behind the metatarsal heads; may slip forward
, particularly if shoe has relatively high heel.
• Some inserts… extend the full length of the sole, preventing
slippage but occupying often limited space

• Internal modifications are fixed to the shoe’s interior,
guaranteering the desired placement but limiting the patient
to the single pair of modified shoes.
• Reduce shoe volume…. So must be judged
• Materials
• Soft material….viscoelastic plastics
• Semirigid or rigid plastics, rubber, or metal often with a
resilient overlay.

• Heel-spur insert orthosis, for example, may be made of
viscoelasticplastic or rubber.
• Orthosis slopes anteriorly and a concave relief….. Reduce pressure
on the tender area.
• Longitudinal arch supports… intended to prevent depression of the
subtalar joint and flattening of the arch (pes planus)
• Orthosis may include a wedge to alter foot alignment.
• Rubber scaphoid pad apex lies between talus and navicular
tuberosity.

• Flexible flat foot:- realigned by a semirigid plastic UNIVERSITY
of California Biomechanics Laboratory (UCBL) inserts.
• It covers heel and midfoot
• Investigations suggest For alters onset of errector spinae and
gluteus medius activity so reduces patellofemoral pain
• While others show little or no effect.

• The metatarsal pad:-
• Convexity may be incorporated in an insert or may be resilient
domed component glued to the inner sole…. Apex is under the
metatarsal shafts.
• Transfers stress from the metatarsal heads to the metatarsal shafts.
• Occasionally modifications are sandwiched between inner and
outer soles, for example pt with marked arthritic changes
• Long steel springs…..eliminate motion at the painful jt
• Same effects with rigid insert

External modifications
• Ensures that the patient wears the appropriate shoes and does
not reduces shoe volume
• Erode as the pt walks
• Client limited to wearing the modified shoe, rather than being
able to choose from a wide selection of shoes

Heel wedge
• Frequently prescribed external modification…… alters aligment
of calcaneus
• A medial heel wedge: aid in realigning flexible pes valgus, can
accommodate rigid pes varus.
• Cushion heel….. Resilient material…absorb shock
• Indicated…. Pt wears an orthosis with a rigid ankle.

Lateral heel wedge
• Shifts weight bearing to the medial side of the front of the foot
• Indication:-
fixed forefoot valgus
Sole wedge
Alter medial-lateral metatarsal alignment

Metatarsal bar
• Flat strip of leather or other firm material placed posterior to
the metatarsal heads
• At late stance, the bar transfers stress from MTP jt to
metatarsal shafts.
• Rocker bar is a convex strip…. Affixed to the sole proximal to
the metatarsal head
• pt with leg length discripancy of more than ½ in. will walk
better with a shoe lift made of cork or light weight plastic

• Foundation for most L/L orthoses
• Transfer body weight to the ground and protect the wearer
from the terrain and weather.
• Individual with an orthopaedic disorder, fotwear can serve two
additional purposes:
• 1) it reduces pressure by redistributing force
• 2) it serves as the fondation for AFOs and more extensive
brace.

• Major parts of the shoe are
• Upper
• Sole
• Heel
• Reinforcements
• These features are found in both the traditional leather shoes
and athletic sneaker.

upper
• Portion of the shoe over dorsum of the foot is the Upper.
• Anterior component:- vamp
• Posterior part:- quarter
• In a laced shoe, the vamp contains the lace stays, which have
eyelets for shoelaces.
• Laces provide more precise adjustment over the entire opening
than do strap closure, but strap shoe however enable some
individuals with limited manual dexterity to manage the shoe more
easily.

• For most orthotic purposes, a blucher lace stay Is preferable.
• Distinguished by the separation between the anterior margins
of the lace stay and the vamp. Permits substantial
adjustability…pt with e

• The alternate design is the Bal, or Balmoral, lace stay, in which
the lace stay is continuous with the vamp.

Quarter
• Quarter height
• Low quarter…. Terminates below malleoli….. Satisfactory for
most clinical purposes….. Does not restrict foot and ankle
motion.
• A high quarter shoe….. Covering the malleoli…… indicated in
pes equinus
• For foot stability in the absence of an AFO.
• Expensive and difficult to don

sole
• Bottom portion
• Two parts outer and inner sole made of leather.
• Leather soles absorb little impact shock and provide minimal
traction as compared to rubber sole
• To absorb shock, the shoe may have a resilient outer sole, inner
sole, or insert.
• Regardless of the material, outer sole should not contact the floor
at the distal end; the slight rise of the sole is known as toe
spring……….rocker effects

Heel
• Heel is the portion of the shoe adjacent to the outer sole,
under the anatomical heel.
• Broad, low heel provides greatest stability and distributes force
between the back and front of the foot.
• For adults, a 1 in. (2.5cm) heel tilts the centre of gravity slightly
forward to aid transition through stance phase, but does not
disturb normal knee and hip alignment significantly.

• A higher heel places ankle in its extreme plantarflexion range
and forces the tibia forward.
• Wearer compensates either by retaining slight knee and hip
flexion
• Or by extending the knee and exaggerating lumbar lordosis.
• Higher heel transmits more stress to the metatarsals.

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