3.

Orthotics and Prosthetics

By Ellen Sobel, DPM, PhD & Lauren Jones, DPM

Foot Orthoses
Orthosis means to straighten. There are orthoses for every part of the body from the head to the toe. An orthosis is named for the joints that it crosses. The type of orthosis used in podiatric orthopedics for arch support and cushioning for painful submetatarsal calluses is a foot orthosis (FO). The ankle foot orthosis (AFO) crosses the ankle. An orthosis that crosses both the ankle and the knee is called a knee-ankle foot orthosis (KAFO).

Functional Foot Orthosis

The Functional Foot Orthosis is designed to place the foot morphology in its most functional position, decrease the amount and rate of subtalar joint pronation, control function of the midtarsal joint, and support compensatory osseous deformities of the forefoot. The patient must be casted off weight bearing in the subtalar joint neutral position and then the foot will take on a three dimensional shape generally with more of an arch and a compensatory forefoot supinatus. The root Functional Foot Orthosis consists of a thermoplastic shell made of polypropylene, polyethylene, acrylic, or composite materials. Angular posts added to the plantar aspect of the shell maintain the position of the rearfoot around the subtalar joint neutral position and support compensatory deformities of the forefoot. The Root Functional Foot Orthosis may be made with a shallow or deep heel seat.

Materials for the Functional Foot Orthosis

Table 1. Materials for Foot Orthosis Shell

Characteristic Rigid Material Polypropylene Rigidur Composite Polyethylene Subortholen Composite Toprelle Leather Molded EVA

Semi-Rigid

Flexible

Thermoplastics soften as they are heated and harden each time they are cooled. Polypropylene thermoplastic is the most common material composing the shell of the rigid foot orthosis. Polypropylene is a thermoplastic polymer with low specific gravity and good resistance to chemicals and fatigue. The polymer structure gives polypropylene high stiffness and good tensile strength. Polyethylene thermoplastic is the most common material used for the semirigid foot orthosis shell. Acrylics (Rigidur, Plexidur, Nyoplex) are polymerized from methymethacrylate polymers. They are a stiff, dense, tough material. Acrylic shells are commonly 3-5 mm thick. Composites are combinations of different plastics into one form. A composite of carbon fiber and acrylic is a popular combination used in foot orthosis shells called Carboplast. Combining acrylic plastic with carbon fibers creates a plastic sheet as rigid as acrylic and polypropylene, but with only half the thickness. Leather is a flexible animal hide material, which is used in flexible foot orthoses and is very easy to modify. Most leather foot orthoses are chrome-tanned.

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Rubber is an elastic substance produced from the milky sap (latex) of tropical plants or made synthetically. Rubber is tough, resilient, and a high shock absorber. The three classes of rubbers are expanded, sponge, and latex. Microcellular rubber,Ethylvinylacetate (EVA) is a hollow material that creates an internal network of air cells used to construct lightweight shock absorbing insoles of low density. Toprelle is a hybrid of rubber and thermoplastic which makes a lightweight relatively flexible orthotic shell. Closed-cell expanded rubber (spenco). Closed-cell expanded rubber or spenco is manufactured by the introduction of nitrogen gas under pressure to the rubber mix. External pressure is lowered allowing absorbed gas to expand and form thousands of individual closed cells. Spenco has a nylon top cover and is a very common flexible insole material. Open-cell sponge rubber (Lynco). Open-cell sponge rubber (Lynco) is formed by mixing a blowing agent into a rubber compound. Gas is liberated during the vulcanization process forming open cellular structures. It is a very soft material used for foot insoles. Rubberized cork known as cushion cork or korex is cork combined with a rubber binder that makes the cork more flexible, reducing cracking and adding additional shock absorption. Polyethene foams (e.g., Plastazote) is a closed cell polyethylene foam manufactured from a block of polyethylene plastic that is placed in a mold, then in an oven, and expanded. Felt (Orthofelt, Hapads). Platform felt is a fabric made of wool fibers matted together by steam and pressure. Adhesive-backed, precut felt can be used as heel, arch, metatarsal, and callus pads which can be placed directly on the foot or onto the foot orthosis. Viscoelastic polymer made from polyurethane elastomers create rubber like insoles, heel pads, and foot orthoses. They are rather heavy and difficult to cut. The SofSpot Viscoheel (Bauerfeind USA, Inc, Atlanta, GA) is a silicone polymer heel cushion that has a built in area of softer durometer specially designed to disperse weight around the plantar medial tubercle of the calcaneus, the site of inflammation in plantar fasciitis. Viscoelastic heel pads have been reported to reduce the impact of heel strike on the leg and low back by as much as fifty percent. The Tuli heel cup (Tuli International Comfort Products, San Marcos, CA) is a soft rubber heel cushion with trademark waffling. In patients with heel pain caused by fat pad atrophy, hard plastic heel cups (M-F Athletic company, Cranston, RI) theoretically position the heel pad underneath the calcaneus restoring the natural cushioning and compressibility. Poron and PPT are open-cell polyurethane foams made that are commonly used as soft shock absorbing insoles and as a soft top cover over the rigid shell of the functional foot orthosis.

Orthotic Device Modifications

A POST is a wedge that is added beneath the exterior surface of the orthotic shell (extrinsic opost). The post may be made by making modifications to the shape of the positive impression itself (intrinsic posting). Rearfoot Varus Post A rearfoot varus post is an added wedge under the medial heel of the orthotic shell (Table 2). The thickness or apex of the post is under the medial side. The rearfoot varus post is the most common type of posting added to the Functional Foot Orthosis. The indications are for a flexible pronated foot type to prevent subtalar joint pronation and to hold the rearfoot in a more inverted position. The rearfoot varus post may be an extrinsic post, which is added to the shell of the orthosis, or it may be an intrinsic post, which is built into the shell of the orthosis. Generally the rearfoot varus post is no greater than four degrees.

Figure 1. Rearfoot Post

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Table 2. Orthotic Modifications

BIOMECHANICAL Limit subtalar joint pronation Deep heel seat Rear foot varus posting (for flexible foot type) High medial heel cup Blake orthosis modification Kirby heel skive Forefoot posting Forefoot balancing Calcaneal pitch 1st ray cut out Kinetic Wedge Heel lift Solid ankle foot orthosis Plantar fascial groove heel lift Whale pad U-pad Donut pad

Limit midtarsal joint motion

BY PATHOLOGY

Accommodation of 1st ray problems-hallux rigidus, sesamoiditis Accommodation of ankle equines For plantar fasciitis

Figure 2. Forefoot Post

Forefoot Varus Post A forefoot varus post is an added wedge under the medial forefoot of the orthotic shell (Table 2). The thickness or apex of the post is under the medial side of the forefoot. The forefoot varus post is used with a rearfoot varus post if the rearfoot varus post is insufficient to hold the foot in the corrected position. The forefoot varus post supports a compensatory rigid forefoot supinatus deformity. Forefoot Valgus Post A forefoot valgus post is an added wedge under the lateral forefoot of the orthotic shell (Table 2). The thickness or apex of the post is under the lateral side of the forefoot. A forefoot valgus post is indicated for prevention of ankle sprains and for a rigid forefoot valgus deformity. Rearfoot Valgus Post A rearfoot valgus post is an added wedge under the lateral rearfoot of the orthotic shell (Table 2). The thickness or apex of the post is under the lateral side of the rearfoot. This type of post is the least commonly used as it will increase subtalar joint pronation. Indications for the rearfoot valgus post include prevention of ankle sprains and to accommodate a rigid equinovalgus deformity such as occurs in neuromuscular such as disease-cerebral palsy. Zero Degree Post The zero degree post stabilizes the heel in a vertical position in situations in which the total rearfoot varus deformity is less than 8 degrees, but exaggerated pronation is still a concern, and the rearfoot may be posted to zero degrees.
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Bar Post A bar post is a flat forefoot post that may effectively decrease pressure on the metatarsal heads by supporting the metatarsal necks. It is common to request a two-five bar post when treating a plantar flexed 1st ray. Biplanar Grind The biplanar grand is a grind down wedge on the distal medial portion of the extrinsic rearfoot post, which theoretically maintains ideal osseous alignment through the unaltered rearfoot post but allows the rearfoot to pronate the necessary four degrees for shock absorption during the contact phase of gait. Deep Heel Seat The heel cup height is the vertical distance between the heel contact point of the positive cast and the circumscription line of the heel cup on the positive representation of the foot. A deep heel seat especially a high medial heel cup is used to limit excessive subtalar joint pronation as manifested by eversion of the calcaneus. Calcaneal Inclination Angle (Calcaneal Pitch) The calcaneal inclination angle involves removing one-fourth inch to one-half inch of material from the plaster positive and then forming the shell to this contour. The calcaneal inclination angle (calcaneal pitch) is used to control sagittal plane motion at the midtarsal joint by supporting the head of the calcaneus. Lateral Flange The lateral flange is an increase in the height of the orthosis on the lateral side of the foot starting lateral to the heel and continuing distally at viable length usually not beyond the 5th metatarsal head. The height is variable but no higher than inferior to the lateral malleolus. Indications for a lateral flange are for prevention of ankle sprains, to prevent lateral slide off of the foot, and to control and support rigid rearfoot varus deformity such as in clubfoot. In general when the rearfoot valgus deformity is flexible, it can be corrected with a rearfoot varus post, however, if the rearfoot varus deformity is rigid such as in clubfoot or long-standing equinovarus deformity of neuromuscular disease, a lateral flange will control the rigid varus deformity of the rearfoot. Lateral Clip The lateral clip is an increase in the height of the orthosis on the lateral aspect of the foot starting proximal and lateral to the center of the heel and ending distally at the proximal aspect of the 5th metatarsal base. The height is variable, but should be no higher than the inferior surface of the lateral malleolus. Indications are the same as for a lateral flange. Medial Flange The medial flange is an increase in the height of the orthosis on the medial side of the foot starting medial to the heel and extending distally with increasing height with the apex near the navicular and then decreasing in height to end along the first metatarsal shaft. Indications for the medial flange are for control of pronatory problems especially when they are rigid. To tolerate a medial rearfoot post, there must be some flexibility to the foot with a range of motion, however, a rigid rearfoot valgus deformity such as occurs in endstage flatfoot disorders with no range of motion may be controlled somewhat with a high medial flange. Toe Crest A toe crest may be used to treat hammer toe or claw toes. By supporting the central portions of the second through fifth digits, toe crests function to reduce pressure beneath the metatarsal heads and distal toes by distributing pressure over a larger surface area. Also, because toe crests effectively stabilize the distal phalanges, their addition helps improve the propulsive period function of the flexor digitorum longus, which does not function properly (Flexor stabilization) when digital contractures are present. First Metatarsal Head Cutout This is complete removal of the orthotic shell under the first metatarsal head. Indications for the first metatarsal head cutout include: sesamoiditis, forefoot valgus deformity, and hallux limitus.

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Kinetic Wedge This is a cutout under the 1st metatarsal head replaced with softer durometer material. The shape of the cutout with a wide medially shaped wedge angle similarly to the 1st ray axis. The kinetic wedge is indicated to promote plantarflexion and eversion of the 1st ray for Functional Hallux Limitus deformity. Mortons Extension Material is added under the orthotic shell extending through the 1st ray and crossing the 1st metatarsophalangeal joint to immobilize the joint. Indications for a Mortons Extension modification are for a painful hallux limitus/rigidus for splinting and immobilization. See Table 2 for summary of Foot Orthoses Modifications.

Figure 3. Kinetic Wedge

Figure 4. Mortons Extension

Cuboid Pad A cuboid pad is a small pad placed directly beneath the cuboid, used with prefabricated orthotics to accommodate plantarflexed 4th or 5th rays. Some orthotic companies put a cuboid pad on all orthotics claiming that it supports the lateral arch.

Figure 5. University of California Biomechanics Laboratory Orthosis (UCBL)

University of California Biomechanics Laboratory Orthosis (UCBL)

See Figure 5. The UCBL is used to treat flexible flat foot, plantar fasciitis, and calcaneal spurs. The UCBL is casted in the full weight-bearing position. The device elevates the arch by holding the foot in a position of forefoot adduction and hindfoot inversion. In one study-patients wearing a UCBL orthosis for three months had a 60-100% relief of heel pain. The UCBL orthosis was found to reduce the degree and duration of abnormal pronation during the stance phase of gait in flatfoot patients. The UCBL orthosis with medial posting has been successfully used to treat posterior tibial tendon dysfunction.

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Dynamic Stabilizing Insole System (DSIS)

This foot orthosis is unique for having a split forefoot plate for individual function of the medial and lateral column. It has a 5 degrees intrinsic varus offset heel. The orthosis is indicated for childrens flatfoot pronatory conditions.

Figure 6. DSIS

Orthotic Devices for Arthritis Patients

The arthritic foot generally demonstrates stiffness with loss of passive range of motion at the subtalar joint. Typical foot problems of the arthritis patient include metatarsalgia and hindfoot valgus. Metatarsalgia The patient with pain under the metatarsals usually has painful burning calluses under the metatarsal heads and atrophy of the plantar fat pad. Foot orthoses for forefoot pain generally consist of soft materials such as closed celled polyethylene foam (plastazote) and open cell polyurethane foam (PPT) and microcellular rubber (spenco). Metatarsal pads can be placed proximal to the metatarsal heads on the orthoses to unload painful plantar callosities. If subluxation at the metatarsophalangeal joint has occurred with plantar-plate rupture, a stiff, full-length insole that limits hyperextension of the metatarsophalangeal joint may be helpful. Examples include a thin carbon fiber orthosis. Shoe corrections for metatarsalgia include a metatarsal bar to unload painful metatarsal heads and a rocker bar to facilitate motion over the metatarsophalangeal joint. The heel of the shoe should be low in the arthritic patient with metatarsalgia. Hindfoot Valgus Since the calcaneus is lateral to the weight-bearing axis of the tibia, most midfoot and ankle problems in arthritic patient result in hindfoot valgus deformity. The goal of the orthosis is generally to prevent further pronation of the midfoot and valgus of the hindfoot. If the hindfoot valgus is still somewhat flexible, a rearfoot varus post, Kirby heel skive, or Blake-inverted orthosis modification may be added to the foot orthosis. If the patient has a rigid hindfoot valgus, then a high medial flange may offer support to a rigid foot. Shoe corrections for the patient with rigid hindfoot valgus include medial offset heel, medial buttress, stiff heel counter, rigid shank and high top. Ankle Arthritis When arthritis affects the ankle, a solid ankle foot orthosis may be indicated, either of plastic or metal. A solid AFO may also be indicated for the totally collapsed arch with painful bursa under the talar head or for severe instability of the subtalar and/or ankle joint. When a solid AFO is worn immobilizing the ankle, shoe corrections need to be added to accommodate the limitation of ankle motion. Shoe corrections for the painful arthritic ankle include a Solid Ankle Cushion Heel (SACH), which facilitates plantarflexion at heel strike and cushions the heel from heel strike to midstance. It attenuates shock and reduces ankle range of motion from heel strike through midstance to toe-off. A rocker bottom sole is usually worn with the SACH heel to facilitate roll over. Elastic ankle wraps, the Aircast Stirrup, and a cloth lace-up gauntlet type ankle braces (Swedo-ankle brace) may be helpful in immobilization and support of the painful arthritic ankle.

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Ankle Foot Orthosis

Orthotic Devices for Neuromuscular Disease
Indications The AFO is the most common type of orthosis used. The AFO is also known as: short leg brace, drop foot brace, Klenzak ankle brace, and coil spring brace. It may be fabricated as a metal double upright or as a plastic shoe insert orthosis. The main indications for the AFO is for individuals with neuromuscular disease who have a flaccid drop foot or spastic equinus. The AFO provides ground clearance during the swing phase of gait. The brace also provides stability during the stance phase of gait for patients with weakness, spasticity, and instability. For patients who are nonambulatory the AFO is utilized to maintain position and prevent contractures. See Table 3 Bracing the Neuromuscular Patient on page 137 for a summary of indications for Ankle Foot Orthoses.

Table 3. Bracing the Neuromuscular Patient

GROUP ADULTS PROBLEM Flaccid drop foot with isolated dorsiflexor weaknes Flaccid drop foot with dorsiflexor and plantar-flexor weakness Spastic ankle equinus Spastic equinovarus BRACING SOLUTION Posterior Leaf Spring (PLS) Ankle Foot Orthosis (AFO) (May be plastic or metal) Solid Ankle Foot Orthosis (May be plastic or metal) Semirigid or Solid Ankle Foot Orthosis (May be plastic or metal) Semirigid or Solid Ankle Foot Orthosis with correction for varus, which may include lateral t-strap, lateral calf flange (Only the metal orthosis has the t-strap) AFO Double upright metal

CHILDREN

Patient with insensitivity, or edema, or previous ulcers from plastic AFO Mild ankle equinus/drop foot with poor dorsiflexion Spastic ankle equines with good dorsiflexion power Medial/lateral ankle instability

Posterior Leaf Spring AFO Articulated Ankle Foot Orthosis Supramalleolar Orthosis

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Figure 7. Double Upright Ankle Foot Orthosis (AFO)

Metal Double Upright Ankle Foot Orthosis

Before the introduction of plastic the metal double-upright AFO (See Figure 7) was the standard brace used for drop foot, and all upper and lower motor neuron conditions requiring a below knee leg brace. The double upright metal AFO is still considered the safest orthosis for patients with sensory loss and edema who cannot tolerate the hard margins of plastic against the skin (See Table 3 for summary of the indications of Ankle Foot Orthoses). The ankle joint of the metal brace is usually set at 90 with the foot perpendicular to the leg. The ankle joint can be positioned at 10 to 15 dorsiflexion to increase the toe pickup during the swing phase and avoid tripping. However a 10 to 15 dorsiflexed ankle brace tends to increase the flexion moment at the knee during stance phase and reduces the degree of genu recurvatum produced from the ankle equinus. The dorsiflexed brace may cause the knee to buckle. There is a direct trade-off between the amount of toe pickup and the amount of knee instability, which a dorsiflexed ankle setting position will create. The more toe pick up that the orthosis provides, the greater the instability at the knee. The brace may help to achieve maximum stability of the knee over most of stance by setting the ankle in mild plantar flexion (5-10 plantarflexed). However, this setting provides the least toe clearance. When the knee extensors are weak, mild ankle equinus deformity and genu recurvatum may be useful to the hemiplegic patient as a means of providing stability of the knee during weight bearing. The ankle of an AFO may be set in five to ten degrees of plantarflexion to create a recurvatum moment at the knee to compensate for weak quadriceps muscles. When the knee is very unstable a knee-ankle-foot orthosis (KAFO) may be necessary. The variations in the double-bar AFO function are achieved by adjustments at the ankle joint. A FREE MOTION ankle allows motion in any direction. The ankle joint may be set to prevent all motion (STOP), which is indicated when immobilization is required to alleviate pain and to enhance stability, such as in patients with painful arthritis. A metal AFO with a rigid ankle is known as a Solid Ankle Foot Orthosis. The ankle joint of the metal AFO may be fixed so that plantar flexion can not go past 90 (foot perpendicular to the leg). This is known as a 90 posterior plantarflexion stop. The 90 posterior plantarflexion stop is helpful for patient with severe spastic ankle equinus. The anterior (dorsiflexion) stop limits dorsiflexion, thus acting as a calf muscle substitute. It blocks dorsiflexion during the end of mid-stance and push-off. The anterior stop prolongs mid-stance and delays heel-rise. It mechanically assists push-off. When active plantarflexion is present, a spring assist may be added to return the ankle to neutral and attain ground clearance during swing. The double upright AFO is generally worn with a blucher oxford shoe. A leather T-strap may be attached to the shoe and buckled around the medial or lateral upright to correct varus or valgus deformity. In the pronated (valgus)

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foot, the T-strap is attached on the medial side and buckled around the lateral upright. In the varus foot, the T-strap is attached to the lateral side and buckled to the medial upright to pull the foot out of varus. There are several advantages of the double upright AFO over the plastic variety. The double upright AFO is the best orthosis for patients who have sensory deficit and are likely to ulcerate with a plastic AFO. The metal AFO may tend to be sturdier than the plastic type. The solid ankle variety is excellent for stroke patients with severe spasticity. The chief disadvantage is that it is usually only possible to wear one pair of shoes, which are attached to the uprights. In some patients with hemiplegia who have markedly limited active hip and knee flexion, toe-drag will not be eliminated by an AFO. When the patient has markedly limited hip and knee flexion, it is impossible to clear the toe on swing-through even though the AFO is adequate. In this case, it is useful to raise the heel and sole of the contralateral shoe sufficiently to allow clearance of the involved side on swing-through, usually one-quarter to one-half inch being enough.

Figure 8. Solid AFO on left, PLS on right, Semirigid AFO center

Plastic Ankle Foot Orthosis

The plastic AFO designs (see Figure 8) consist of Posterior Leaf Spring Orthosis (PLS) Solid ankle foot orthosis Articulated (jointed) ankle foot orthosis Total contact ankle foot orthosis (with anterior shell) Supramalleolar orthosis (short orthosis) with proximal trim lines cut just above the malleoli

Figure 10. Arizona Brace

Figure 9. Posterior Leaf Spring (PLS) Orthosis Orthopedics | Orthotics and Prosthetics

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Posterior Leaf Sprint Plastic Ankle Foot Orthosis

The polypropylene Posterior Leaf Spring (PLS) (see Figure 9) orthosis is a lightweight, flexible AFO created by narrowing the distal posterior ankle of the calf shell so that the trim lines are posterior to the malleoli. This makes the orthosis more flexible and allows plantarflexion at heel strike and following push-off returns the orthosis to neutral for the swing phase, providing toe pickup. The orthosis can be strengthened with vertical corrugations built into the ankle joint and still retain the posterior trim line. For maximal resistance to varus or valgus, a flange may be placed on the middle third of the calf shell, which creates a three-point pressure system. When placed on the lateral side, the flange controls varus deformity. The patient who is prescribed the PLS polypropylene orthosis may have little or no dorsiflexion power. Because dorsiflexion is only partially resisted by the PLS, it is contraindicated with weak plantar flexors. There should be good mediolateral stability in stance phase. Passive ankle dorsiflexion to 90 should be possible with the foot becoming plantigrade during midstance. Mild spasticity may be present when prescribing the PLS orthosis. The very thin polypropylene AFO to correct drop foot does not provide the stability for a weak calf and significant spasticity, which is present in many stroke patients. The PLS orthosis will provide toe clearance during swing phase, a mild degree of mediolateral stability during swing and stance phase, and allow physiologic plantarflexion after heel strike and permit the plantar flexors to function for push-off. The PLS orthosis is the counterpart of the metal double upright brace with a dorsiflexion assist. A 90 plantarflexion stop should not be used with a PLS orthosis since it will prevent plantarflexion at heel strike.

Figure 11. Solid Ankle Foot Orthosis

Plastic Solid Ankle Foot Orthosis

The solid ankle foot orthosis (see Figure 11) is indicated for patients with significant spasticity, severe weakness or absence of ankle dorsiflexors and plantar flexors, and mild to severe mediolateral instability during swing and stance. The rigid polypropylene orthosis has been shown to provide the same ankle stability as a fixed ankle double upright orthosis. It is also used for painful arthritic conditions in which it is desirable to immobilize the ankle. The function of the solid-ankle polypropylene orthosis is to restrict all motion at the ankle. An anteriorly placed trim line at the level of the malleoli will provide the orthotic with the rigidity required. The solid ankle foot orthosis with a distal filler attachment may be indicated in the case of less stable partial foot amputations. The foot must be plantigrade with no equinus contractures. A partial foot amputee with an edematous stump and/or leg with potential pressure against rigid margins of the shoe insert will not be able to tolerate a plastic insert AFO design. The absence of sensation in the diabetic foot will remove a warning signal if irritation should occur and is also a contraindication to the use of a plastic shoe insert AFO. External orthoses are preferred when there is significant fluctuating edema or an absence of sensation.

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Figure 12. Articulated Ankle Foot Orthosis

Articulated Ankle Foot Orthosis

The Articulated Ankle Foot Orthosis (see Figure 12) has an ankle joint built into the plastic orthosis. The articulated AFO is used in adults and in children with spastic cerebral palsy. The articulated AFO is also used as a tone reducing night splint. There are several tone reducing features of the articulated AFO which include: 1. 15 to 20 of metatarsal phalangeal extension in the foot plate; 2. Recessing area under the metatarsal heads in order to reduce stimulation under the plantar surface to reduce the plantar grasp and decrease the positive support reflex; 3. Build up of the medial aspect of the foot plate to control foot valgus and recess slightly at the lateral areas of the calcaneus to elicit inversion reflex; 4. Build up of the lateral side of the foot plate for the foot to be in inversion, eliciting eversion reflex; 5. Figure of eight ankle strap; 6. Fixed five degrees dorsiflexion for patients with extensor tone. Disadvantages of the articulated AFO include compromised ability to control varus and valgus, problems with the structural integrity for the aggressive walker who puts enormous forces on the ankle joint area; Less cosmetically acceptable as it is bulkier, utilizes more plastic and is much more difficult to disguise. Skin breakdown at joint articulations when varus or valgus is severe; as i the inability of elderly patients to tolerate this brace.

Figure 13. Total Contact Insert (TCI) AFO with Toe Filler Also Known as Chopart Clam Shell Prosthesis

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Figure 15. Ritchie Brace

Total Contact Ankle Foot Orthosis

The Total Tontact Ankle Foot Orthosis (Figure 13) consists of a plastic solid ankle foot orthosis with an anterior shell added for further reinforcement. The total contact AFO was modeled after the total contact plaster cast and the orthosis tries to reduce pressure by completing surrounding the foot.

Figure 16. Supramalleolar Orthosis

Supramalleolar Orthosis (SMO)

The Supramalleolar Orthosis (SMO see Figure 16) is a plastic orthosis with proximal trim lines ending right above the malleoli. The orthosis offers good medial and lateral stability. It is good for treating ankle sprains and for childrens neuromuscular disease.

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Orthotic Devices for the Diabetic Patient and Partial Foot Amputation
Orthotic devices for people with diabetes mellitus have focused on reducing plantar weight bearing pressure on the foot. Orthotic devices include prefabricated foot inserts and custom foot orthoses, the prefabricated walking brace, Patellar Tendon Bearing orthosis (PTB), and Charcot Restraint Orthotic Walker (CROW) Orthosis.

Figure 17. DH Pressure Relief Prefabricated Walking Brace

Prefabricated Below Knee Walking Brace

The prefabricated below-knee walking braces (see Figure 17) including the DH-Pressure Relief Walker (Royce Medical Co., Camarillo, CA), Equalizer Premium Walker (Royce Medical Co., Camarillo, California), and Aircast Pneumatic Walker (Summit, New Jersey) formerly used for lower extremity trauma, have recently been found to be effective in reducing plantar pressure in the diabetic foot and have become very popular unweighting devices. Average peak forefoot pressures were reduced greater than 51% using the Equalizer Premium Walker and Aircast Walker. In contrast to the total contact cast they are relatively easy to use, inexpensive, and allow easy access to the wound for dressing changes. The prefabricated walking brace provides the necessary stability while allowing easy donning and doffing for physical therapy sessions, washing and sleeping. A rocker sole or ankle joints may be added to facilitate ambulation. The prefabricated walking brace can be used for immobilization of the charcot foot in diabetic patients. In one study the DH Pressure-Relief walker (Royce Medical Orthopaedics, Carmarillo, CA) reduced plantar pressures under all the metatarsals and the great toe significantly better than several other off-loading devices tested and reduced forefoot pressure equally as well as the total contact cast. In another study comparing the DH Pressure Relief Walker with the total contact cast in the reduction of plantar pressure, the DH Pressure Relief Walker reduced plantar forefoot pressure 85% from baseline as compared to 76% reduction in plantar pressure with a Total Contact Cast.

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Figure 18. Pneumatic Air cast Prefabricated Walking Brace

Aircast Pneumatic Walker

The Aircast Pneumatic Walker (Figure 18) because of it air bladders in the rigid shell has the advantage over other prefabricated below-knee walkers of a total contact fit to reduce edema and shear forces. In a study comparing the Aircast Pneumatic Walker with the total contact cast, the Aircast Pneumatic Walker decreased peak plantar foot pressures to an equal or greater degree than the total contact cast in all tested locations of the forefoot, midfoot, and hindfoot in 10 healthy male volunteers. Although these prefabricated walking braces have been found to reduce plantar weight-bearing pressure in healthy and diabetic subjects, their effectiveness in actually healing diabetic ulcers in random clinical trials has not yet been demonstrated.

Figure 19. Charcot Restraint Orthotic Walker (CROW) Orthosis

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Crow Orthosis
For patients with charcot foot too deformed to fit into an extra depth shoe, the Charcot Restraint Orthotic Walker (CROW) may be indicated (see Figure 19). The CROW orthosis is a rigid, custom full-foot enclosure anklefoot orthosis that provides immobilization and protection during the prolonged healing of diabetic neuroarthropathy. The orthosis is constructed with a total posterior and anterior shell that includes the foot so that a patient does not need to wear a shoe with the brace as would be necessary with a regular plastic AFO or PTBO.

Figure 20. PTB Orthosis

Patellar Tendon Bearing Orthosis

The Patellar Tendon Bearing Orthosis (PTBO) is one of the original orthoses for unweighting the rearfoot and the leg (see Figure 20). The PTBO is constructed with a pretibial component in which the patient rests his upper leg and knee when ambulating. Patients are trained to walk by sinking their weight into the pretibial shell and the weight is transferred down the uprights to the floor, bypassing the leg and the rearfoot. When patients walk properly with the PTB and a cane, it has been found to reduce weight bearing on the leg and rearfoot up to 60%. The PTB was originally indicated for patients with fractures of the leg and rearfoot, and to unweight a painful diabetic charcot rearfoot. It has been used to unweight patients with painful chopart joint amputations. Patients are able to walk with the PTBO while the ulcer is healing and once the ulcer has healed the brace can be used prophylactically. The PTBO has the advantage over total contact casting of being removable and is easier to maintain. It comes in metal and plastic varieties and must have a solid ankle and rigid anterior shell closure to work properly. It is also helpful to have a heel-shoe clearance of 3/8 inch to one inch and a rocker sole. The advantage of the metal double upright variety is that patients with diabetes with neuropathy, who are most likely to use this orthosis, may not be able to tolerate a plastic orthosis directly against the skin even if the orthosis is lined with pelite or plastazote foam.

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Figure 21. Half-Shoe With Dorsiflexory Wedge

IPOS Postoperative Half Shoe/Healing Sandal

The IPOS postoperative shoe (see Figure 21) was originally designed to take all pressure off the forefoot for use after surgery. The shoe has a 10 doriflexory wedge and the heel is elevated four centimeters to avoid any forefoot contact with the ground when walking. The shoe cannot be worn by individuals with ankle equinus or used for bilateral ulcers. Half shoes were shown to heal ulcers faster and be associated with fewer serious infections than patients treated with standard wound care therapy.

Figure 22. Silicone Cosmetic Foot Prosthesis

Partial Foot Amputations

For the patient with partial foot amputations, the orthotic/prosthetic prescription varies depending upon the level of amputation. The patient missing one or more lesser digits does not need any special orthosis or prosthesis. In fact a toe filler is likely to rub against the remaining toes and result in further ulceration and amputation. The patient with an amputated great toe lacks push-off. These patients require a sturdy shoe. Some patients with hallux amputations require a toe filler, but usually the hallux deviates medially after a while and no toe filler is required.

Figure 23. Foot Insert with Toe Filler

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Partial foot amputations from the level of all toes, ray amputations, transmetatarsal amputations to Lisfrancs amputation level generally can be accommodated very well by a foot orthosis with toe filler (Figure 23) in conjunction with either a sturdy blucher oxford, running shoe, or high-top shoe. Patients with transmetatarsal amputations frequently require a high-top shoe.

Figure 24. AFO with Toe Filler

Patients with amputations of one or more rays of the foot have what is known as longitudinal amputations. Amputation of one lateral ray can be accommodated by a custom-foot orthosis with toe filler and a sturdy shoe. However when several rays have been resected or when the entire 1st ray is resected, the foot becomes narrow and unstable. An ankle foot orthosis with toe filler and/or high-top shoe may be required to add stability (Figure 24). Individuals with chopart amputation have just the talus and calcaneus left on the foot. The remaining foot stump tends to develop equinus contractures, ulcerate and a higher revisional amputation is required. The chopart amputation without equinus contractures, which has been stabilized with tendoachilles lengthening and/or ankle fusion, may be accommodated by a solid ankle foot orthosis with toe filler. For patients with chopart amputations with equinus contractures, a clambshell partial foot prosthesis is required. The final level of foot amputation is the Syme Amputation, which involves the removal of the entire foot. A special prosthesis, the Syme Prosthesis is required for amputation (see Figure 25).

Figure 25. Syme Opening Window Canadian Amputation Prosthesis

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Orthoses for Sports Medicine

Figure 26. Tension Posterior Night Splint

Posterior Tension Night Splint

Recently the Tension Posterior Night Splint (Figure 26) has been used in the treatment of recalcitrant cases of plantar fasciitis. During sleep, the unbraced foot and ankle assumes a plantarflexed position due to the normal tone in the gastrocsoleus muscles. This nonfunctional plantarflexed position results in tightness of the posterior muscle group and the plantar fascia is thought to account for the severe pain that patients with plantar fasciitis experience upon their first step out of bed in the morning as the plantar fascia resumes its functional weight-bearing length. Stress relaxation is the decrease in stress with time once a material under loading has deformed to a constant length. This is due to the viscoelastic nature of all biological tissues. Similarly, when the plantar fascia is kept in a dorsiflexed, stretched position by the night splint, the biomechanical phenomenon of stress relaxation occurs and the plantar fascia relaxes in the new stretched position. The tension night splint maintains the foot in a dorsiflexed attitude while sleeping, thereby preventing tightness and contractures of the Achilles tendon and plantar fascia that occurs as a result of the plantarflexed posture of the foot during sleep. The tension night splint is typically used in combination with other treatments for heel pain. A night splint in conjunction with stretching, viscoheels, and nonsteroidal antiinflammatory medications was more effective in the treatment of plantar fasciitis than the same treatments without the night splint. This study used an office made plaster night splint constructed with the ankle in maximum dorsiflexion. These authors felt that their splint produced both ankle dorsiflexion and toe extension, which they considered critical to maintain tension in the plantar fascia.

Figure 27. Aircast Stirrup

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Ankle Braces
The Aircast Stirrup (Figure 27) and a variety of cloth lace-up gauntlet type ankle braces have become popular in the treatment of ankle sprains and other sports injuries about the ankle. Some of these sports ankle braces may even take the place of a plaster cast for a simple non-displaced ankle fracture. Ankle braces prevent active and passive inversion at the ankle, improve proprioceptive capability, and have been shown to be more effective than taping for prevention of ankle injuries. Athletes also report that they are more comfortable in an air-stirrup brace than adhesive ankle taping. More importantly, ankle braces have not been shown to inhibit athletic performance. Ankle braces are effective in the treatment of lateral ankle instability and ankle fractures. Traditionally, the treatment for stable lateral ankle fractures was a below-knee walking cast until five to six weeks after the trauma. In one study, 66 adult patients with supination external rotation ankle fractures were successfully treated with either an aircast air-stirrup ankle brace or DonJoy R.O.M.-Walker brace for five weeks with an average time until return to work of sex weeks. In a study of 0 patients with acute inversion ankle sprains, 10 patients were treated with a dynamic orthopaedic ankle brace after a 10-day plaster immobilization, and a control group of 10 patients was treated with a weight-bearing, short-leg plaster cast for 25 days. An earlier and more functional recovery occurred in the dynamic brace group. Similarly, patients treated with an Air-Stirrup ankle brace were more mobile and had shorter sick leave time than patients treated with a compression bandage.

PRESCRIPTION FOOT WEAR

Basic Terminology
Last The Last is a three-dimensional model on which the shoe is made. The shape of the toe box, the instep, the girth, and the foot curvature are determined by the last. A Single Last shoe consists of a last with the heel in proportion to the forefoot. A double (or combination) last is when two different sizes or two different proportions are used in constructing a model for shoe fabrication. The last of the shoe can also be an Out Flare Last which accommodates an abducted forefoot or painful bunion or an In Flare Last which accommodates an adducted forefoot or a foot in slightly fixed varus. A Straight Last shoe is well-aligned in the forefoot and rearfoot. The straighter the last, the more medial support is provided; therefore a straight last shoe is recommended to help control overpronation. Because most feet have a slight inward curve, most companies that make athletic shoes use a last that is curved inward approximately seven degrees.

Figure 28. Shoe Last

A board-lasted shoe has a hard fibrous board on its innersurface that provides stability and is more appropriate for individuals who overpronate. The board-lasted shoe is stiffer and may lead to an Achilles tendon injury. In a sliplasted shoe, the upper is stitched into a one-piece moccasin and then glued to the sole. These shoes provide less stability but are lighter, more flexible, and roomier in the toe box (making them an excellent choice for individuals with cavus foot types). The combination last usually consists of a board-lasted heel for rear foot stability with a board-lasted forefoot for flexibility.

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Shoe closures include the Blucher in which the shoe quarters extend forward over the throat of the vamp and are therefore loose at the inner edge. The Blucher adds room in the shoe and is preferred for insole modifications, foot orthoses, and to be worn with braces. The Blucher Oxford is the classic orthopedic style shoe. The Balmoral shoe closure has the vamp sewn over the quarters of the front of the throat. This is more of a dress shoe and the shoe does not open as easily or as fully. In-Depth Shoe The in-depth shoe is usually oxford style and has a Blucher closure. The shoe is designed with a minimum of 3/16 inch to 1/4 inch depth thoughout the shoe. The in-depth shoe usually has a deep broad high toe box, a full length wedge sole with longitudinal arch support, and a stiff counter. Work boots, even with steel toes, comfort shoes and athletic shoes are being made in expanded size with removable insoles and high wide toe box and function as in-depth shoes.

Figure 29. In-Depth Shoe

Custom-Molded Shoe A custom-molded shoe is made from a cast of the patients foot to accommodate or support a specific foot deformity. The last is a solid form over which the shoe materials are stretched to conform to the shape of the foot. The last for a molded shoe is made by taking a cast of the foot, and once dry, filling the cast with plaster to make a positive mold of the foot and leg. Custom-molded shoes are required when the foot deformity is such that a conventional, extra-depth shoe cannot be modified to accommodate the deformity or when there are special functional requirements. Custom shoes are often prescribed for patients with residual clubfoot deformities, proximal partial foot amputations, severe neuropathic arthropathy (charcot foot), nonplantigrade foot conditions such as severe equinovarus foot of neuromuscular disease, and end stage Rheumatoid arthritis foot.

Figure 30. Custom-Molded Shoe

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External Shoe Modifications

Solid Ankle Cushion Heel (SACH) The Solid Ankle Cushion Heel (SACH) heel is a wedge interposed into the heel of the shoe made of compressible foam material. The SACH heel simulates plantarflexion on heel strike and absorbs stress and impact diminishing the force to the heel. The SACH heel actually limits motion at the heel on heel strike simulating plantarflexion and is therefore good for painful ankle and heel conditions including ankle arthritis, and postoperatively for ankle fusions. Rocker Bottom Sole The anterior half of the sole is curved upward toward the end of the shoe, with the apex of the curve just proximal to the metatarsal heads allowing for more smooth transmission of weight bearing from heel to toe during stance phase of gait and decreases the weightbearing load beneath the metatarsal heads. The rocker bottom sole must be made of a rigid material. The rocker bottom sole is useful for relieving metatarsalgia, hallux limitus, and plantar forefoot ulcers. The rocking action of the sole compensates for lost ankle motion and is useful for patients with ankle arthritis, following fusions of the hindfoot, or attached to a solid ankle foot orthosis. The rocker bottom sole should be added to any shoe requiring an extended steel shank.

Figure 31. Heel Rocker

Toe Spring Toe spring is the upward curve of the distal midsole representing a modified rocker bottom that serves to shorten functional length of the shoe while allowing the metatarsophalangeal joint to move through a lessened range of motion during propulsion. A negative heel rocker is a toe rocker with a negative heel and may be helpful for patients with the foot fixed in the calcaneus position. Rigid Sole A rigid sole consists of either adding a rigid sole bar such as adding a steel spring or fiber glass plate interspersed between the midsole and outsole. It extends from the midpoint of the heel to the sulcus of the toes. It prevents dorsiflexion at the metatarsophalangeal joints. It must be used with a rocker sole. Indications for a rigid sole include hallux limitus, arthritis, metatarsal ulcers and forefoot amputations. Extended Heel Counter The counter is the stiff material in the heel portion of the upper that helps control the alignment of the hindfoot. Extended counters on either the medial or lateral side are used when additional hindfoot control or stabilization is necessary. An extended medial counter is used for ponation deformities with hindfoot valgus. If the foot is rigid with a severe heel valgus or varus on weight bearing (relaxed calcaneal stance position), a stiff countered shoe may result in pressure sores and ulceration on the medial or lateral aspect of the foot inferior to the malleoli especially in the patient with neuropathy. **Do not use with rigid deformity. Sole Wedges Lateral heel and sole wedges are used to correct flexible hindfoot varus deformities and decrease varus instability with lateral ankle sprains. Neuromuscular conditions that may be managed partially with lateral sole wedges

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include post-polio syndrome, and Charcot-Marie Tooth disease. Medial sole sole wedges help control excessive pronation and flexible hindfoot valgus deformities. The apex of the wedge is generally one-eighth inch to onefourth inch thick. **Do not use sole wedges with rigid deformity. Sole/Heel Flare A sole flare is an extension of the edge of the sole material in either a lateral or medial direction to make the shoe more stable. The flare increases the surface area in contact with the floor by 1/4 inch to one inch. Medial sole flares are used to decrease medial tilting of the shoe in severe pronation deformities and can be used with rigid deformity. Lateral sole or heel flares are used to reduce lateral ankle ligament instability and to decrease lateral tilting of the shoe in severe hindfoot varus deformities such as occurs in rigid clubfoot and equinovarus deformities of neuromuscular disease. A large lateral heel flare (as seen on some running shoes) increases both the range and speed of initial subtalar joint pronation. **Heel and sole flares can accommodate rigid fixed deformities. Heel Buttress (OFFSET) The heel buttress (offset) is firm density soling material added to the lateral or medial side of the shoe. A medial heel buttress resists pronation force and a lateral heel buttress resists varus force. **Heel buttresses can be used to manage rigid fixed deformities. Sole Elevations Sole elevations are useful to accommodate severe limb-length deficiencies. Blocks of material of known thicknesses can be placed beneath the short leg until the pelvis appears level. Usually 1/4 inch to 1/2 inch less than the full amount of the leg length difference is added to the sole to allow easier swing through of the foot during walking. Thomas Heel The Thomas heel has an anterior medial extension of at least one-half inch longer than the standard heel. It is designed to give added support under the sustentaculum tali and the medial longitudinal arch for symptomatic pes planus. The Reverse Thomas heel has the lateral portion of the heel extending anteriorly under the calcaneal cuboid joint and externally rotates the foot.

Figure 32. Thomas Heel

Metatarsal Bar The metatarsal bar is an external shoe correction that involves placing a firm material with the apex just proximal to the metatarsal bar on the sole of the shoe. Metatarsal bars unload the metatarsal heads and are indicated for painful metatarsalgia conditions including metatarsal calluses, sesamoiditis, and neuroma. Internal Shoe Modifications The shank of the shoe is equivalent to the arch of the shoe. Internal shoe modifications such as the steel shank, cookie pad, navicular scaphoid pad, longitudinal arch support, and extended medial counter all support the medial longitudinal arch.

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