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Common Orthotics Thomas Howard, MD 2010.

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Presentation on theme: "Common Orthotics Thomas Howard, MD 2010."— Presentation transcript:

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 Lace-up brace Tri-loc AFO Night splint
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 Heel wedge
Insole Heel wedge Metatarsal pad

15 Terminology

16 Types of Orthotics Prefabricated OTC Advantage Disadvantage
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 Disadvantage
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


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

23 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

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

25 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

26 How are they made?? Casting Impressions Gait/Balance Analysis

27 Modifications Metatarsal (MT) head cut-out Heel cushioning
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

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

29 Subtalar Joint Anatomy: -Talus (superior) -Calcaneus (inferior)

30 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

31 SubTalar Joint Oblique axis: -23 degrees from long axis of foot
horizontal plane

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

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

34 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

35 Gait Biomechanics

36 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

37 Subtalar Joint Motion

38 Heel Strike Internal rotation of tibia Inversion of STJ
Eversion of calcaneus

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

40 Heel Strike: Pronation

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

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

43 Stance toe-off: Supination

44 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

45 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

46 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

47 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

48 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??

49 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

50 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

51 Kaufman KR, Brodine SK, et al. Am J Sports Med. 1999;27(5):585-93
Prospective study on Navy Seals Biomechanics measured prior to training and injuries logged over 2 years Results: -Pes planus & cavus had 2X incidence of stress fracture compared to normal arch

52 Simkin A., et al. Foot Ankle. 1989;10(1):25
Prospective study of military recruits Arches measured and incidence of stress fractures recorded Femoral/tibial stress fractures higher with high arches Metatarsal stress fractures higher in low arches

53 Increased risk of Stress Fracture/Overuse injury with Pes Cavus
Cowan, D., etal. MSSE 1989; 21: S60. McKenzie, D., et al. Sports Med. 1985;2: 334. Messier, S. P, et al. MSSE. 1988; 20: 501. Warren, B. L, et al. MSSE. 1987; 19: 71. Rodgers MM. Phys Ther. 1988; 68: 1822. Chan CW. Mayo Clin Proc. 1994; 69: 448.

54 How do orthotics work?? Foot orthoses are generally believed to align the skeleton and to reduce the loading of biological structures in the lower extremities …but is there evidence??

55 Mundermann, Nigg, et al. Clin Biomech. 2003; 18: 254
Effects of posting and custom-molding of foot orthotics on lower extremity kinematics Results Molding reduced maximum tibia rotation, foot inversion, and foot inversion velocity Molding also reduced magnitude of vertical impact force Results similar by adding medial post

56 Eng JJ, Pierrynowski MR. Phys Ther. 1994;74:836.
Effect of custom foot orthotics on subtalar joint and knee joint during walking and running Adolescent females with PFPS and measured forefoot varus +/- calcaneal valgus >6° Results Subtalar joint rotation reduced 1 to 3 ° with orthotics Knee motion reduced in frontal plane during walking, not running

57 Nester CJ, et al. Gait Posture. 2003; 17: 180.
Assess the effect of medially and laterally wedged foot orthotics on joint movements Healthy subjects Results Medial wedge Decreased rearfoot pronation Increased lateral ground reaction force Lateral wedge Increased rearfoot pronation Decreased lateral ground reaction force

58 MacLean C, et al. Clin Biomech. 2006 (in press).
Evaluate influence of custom foot orthotics on kinematics in runners Healthy runners (normal eversion angles) Results Statistically significant reduction in rearfoot eversion angle in initial stance No significant findings at knee joint

59 Stacoff A., et al. Clin Biomech. 2000; 15: 54.
Effects of medial foot orthotics on skeletal movements in running Healthy male subjects (no overpronators) Results: -No change in eversion or tibial rotation with orthotics

60 Ferber R, et al. J Biomech. 2005; 38: 477.
Compare joint-coupling patterns (eversion/tibial internal rotation) with/without orthotics during running 11 overpronators measured Results No difference observed in treated group

61 Can orthotics help prevent and/or treat injury????

62 Rome K, et al. Cochrane Database Syst Rev. 2005; Issue 2.
Evaluated evidence from 10 randomized controlled trials of interventions for prevention of stress fractures All trials involved military recruits and “shock-absorbing” inserts Results 4 trials showed decrease in stress injuries Evidence not consistent on particular design Comfort very important

63 Gross ML et al. Am J Sports Med. 1991;19:409.
Questionnaire to runners wearing orthotics for various lower extremity complaints Predominant insert type was flexible Results 75.5% found improvement in their condition since wearing orthotic 90% continued to wear them after symptom resolution

64 Johnston LB, Gross MT. J Orthop Sports Phys Ther. 2004;34:440.
Effect of foot orthotics on quality of life in those with PFPS who demonstrate excessive pronation 3 month intervention with orthotics Results Significant decreases in pain/stiffness after only 2 weeks compared to pretreatment evaluation

65 COLLINS, ETAL. BJM :a1735 Compare PT, flat inserts or custom orthotics 52 wks all similar improvement

66 Others… James S., et al. Am J Sp Med. 1978; 6: 40.
78% with knee pain returned to running with orthotic use. D’Ambrosia, et al. Clin Sports Med. 1985; 4: 611 Custom orthotics reduce frequency of running injuries. Donatelli R., et al. J Orthop. Sports Phys. Ther. 1988; 10: 205 Survey showed 96% had pain relief from orthotics in treating tibial, knee, and ankle pain 70% able to return to activity

67 Take home points… Foot orthotics come in all shapes/sizes and are used for a variety of conditions When writing prescriptions: -Know your foot type and activity level -Identify trouble spots (for pads, wedges, etc…) Subtalar joint is an important factor in understanding gait biomechanics and keeping in neutral controls compensation

68 Take home points… Abnormal biomechanics are proven to increase risk for injury Still debate over how orthotics actually work Still work to be done on effectiveness…but comfort is key!!!


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