foot orthoses

FOOT ORTHOSES

Orthoses

•A mechanical device fitted to the body to maintain it in an anatomical or fuctional position

Functional classification

•Supportive•Functional•Corrective•Protective•Prevent substitution of function•Strengthening•Relief of pain•Prevention of weight bearing

Regional classification

•Cervical orthosis•Head cervical orthosis•Head cervical thoracic orthosis•Lumbo sacral orthosi•Upperextrimity orthosis•Lower extremity orthosis

Principle of jordan

•Three point system of Jodan• F1=F2+F3 f1 DEFORMITY

f2 f3

Lower limb orthoses

•Foot orthoses•Ankle foot orthoses•Knee ankle foot orthoses•Hip knee ankle foot orthoses

•A lower limb orthosis is an external device applied or attached to a lower body segment to improve function by controlling motion, providing support through stabilizing gait, reducing pain through transferring load to another area, correcting flexible deformities and preventing of progression of fixed deformities

Foot orthoses

• Essentially it is a boot or a shoe which covers the malleoli , togather with all removable foot supports made of various materials placed inside to manage different foot symptoms and deformities

•They include modifications made to the footwear and have advantage that they can be transferred from shoe to shoe

•Modified without disturbing the shoe and are more durable than the modified shoe

Clinical indications

•Custom made FO’s are preferred when maintanance of a specific foot alignment over a long periods of tym

•Relieve pressure•To support weak or flat longitudinal or

transverse arches •To control foot position•Help in alignment of lower limb joints

Types of foot orthoses

•Soft or flexible FO’s made from leather, cork, rubber, soft plastics and plastic foam

Soft FO’s are fabricated in full length from heel to toe with increase thickness where weight bearing is indicated and relief where no or little pressure should occur

•Rubber FO’s are least acceptable as they are

•Poor permeable to increased perspiration•Lack of moulding properties•Excessive compression on weight bearing•Materials which provide best cushioning

tend to get damaged fast, therefore need to be replaced

•Most rigid FO’s are made up of metal usually steel or duraluminium, covered with leather and molded on a positive casts of the patients foot

•Plastozole available in different thicknesses and densities

•They are commonly used for Ishemic, Insensitive, Ulcerated, and arthritic feet

•Semi rigid and rigid FO’s are made of materials like leather, cork, and metals

•They are moulded to support under the longitudinal arch and metatarsal area and to provide relief of pain or irritated areas

Checklist for foot inspection

•Skin : color, texture, moisture, temperature, mobility, lesions, sensation

•Hair : quality, distribution•Nails : color, thickness, deformities (pits,

grooves), redness•Osseous or soft tissue deformities, such as

bunions, subluxed fat pads, charcot’s joints•Talocrural, subtalar, metatarsophalangeal,

interphalangeal passive mobility

•Foot and ankle muscle strength•Pulses : dorsalis pedis, posterior tibial•Achilles’ tendon reflex•Special tests : homan’s sign (DVT),

plantar fascia test (heel spur)

Shoe

•Components of lower part of shoe•Sole•Ball•Shank•Toe spring•Heel

•Upper part components•Quarter•Heel counter•Vamp•Toe box•Tongue•throat

Orthotic interventions

• Inserts and Internal Modifications•Most common foot orthosis can be placed

in many shoes•An alternative FO’ is an internal shoe

modification, which is biomechanically identical to the insert but cant be removed or transferred

•Not visible •Advantage :- gurantees the patient wears

the appropriate shoes using modification

•A three quarter insert terminates just proximal to the metatarsal heads without crowding the fore foot

•A full length insert terminates at the distal end of the toe box, thereby preventing slippage of the insert

•It should be fitted perfectly•Benefit of heel orthoses in patients with

▫Leg length reduction▫Postural instability▫Disorders that originate outside the foot

Conditions that can be managed by insets•Heel spurs•Achilles’ tendon contracture•Hind foot malalignment

Internal heel orthoses

•Reduce discomfort with heel spurs•A resilient, tapered cushion absorbs shock

at heel contact and transfers load to the forefoot

•Presence of wall i.e medial, posterior, and lateral portions of the anatomic heel will reduce irritating sliding in the shoe

•The cushion has a concave relief to minimize pressure in heel spur condition

Hind and mid foot orthoses

•Used in malalignment of the hind and mid foot

•Pes planus (pes valgus, pes planovalgus)•Pes varus•FO for pes planus should apply an

upward and laterally directed force to the alus and medially directe forces to the calcaneus and forefoot to counteract the abnormal foot alignment

•Inserts are of different material ranging from rigid plastic to semirigid cork, molded leather and plastics to relatively resilient plastics

•Optimal firmness is measured by patient’s weight activity and the extent of deformity

•Medial wedge (posterior) within the shoe helps the shoe counter to fit properly

•A shoe with long medial counter is sometimes prescribed for childeren with flexible flat foot

•UCBL insert orthosis for flexible hyperpronation

•An innovative shoe features a midsection fitted with a screw.

•One can raise or lower the height of midsection to confirm the the contour of the wearer’s foot by adjusting the screw

•For hypersupinated foot (pes cavus) a resilient insert is benificial, particularly if it has a total contact contour to increase pressure distribution

Metatarsal pads

•Helps to reduce stress over the metatarsophalangeal joints

•Convexity is present over the metatarsal shafts

•Anterior margin of the pad terminates proximal to the metatarsal heads

•Sesamoiditis :- anterior extension on the medial side

•Toe deformities :- toe crest, a convex pad placed under the sulcus area of the toes

insoles

•It influences pressure distribution and shock absorption

•Flat inserts made of resilient plastics like closed cell polyetylene foam, open cell foam, viscoelastic polymer,etc reduce high pressure concentrations when the foot is not much deformed

•Diabetic neuropathy patients•Poor balance

•Molded inserts confirm to the plantar contour and are more effective in presence of severe deformity

•Athletic shoes have this feature with air chambers designed to absorb high impact

External modifications

•Modification to the exterior of the shoe assuring that the suitable shoes will be worn and does not reduce space inside the shoe

•Hampers with the appearance of the shoe

Heel modifications

•Heel flare to stabilize the hind foot•A resilient heel or heel with posterior

bevel aids knee stability •The individual who wears a solid ankle

AFO should wear a shoe with a resilient heel or beveeled heel.

•Medial and lateral heel wedges are external modifications that alter the alignment of the entire foot

•Lateral resilient:- it accomodates hindfoot varus without causing the midfoot to increase its pronation

•Thomas heel :- it has anterior border curved with a medial extension and a slight medial wedge

Outsole

•Resilient outsole reduces the differences in the pressure concentration and absorbs shock

•A sponge rubber sheilds the wearer from the abrupt forces caused by the irregular walking surface than leather outsole

•Rubber sole improves traction between it and pavement

Rocker Bar

• It has a plantar transverse convexity which changes stance phase loading

•Apex of the curve lies slightly posterior to the metatarsal heads reducing metatarsalgia

• It helps in achieving stance phase earlier than in flat feet

•Helpful in patients with weakness of plantarflexors

•Diminishes need of full ankle excursion

Metatarsal Bar

A flat plantar surface present posteriorly from the fore foot.

The bar lies transversely across the sole beneath the metatarsal shafts

Transfers weight from the metatarsal heads to its shafts

Heel and sole elevations

•Pes equinus :- helps to bear the weight on the heel when the patient stands and also to enable to the patient to have heel and ankle rocker action during stance phase

•Leg length discrepency•For the patient in hemiparesis a 1 cm heel

and toe lift in the shoe on non paretic side faciliates paretic foot to clear during swing phase and weight bearing symmetry in stance on the paretic side

Clinical conditions

•Limb shortening•Objective modification:- provide

symmetric posture•Modifications :- heel elevation•If <1/2 : internal and >1/2 then external•Heel and sole elevation >1•Rocker bar•High quarter shoe

•Arthritis, fusion, instability of ankle and subtalar joints

•Objectives :- support and limit joint motion, accommodate deformities, improve gait

•Modifications :- high quarter shoe, reinforced counters,long steel shank, rocker bar

•Calcaneal spurs•Objective :- releive pressure on painful areas•Modifications :- heel cushion•Inner relief in heel and fill with soft sponge

•Metatarsalgia •Objective :- reduce pressure on MT heads,

supports transverse arche•Modification :- metatarsal pad•metatarsal or rocker bar•Inner sole relief

•Hammer toes•Objectives :- relieve pressure on painful areas,

support tranvesrse arch, improve push off•Modifications :- soft vamp, extra depth shoe

with high toe box or balloon patch, metatarsal pad

•Foot fractures•Objectives :- immobilize the fracture part•Modification :- long steel plank•Longitudinal arch support •Metatarsal pad, Metatarsal or rocker bar

•Hallux valgus•Objective:- reduce pressure on the 1st MTP

joint and big toe, prevent forward foot slide, immobilize the 1st MTP joint, shift weight laterally

•Modifications:- soft vamp with broad ball and toe, metatarsal or sesamoid pad, medial longitudinal arch support

•Pes plano valgus•Objectives :- reduce eversion, support

longitudinal arch•Modifications :- for children•High quarter shoe with broad heel•Long medial counter, medial heel wedge•For adults :-•Medial heel wedge•Medial longitudinal arch support

•Pes equinus•Objectives :- provide heel strike, contain foot in

shoe, reduce pressure on MT head, ease putting on of shoe, equalize leg length

•Modifications :- high quarter shoe •Heel elevation•Heel and sole elevation on the other shoe•Modified lace stay for wide opening•Medial longitudinal arch support•Rocker bar

•Pes varus•Objectives :_ obtain alignment for flexible

deformity, accommodate a fixed deformity, increased medial and posterior weigt bearing on foot

•Modifications :- high quarter shoe •Long lateral counter•Reverse thomas heel•Lateral sole amd heel wedges for flexible

deformity•Medial wedges for fixed deformity•Medial longitudinal arch support

•Pes cavus •Objectives :- distribute weight over the entire

foot, restore antero posterior foot balance, reduce pain and pressure on MT heads

•Modifications :- high quarter shoe•High toe box•Lateral heel and sole wedges•Metatarsal pads or bars•Molded inner sole•Medial and lateral longitudinal arch support

Pediatric foot orthoses

•Dennis Browne Splint•Hinged shoe

Guidelines for prescription•To reduce pressure on the heel•1 heel cushion•2 resilient insole

•To stabilize the hindfoot•1 shoe with high firm uppers•2 medial heel flare•3 lateral heel flare•4 bilateral heel flare•5 heel with resilient medial wedge

•To increase comfort in the presence of plantar fascitis or patellofemoral discomfort

•1 heel cushion or resilient heel•2 hindfoot and mid foot longitudinal arch

support

•To reduce flexible hyperpronation•1 medial heel wedge•2UCBL insert•3 hind foot and mid foot longitudinal support•4 thomas heel

•To accommodate fixed hyperpronation•Shoe with long medial counter

•To accommodate fixed hypersupinated foot•1 resilient hind and mid foot longitudinal

support

•To reduce pressure on the metatarsal head•1 metatarsal pad•2 metatarsal bar

•To reduce pressure on hammer toes•Shoe with a high toe box and extra depth

•To reduce pressure on bunions•Shoe with extra medial width; maybe made on

bunion last

•To stabilize knee during early stance•1 resilient heel•2 beeveled heel

•To facialiate mid and late stance•Rocker bar

references

•Rehabilitation medicine principles and practice 3rd edition by Joel a Delisa

•Orthotics by Joan E. Edelstein and Jan Bruckner

•Physical medicine and rehabilitation by Randall L. Braddom

•Physical therapy by Susan O’ Sullivan•Orthosis by Sunder

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