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Common Orthotics Thomas Howard, MD 2010. Objectives Define Orthotics Define Orthotics Discuss Common Orthotics Discuss Common Orthotics Focus on Foot.

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Presentation on theme: "Common Orthotics Thomas Howard, MD 2010. Objectives Define Orthotics Define Orthotics Discuss Common Orthotics Discuss Common Orthotics Focus on Foot."— Presentation transcript:

1 Common Orthotics Thomas Howard, MD 2010

2 Objectives Define Orthotics Define Orthotics Discuss Common Orthotics Discuss Common Orthotics Focus on Foot 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? Prevent abnormal motion or movement? Change mechanics? Change mechanics? Proprioception? Proprioception?

5 Elbow Tennis Elbow Tennis Elbow

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

7 Finger Stax splint Stax splint Dorsal PIP splint Dorsal PIP splint

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

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

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

11 Foot Met Pad Met Pad Bunion brace Bunion brace Hammer toe brace Hammer toe brace PSC PSC Arch Brace 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 Heel wedge Medial/lateral wedge Metatarsal pad Insole

15 Terminology

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

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

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

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

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

21

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

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

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

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

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

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

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

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

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

31 SubTalar Joint Oblique axis: Oblique axis: -23 degrees from long axis of foot -41 degrees from horizontal plane

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

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

34 Tibial Rotation Torque developed by foot movement transmits proximally Torque developed by foot movement transmits proximally 1:1 relationship between degree of 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 Heel Strike (0-15%):pronate Stance/foot flat (15-30%): pronate to supinate Stance/foot flat (15-30%): pronate to supinate Push/toe off (30-45%): supinate Push/toe off (30-45%): supinate Swing (45-60%): supinate to pronate Swing (45-60%): supinate to pronate

37 Subtalar Joint Motion

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

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

40 Heel Strike: Pronation

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

42 Gait Biomechanics Mid-Stance: 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°) Add 6° eversion to calcaneal ROM (nl=20°) Increase ground reaction forces along medial chain Increase ground reaction forces along medial chain Excess internal rotation of tibia Excess internal rotation of tibia Muscles work harder to keep balance Muscles work harder to keep balance Decrease stability during propulsion Decrease stability during propulsion

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

46 Subtalar Joint and Orthotics Position of STJ affects position and function of entire foot 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 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 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 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 abnormal properties of gait lead to clinical pathology?? Do orthotics change biomechanics of gait?? Do orthotics change biomechanics of gait?? If so, have they been proven to prevent injuries?? If so, have they been proven to prevent injuries??

49 Messier SP, Pittala KA. MSSE: Oct 1988;20(5):501-5 Retrospective study Retrospective study Relationship between biomechanical variables and injury (ITB, shin splints, plantar fasciitis) Relationship between biomechanical variables and injury (ITB, shin splints, plantar fasciitis) Results: 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 Prospective study in freshmen athletes in Belgium Risk factors for exercise-related lower leg pain (ERLLP) Risk factors for exercise-related lower leg pain (ERLLP) Gait examined and injuries logged Gait examined and injuries logged Results Results –Overpronation associated with increased incidence of ERLLP

51 Kaufman KR, Brodine SK, et al. Am J Sports Med. 1999;27(5): Prospective study on Navy Seals Prospective study on Navy Seals Biomechanics measured prior to training and injuries logged over 2 years Biomechanics measured prior to training and injuries logged over 2 years Results: 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 Prospective study of military recruits Arches measured and incidence of stress fractures recorded Arches measured and incidence of stress fractures recorded Femoral/tibial stress fractures higher with high arches Femoral/tibial stress fractures higher with high arches Metatarsal stress fractures higher in low 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. Cowan, D., etal. MSSE 1989; 21: S60. McKenzie, D., et al. Sports Med. 1985;2: 334. McKenzie, D., et al. Sports Med. 1985;2: 334. Messier, S. P, et al. MSSE. 1988; 20: 501. Messier, S. P, et al. MSSE. 1988; 20: 501. Warren, B. L, et al. MSSE. 1987; 19: 71. Warren, B. L, et al. MSSE. 1987; 19: 71. Rodgers MM. Phys Ther. 1988; 68: Rodgers MM. Phys Ther. 1988; 68: Chan CW. Mayo Clin Proc. 1994; 69: 448. 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 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 Effects of posting and custom-molding of foot orthotics on lower extremity kinematics Results 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 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° Adolescent females with PFPS and measured forefoot varus +/- calcaneal valgus >6° Results 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 Assess the effect of medially and laterally wedged foot orthotics on joint movements Healthy subjects Healthy subjects Results Results –Medial wedge Decreased rearfoot pronation Decreased rearfoot pronation Increased lateral ground reaction force Increased lateral ground reaction force –Lateral wedge Increased rearfoot pronation Increased rearfoot pronation Decreased lateral ground reaction force Decreased lateral ground reaction force

58 MacLean C, et al. Clin Biomech (in press). Evaluate influence of custom foot orthotics on kinematics in runners Evaluate influence of custom foot orthotics on kinematics in runners Healthy runners (normal eversion angles) Healthy runners (normal eversion angles) Results 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 Effects of medial foot orthotics on skeletal movements in running Healthy male subjects (no overpronators) Healthy male subjects (no overpronators) Results: 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 Compare joint-coupling patterns (eversion/tibial internal rotation) with/without orthotics during running 11 overpronators measured 11 overpronators measured Results 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 Evaluated evidence from 10 randomized controlled trials of interventions for prevention of stress fractures All trials involved military recruits and “shock-absorbing” inserts All trials involved military recruits and “shock-absorbing” inserts Results 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 Questionnaire to runners wearing orthotics for various lower extremity complaints Predominant insert type was flexible Predominant insert type was flexible Results 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 Effect of foot orthotics on quality of life in those with PFPS who demonstrate excessive pronation 3 month intervention with orthotics 3 month intervention with orthotics Results 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 Compare PT, flat inserts or custom orthotics 52 wks all similar improvement 52 wks all similar improvement

66 Others… James S., et al. Am J Sp Med. 1978; 6: 40. 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 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 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 Foot orthotics come in all shapes/sizes and are used for a variety of conditions When writing prescriptions: 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 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 Abnormal biomechanics are proven to increase risk for injury Still debate over how orthotics actually work Still debate over how orthotics actually work Still work to be done on effectiveness…but comfort is key!!! Still work to be done on effectiveness…but comfort is key!!!

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