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Common Orthotics

Common Orthotics. Thomas Howard, MD 2010. Objectives. Define Orthotics Discuss Common Orthotics Focus on Foot Orthotics Explain importance of Subtalar Joint Review biomechanics of the foot- normal and pathologic Review functional theories of foot orthotics

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Common Orthotics

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  1. Common Orthotics Thomas Howard, MD 2010

  2. Objectives • Define Orthotics • Discuss Common Orthotics • Focus on Foot Orthotics • Explain importance of Subtalar Joint • Review biomechanics of the foot- normal and pathologic • Review functional theories of foot orthotics • Assess foot orthotics role in the prevention and treatment of injury

  3. What is an Orthotic?? Definition: An orthopedic appliance/device designed to correct, straighten or support a body part

  4. How do they work?? • Prevent abnormal motion or movement? • Change mechanics? • Proprioception?

  5. Elbow • Tennis Elbow

  6. Wrist • Cock-up splint • TSS • Carpal tunnel brace

  7. Finger • Stax splint • Dorsal PIP splint

  8. Back • TLSO • Milwaukee brace • Lumbar Corset • Hyperextension Brace • Cervical collar

  9. Knee • ACL/de-rotation brace • MCL brace • Knee sleeve • Cho-pat strap • Single and dual strap

  10. Ankle • Stirrup brace • Short and long • Lace-up brace • ?figure-eight strap • Tri-loc • AFO • Night splint

  11. Foot • Met Pad • Bunion brace • Hammer toe brace • PSC • Arch Brace

  12. Foot Orthotic Basics

  13. What is a Foot Orthotic?? Device used to accommodate foot deformity or pressure lesions, cushion the foot, alter sensory input, or realign foot posture

  14. Terminology Arch support Medial/lateral wedge Insole Heel wedge Metatarsal pad

  15. Terminology

  16. Types of Orthotics • Prefabricated OTC • Dr. Scholls, Spenco, Hapad • Advantage • Cheap • Convenient • Effective • Disadvantage • Mass produced • Nonspecific arch contour • Fails to address positional/structural deformities and compensations

  17. Types of Orthotics • Biomechanical or Custom • Advantage • Address the source of compensation • Slow rate/extent of deformity • Disadvantage • Cost • Experience of provider • May not help

  18. Accomodative Orthotics • Fit in shoe to stabilize foot deformity • Allows foot to compensate • Transfer weight from painful area • Improves shock absorption • Control ground reactive forces around a specific location • Example: Diabetic foot, Neuropathy, PVD, congenital malformations

  19. Functional or Corrected Orthotic • Addresses patho-mechanical components of the lower extremity/foot/ankle condition • Resists abnormal compensation • Prevent pain during ambulation • Prevent pathologic ROM • Example: athletes, pes planus, pes cavus

  20. Custom: Stiffness • Rigid (pes planus) • control foot function • provide stability • firm material • Semi-rigid (athletes) • dynamic balance of foot • layers of soft/rigid laterial • Soft (pes cavus) • absorb shock • improve balance • remove pressure • compressible material

  21. Materials • Thermoplastic/Polypropylene • EVA (Ethyl vinyl acetate) • Carbon Fiber • Polyethylene Foam (“Plastazote”) • Cellular Urethane (“Poron”) • Graphite

  22. Indications • Support and correct intrinsic deformities • Decrease frequency of lower limb injuries • Control ROM • Improve sensory feedback / proprioception/neuromuscular responses • Dissipate pathologic ground reaction forces and improve shock absorption • Improve LE biomechanics

  23. Evaluation • Chief complaint • Assess mobility (hypo, hyper) • Type of orthotic needed (dress, athletic, street) • Rigidity • Material

  24. Evaluation • Assess ROM, positioning • Test lower quadrant muscle strength • Static stance position and toe rise • Leg length measurement • Gait analysis • Assess position & motion of spine hip/pelvis, knee, lesser metatarsals

  25. How are they made?? • Casting • Impressions • Gait/Balance Analysis

  26. MT cut-out Modifications • Metatarsal (MT) head cut-out • Heel cushioning • Metatarsal pads • Morton’s extension • Rigid forefoot extension Morton’s extension Pad Heel cushioning

  27. How are they made?? No matter which method is done….. Subtalar Joint must be in neutral position

  28. Subtalar Joint • Anatomy: -Talus (superior) -Calcaneus (inferior)

  29. Subtalar Joint • Oblique orientation • Allows for pronation and supination • Motion is tri-planar • Affects motion/flexibility of midtarsal joint and tibia • Controls plantar surface pressure and contact with the ground during gait

  30. SubTalar Joint • Oblique axis: -23 degrees from long axis of foot -41 degrees from horizontal plane

  31. Subtalar Joint • Motion is tri-planar • Pronation • Eversion, abduction, dorsiflexion • Supination • Inversion, adduction, plantarflexion

  32. Midtarsal Joint • Calcaneocuboid • Talonavicular • Motion at STJ • Passes from talus/ calcaneus to navicular and cuboid • Affects flexibility or stiffness of foot

  33. Tibial Rotation • Torque developed by foot movement transmits proximally • 1:1 relationship between degree of • Supination and tibial external rotation • Pronation and tibial internal rotation

  34. Gait Biomechanics

  35. Gait Cycle (walk) • Heel Strike (0-15%):pronate • Stance/foot flat (15-30%): pronate to supinate • Push/toe off (30-45%): supinate • Swing (45-60%): supinate to pronate

  36. Subtalar Joint Motion

  37. Heel Strike • Internal rotation of tibia • Inversion of STJ • Eversion of calcaneus

  38. Gait Biomechanics • Heel Strike: Eversion of calcaneus Alignment of mid-tarsal joints (parallel) Allow increased motion/flexible foot Absorb shock/accomodate

  39. Heel Strike: Pronation

  40. Stance Phase • Pronated position holds through 1st 15% of stance; then supination begins • External rotation of tibia • Eversion of STJ • Inversion of calcaneus

  41. Gait Biomechanics • Mid-Stance: Inversion of calcaneus Midtarsal joint axis not parallel Foot becomes more rigid Increased stability

  42. Stance toe-off: Supination

  43. Abnormal Pronation • Add 6° eversion to calcaneal ROM (nl=20°) • Increase ground reaction forces along medial chain • Excess internal rotation of tibia • Muscles work harder to keep balance • Decrease stability during propulsion

  44. Abnormal Supination • Add >12° of calcaneal inversion (nl=10°) • Increased forces along lateral chain • Hypomobility in subtalar joint • Decreased shock-absorbing capability • Decreased stability at heel strike

  45. Subtalar Joint and Orthotics • Position of STJ affects position and function of entire foot • Neutral STJ is the point in the stance phase of gait where joint is not compensated

  46. Subtalar Joint (STJ) and Orthotics • If capture pronated/supinated (compensated) foot for molding orthotic, get contour that reflects and facilitates compensated position • Want orthotic to control STJ motion before it compensates to allow optimal function of joints/muscles

  47. Clinical significance??? • Do abnormal properties of gait lead to clinical pathology?? • Do orthotics change biomechanics of gait?? • If so, have they been proven to prevent injuries??

  48. Messier SP, Pittala KA. MSSE: Oct 1988;20(5):501-5 • Retrospective study • Relationship between biomechanical variables and injury (ITB, shin splints, plantar fasciitis) • Results: -Nonsignificant increase in over-pronation and high- arches in injury group

  49. Willems TM, et al. Gait & Posture 23 (2006):91-98 • Prospective study in freshmen athletes in Belgium • Risk factors for exercise-related lower leg pain (ERLLP) • Gait examined and injuries logged • Results • Overpronation associated with increased incidence of ERLLP

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