Everything You Need to Know About Orthoses

By
Dr. Aliaa El-Hady
MD. Rheumatology & Rehabilitation

An orthosis (orthotics) is a device that is applied
externally to a part of the body.
The word is derived from ortho, meaning straight.
 Brace: is a device that corrects irregularities.
 Splint: usually used after surgery and restrict
movements.
The orthotist is the person who designs, fabricates
and repair the orthotic device.

Indications for recommending orthotic devices:
To relief pain.
To limit motion (immobilization after surgery, after traumatic injury, Compression #
management & Kinesthetic reminder to avoid certain movements).
To correct deformity e.g. Scoliosis management
To relieve symptoms of a disease by supporting or assisting the MSk & neural systems.
To reduce axial loading, mechanical unloading
To improve function in a certain segment of the body.
Assist and improve movement and function
Reduce muscle tone.
Protect against injury.
Provide proprioceptive feedback.
Provide rest.

Design characteristics of an orthotic device:
Most important features include the following:
Weight of the orthosis
Adjustability
Functional use
Cosmoses
Cost
Durability
Material
Ability to fit various sizes of patients
Ease of putting on (donning) and taking off (doffing)
Access to tracheostomy site, peg tube, or other drains
Access to surgical sites for wound care
Aeration to avoid skin maceration from moisture

Duration of orthotic use:
It is determined by the individual situation.
In situations where instability is not an issue, recommend use
of an orthosis until the patient can tolerate discomfort without
the brace.
When used for stabilization after surgery or acute fractures,
allow 6-12 weeks to permit ligaments and bones to heal.

Effects of the orthosis may lead to:
Decrease pain
Increase strength
Improve function
Increase proprioception
Improve posture
Correct of spinal curve deformity
Protect against spinal instability
Minimize complications
Assist healing of ligaments and bones

Associated drawbacks of the use of an orthotic device:
Discomfort
Local pain
Skin breakdown
Nerve compression
Muscle atrophy with prolonged use
Decreased pulmonary capacity
Increased energy expenditure with ambulation
Difficulty donning and doffing orthosis
Difficulty with transfers
Psychological and physical dependency
Increased segmental motion at ends of the orthosis
Poor patient compliance

Benefits of orthosis:
Improve function.
Save energy.
Increase endurance.

Disadvantages & limitations of orthoses:
Limit mobility and ROM of the joint.
Restrict rotation around a joint.
Movement is usually limited to certain
direction.
Weakness of other muscles in opposite
direction.
The device is exposing to wear and tear.
It needs maintenance, care, cleaning, repairing,
and frequent changing of shoes.

Principles and consideration for orthoses:
Orthosis should :
provide support and stability to the hip, knee and ankle
joints.
be designed to permit safe and effective ambulation by
patients.
Provide the need and requirements of the patient to
support or to mobilize.
Correlate to the findings of tests & measurements.
Correlate with pateint personality and the impact of
device upon him.

Principles and consideration for orthosis (cont.):
Prevent the development of deformity and require
modifications in design.
Orthosis is only one component of the treatment and
is not the whole treatment.
Conserve the time and energy of the patient.
The materials used should be light, sturdy and
resistance to wear.

Maintenance of orthosis:
Patient should be taught for:
Cleaning the leather.
Oiling the joints.
Wash the orthosis if possible.

Types of orthosis
Temporarily orthosis:
Used for certain time after injury or operation.
Permanent orthosis:
Used for ever when there is muscle weakness, paralysis or deformity cannot
be corrected.
Static orthosis:
does not allow movement.
Dynamic orthosis :
allows movement.
Or

MATERIALS
An orthosis can be constructed from metal,
plastic, leather, synthetic fabrics, or any
combination.
Plastic materials, such as thermosetting and
thermoplastics, are the materials most
commonly used in the orthotic industry.

Functions of the shoes
To minimize pressure on sensitive, deformed
structures
To redistribute weight towards pain-free areas
To serve as foundation of an orthosis

Sole
Heel
Upper
Lining
Reinforcements
Components of a Shoe

Lies under the anatomic heel
The higher the heel, the more weight is shifted to the
forefoot
Leg length discrepancy
< 2.5 inches - internal heel elevation
> 2.5 inches - external heel sole elevation
HEEL

Spring (1/8”)
Cuban (12/8”)
Military (10/8”)
Oxford (6/8” – 8/8”)
TYPES OF HEEL HEIGHTS

Outer Sole
 Contacts the floor
 Resilient outer sole to cushion
impact
Inner Sole
 Lies under the foot
 Filler: separates the inner from the
outer sole
Midsole – for athletic shoes
SOLE

Tongue
Throat
Eyelets
Lace stay
AgletsVamp

Helps keep feet inside the shoe
Adjustable versus non-adjustable
Closures

Zippers Elastic Webbing Insert
Non-adjustable Closures

Adjustable Closures
Cotton lacesElastic shoe laces
Velcro Flaps

Counter
Toe Box
Shank Piece
Reinforcements

Model over which the shoe is made
Lasts

Straight Inflared Outflared
Types of Lasts

Transfer forces from sensitive to tolerant areas
Reduce friction and shear on sensitive areas
Modify weight transfer patterns
Correct flexible deformities
Accommodate fixed deformities
Limit motion of painful, inflamed or unstable
joints
Internal versus External
Shoe Modifications

disadvantage
advantage
Internal
mechanically
more effective
reduce space
within shoe
External
do not reduce
shoe volume
cosmoses;
subject to
wear
Shoe Modifications

External Shoe Modifications
1. Heel Modifications
2. Sole Modifications
3. Combination Heel and Sole

1-Cushion Heel
Heel Modifications
 Is made of resilient material to
absorb shock at heel strike, because
it provides slight planter flexion
 It is indicating when the patient
wears an orthosis with a rigid ankle, it
reduces the knee flexion moment by
allowing a more rapid ankle plantar
flexion.

Heel Modifications
2-Heel Flare
 A medial flare is used to resist hind foot eversion
 A lateral flare is used to resist inversion.
 Both flares are used to provide heel stability.

Heel Modifications
3-External Heel Wedge
Medial wedge:
 Is used to promote hind foot inversion.
 Incorporated in Thomas heel, intended for
flexible pes valgus. The ant. border of Thomas
heel extended formed on the medial side to
augment the effect of medial wedge to
support the longtudinal arch.
Lateral wedge:
 Is used to promote hind foot eversion.
 Shifts wt. bearing to the medial side of forefoot.
 It compensates for fixed forefoot valgus,
allowing the entire forefoot to contact the
floor.
The exact elevation of the wedge is determined by the
height needed to place the calcaneus in near- vertical
position.

Extended (Thomas) Heel Reversed Extended (Thomas) Heel
Heel Modifications
4- Extended heel (Thomas heel):
a wedge with an extended anterior medial border used to support the
longitudinal arch and correct for flexible pes valgus (pronated foot)
Reverse Thomas heel:
It projects anteriorly on the lateral side to provide stability to the
lateral longtudinal arch.

5- Heel Elevation
Heel Modifications
A shoe lift is used to compansate for fixed
equinus deformity or for any leg-length
discrepancy of less than ½ inch

Sole Modifications
Rocker Bar
1- Rocker Bar
 Is a convex structure placed
posterior to the metatarsal
head to metatarsal shaft to
avoid irritation of ulcers
along a metatarsal head in
patients with DM.
 It also decreases demands
on the plantar flexors.

Rocker bottom
It builds up the sole over the metatarsal heads and improves
push off in weak or inflexible feet.
May also be used with insensitive feet

Sole Modifications
2- Metatarsal Bar
Metatarsal Bar
 Is a flat leather bar placed
across the sole posterior to
metatarsal head.
 It is used to relieve the
pressure from the
metatarsal heads.

3-Sole Wedge
Sole Modifications
This alters mediolateral metatarsal alignment
A medial wedge is used to promote forefoot supination.
A lateral wedge is used to provide pronation.

Sole Modifications
4- Sole Flare
A medial flare is used to resist eversion.
A lateral flare is used to resist inversion.
Both flares promote great stability.

5- Steel sole bar
 Inserted between the inner and outer soles
 Approximately 0.2 cm thick, 1.5 cm wide, and extends from a point
1cm anterior to the posterior edge of the heel counter to 1 cm
posterior to the anterior edge of the toe box
 Prevents motion of the anterior portion of the sole  reduce stress
on the phalanges and metatarsals in the presence of fractures.
 Used with a rocker bar to assisst rollover
Sole Modifications

6- Combination of sole and heel modifications
Shoe lifts and wedges can be combined in both the heel &
sole

 Heel Modifications
 Sole Modifications
 Foot Orthoses (inserts/inlays)
Internal Shoe Modifications

Internal Heel Modifications
1- Heel Cushion Relief:
A soft pad with excavation which may be filled by a
compressible material is placed under the painful point of
the heel.

2- Heel Wedge
Internal Heel Modifications
A medial heel wedge can rotate a flexible hind foot into
inversion.
A lateral wedge can evert a flexible hind foot to avoid
pressure on the cuboid.
It also increases the weight bearing area and can be
used in fixed pes varus.

1-Inner Sole Excavation
 A soft pad with excavation which may be filled by a
compressible material is placed under one or more painful
metatarsal heads.
Excavation is cushioned to protect tender bony prominence
Internal Sole Modifications

2- Metatarsal Pad
A domed pad is designed to reduce the stress from
metatarsal heads by transferring the load to
metatarsal shafts in metatarsalgia.

3- Toe Crest
A crescent-shaped pad is placed behind the 2-4
phalanges to fill the void under the proximal
phalanges and reduces the stress.

4- Scaphoid pad:
 A rubber, cork or plastic foam wedge is extended from ½”
posterior to the 1st metatarsal head to the ant. tubercle of the
calcaneus.
 The apex of the scaphoid pad is between the talonavicular jt.
& the navicular tuberosity.
 The scaphoid pad is used for medial arch support & prevents
depression of the subtalar joint.

Foot Orthoses (inserts/inlays)
1. UCBL (University of California at Berkeley Laboratory)insert.
2. Heel cup.
3. Sesamoid insert.
4. Longtudinal arch insert.
 A foot orthosis is a rigid, semi-rigid, or flexible insert into the
shoe and surrounds the foot medially & laterally below the
ankle.
 It is used to provide support under the arch, the metatarsals,
&/or the heel to prevent, correct or accommodate foot
deformities that improves overall function of the foot.

 This insert is made of rigid plastic, fabricated over a cast of the foot
held in maximal manual correction.
 It extends from the post. border of the foot to a point just post. to
the metatarsal heads.
 It encompasses the heel & mid-foot & has rigid medial, lateral, &
post. walls.
 It is used to accommodate a flexible abnormal foot to help restore
more normalized lower limb biomechanics.
1- UCBL (University of California at Berkeley Laboratory)insert.

2- Heel Seat/Heel Cup
Is a rigid plastic insert that covers the plantar surface of
the heel and extends posteriorly, medially and laterally
up the side of the heel.
It is used to prevent lateral calcaneal shift in the
flexible flat foot.

3-Sesamoid Platform insert
Is an insert amounting to ¾” length with an extension under the
hallux
Stabilizes the first metatarsal
Reduces excessive pressure on the head of the first metatarsal by
transferring some of the load to the MT shafts

4- Longtudinal arch support
 This can be applied medially to support the medial
longtudinal arch or laterally to support the lateral
longtudinal arch.
 Prevent depression of the subtalar joint and correct
for pes planus (flat foot)

AFO
An AFO is commonly prescribed for weakness
or paralysis of ankle dorsiflexion, plantar
flexion, inversion, and eversion to enhance toe
pickup during the swing phase, simulate push-
off and provide mediolateral stability during
the stance phase.
AFOs are used to prevent or correct deformities
and reduce weight bearing.

An AFO has been shown to reduce the energy cost of
ambulation in a wide variety of conditions, such as spastic
diplegia in CP, LMNL weakness of poliomyelitis, and
spastic hemiplegia in cerebral infarction.
As the position of the ankle indirectly affects the
stability of the knee, the best selected orthosis is the one
that can balance the floor reaction force to the patient’s
advantage by reducing deforming forces & allowing a
normal gait.

AFO
Controls the alignment & motion of the foot & ankle
Applies a three-point pressure system

These devices are plastic molded AFOs,
consisting of the following 3 parts:
(1) a shoe insert,
(2) a calf shell,
(3) a calf strap attached proximally.
The rigidity depends on the thickness and
composition of the plastic, as well as the trim
line and shape.
Thermoplastic AFOs are contraindicated in
cases of fluctuating edema and insensation &
inadequate hip & knee strength.
Thermoplastic AFOs

The Trim line:
Is the border of the orthosis, the location of which is a factor in
determining the level of support or flexibility available.

1- Posterior leaf spring (PLS):
The PLS is the most common form of AFO with a narrow calf shell
and a narrow ankle trim line behind the malleoli.
The PLS is used for compensating for weak ankle dorsiflexors.
During early stance, the narrow part resists ankle plantar flexion
and bends slightly backwards then during the swing phase it
recoils to lift the foot into nuteral position.
The orthosis has no mediolateral control.
Thermoplastic AFOs

Swedish AFO
 A moulded polyethylene splint providing dorsiflexion assistance for the full length
of the foot.
 Indications for Use: Flaccid drop foot-Post stroke patients
Features and Benefits:
 Made of durable plastic
 Encourages improved toe clearance in normal gait

2-Spiral AFO:
 This AFO consists of a shoe insert, a spiral that
starts medially, passes around the leg posteriorly,
then passes anteriorly to terminate at the medial
tibial flare where a calf band is attached.
 The spiral AFO allows for limited rotation in the
transverse plane while controlling ankle
dorsiflexion and plantar flexion, as well as eversion
and inversion.
 These orthosis are indicated in the presence of
weal ankle dorsiflexors or plantar flexors with
moderate mediolateral instability & mild weakness
of knee extensors.
 They are contraindicated in pronounced imbalance
of forces acting on the foot-ankle complex,
moderate to severe spasticity, severe mediolateral
instability & fixed ankle deformity.
Thermoplastic AFOs

3- Hemispiral AFO:
 This AFO consists of a shoe insert with a spiral starting on the lateral
side of the shoe insert, passing up the posterior leg, and terminating at
the medial tibial flare where the calf band is attached.
 This design is used for achieving better control of equinovarus than the
spiral AFO can.
Thermoplastic AFOs

4- Solid AFO:
 The solid AFO has a wider calf shell with trim line anterior to the
malleoli.
 This AFO prevents ankle dorsiflexion and plantar flexion, as well as
varus and valgus deviation.
Thermoplastic AFOs

5- AFO with flange:
This AFO has an extension (flange) that projects from the calf shell
medially for maximum valgus control and laterally for maximum varus
control.
Thermoplastic AFOs

6- Articulated or Hinged AFO:
The adjustable ankle hinges can be set to the desired range of ankle
dorsiflexion or plantar flexion.
Thermoplastic AFOs

Thermoplastic AFOs
7- Ground-reaction AFO:
 This orthosis is molded to fit around the front of the leg and foot.
 Straps on the back of the leg (lower & upper parts) hold the heel & leg
in place.
 These straps & the ant. shell limit the forward promoting knee
extension.

This orthosis is used in the presence of correctible knee flexion contractures
or flexible ankle dorsiflexion contracture and contraindicated when these
contractures are fixed
7- Ground-reaction AFO:

8- Tone-reducing AFO (TRAFO):
The broad footplate is used to
provide support around most of the
foot, extending distally under the
toes and up over the foot medially
and laterally to maintain the
subtalar joint in neutral foot position
and hyperextending the toes.
The TRAFO is indicated for patients
with spastic hemiplegia.
Thermoplastic AFOs

Specialized AFOs
Patellar-tendon-bearing brim:
allows for weight distribution on the patellar shelf similar to
patellar-tendon-bearing prosthetic socket; reduces weight
bearing forces through the foot.
PTB, specific weight bearing or total surface bearing, TSB
(inverted cone with lace closure) to unweight the ankle foot
using prosthetic principles

Immobilizing AFO- Cam walkers
Commonly used with a lower extremity deficiency when ankle
immobilization is desired
– distal tibia/ fibula fracture
– foot bone fractures
– tendocalcaneus rupture
– Diabetic Foot (Charcot Foot)
Specialized AFOs

Other AFO’s
Fabric, Air, Leather and Gel Supports

Stirrup:
These are steel plates bent in a U shape that anchors the
uprights to the shoes between the sole and the heel, with the
upper part forming part of the ankle joint.
A solid stirrup is riveted to the shoe, while a split stirrup, placed
in the heel of the shoe, allows for easy detachability of the
uprights.
Leather & metal AFO

Foot Plate:
a molded plastic shoe insert; allows application of the brace
before insertion into the shoe, ease of changing shoes of same
heel height.

 This type of AFO consists of a shoe or foot attachment, ankle joint, 2
metal uprights (medial and lateral), with a calf band (application of
force) connected proximally.
 The stirrup anchors the uprights to the shoes between the sole and
the heel.
 A molded shoe insert is another alternative to fit the stirrup into the
shoe, which also allows maximum control of the foot and aligns the
anatomic and mechanical ankles.
Metal & metal –plastic AFOs

 The axis of the mechanical ankle jt. should be aligned at the
same level with the axis of anatomical joint that runs through
the malleoli.
 The mechanical ankle joints can control or assist ankle
dorsiflexion or plantar flexion by means of stops (pins) or
assists (springs).
 The mechanical ankle joint also controls mediolateral
stability.
 Knee extension moment is promoted by ankle plantar
flexion, and knee flexion moment is promoted by ankle
dorsiflexion.
Ankle joints:
Leather & metal AFO

1- Free motion ankle joint:
The stirrup has a completely circular top, which allows free ankle
motion and provides only mediolateral stability.
Ankle joints & controls

2-Plantar flexion ankle joint stop:
 This joint stop restricts plantar flexion but allows unlimited
dorsiflexion.
 It is produced by :
1-a pin inserted in the posterior channel of the ankle joint
2-or by flattening the posterior lip of the stirrup's circular stop.
3- or by a posterior angulation at the top of the stirrup
 It promotes knee flexion moment at heel strike.
 Adjusting the stop in 5° plantar flexion attenuates the duration and
magnitude of this moment.
 This design is used in patients with weakness of dorsiflexion (foot
drop) during swing phase and flexible pes equinus.

3- Dorsiflexion ankle joint stop:
 The stirrup has a pin inserted in the anterior channel of the ankle
joint or by flattening the anterior lip of the stirrup's circular stop.
 The dorsiflexion stop has an anterior angulation at the top of the
stirrup that restricts dorsiflexion but allows unlimited plantar
flexion and promotes a knee extension moment in the meantime.
 This design is used in patients with weakness of plantar flexion
during late stance.

4- Limited motion ankle joint stop:
 This ankle joint stop has anterior and posterior angulations at the
top of the stirrup with restricted dorsiflexion and plantar flexion
ankle motion.
 The limited motion ankle joint stop has a pin in the anterior and the
posterior channel, and it is used in ankle weakness affecting all
muscle groups.

Double stop

5- Dorsiflexion assist spring joint (Klenzak joint):
 This joint has a coil spring in the posterior channel of the stirrup to
counteract plantar flexion and aid dorsiflexion during the swing
phase.
 It is indicated when muscle function allows a normal range of
plantar and dorsiflexion, but dorsiflexor muscles are inadequate.
 Flexion moment at the knee is less than that of a posterior stop.

6- Varus or valgus correction straps (T-straps):
 A T-strap attached medially and circling the ankle until buckling on
the outside of the lateral upright is used for valgus correction.
 A T-strap attached laterally and buckling around the medial upright
is used for varus correction.

Valgus-Varus Correction Straps
Lateral T-strap
Varus correction strap
Medial T-strap
Valgus correction strap

Leather and Metal AFO’s
Problems
 Foot drop/ pawing/ scuffing
of the toebox
 Calcaneal gait
 Knee buckling
 Severe recurvatum
 Extensor spasticity
(circumducting gait)
 Flexor spasticity
Appropriate Type of Stop
PF stop preset at 0 degrees
DF stop preset at 0 degrees
PF stop preset at 5 degrees of PF
DF stop preset at 5 degrees of DF
PF stop preset at 5 degrees of DF
DF stop preset at 5 degrees of PF

Uprights and attachments
Conventional AFOs have metal uprights (aluminum, carbon
graphite or steel) and a hinged ankle joint allowing plantarflexion
and dorsiflexion.
Provides maximum support if the patients condition is changing
(e.g. peripheral edema), conventional metal AFOs may be easier
to alter to accommodate changes than molded AFOs.

Double metal uprights extend upwards from the ankle on both
sides of the leg and attach to a calf band.
Conventional AFO, calf band (metal with leather lining or
plastic); provides proximal stabilization on leg; anterior
opening and buckle or velcro closure.
Calf bands

Indicated when lesser devices are biomechanically
insufficient; combines KO & AFO
Consists of a shoe attachment, ankle control, uprights, knee
control, and bands or shells for the calf and thigh

KAFO
 KAFO can be used in quadriceps paralysis or weakness to maintain
knee stability and control flexible genu valgum or varum.
 These orthosis can be made of metal-leather and metal-plastic or
plastic and plastic-metal.
 The metal designs include double upright metal KAFO (most
common), single upright metal KAFO (lateral upright only), and Scott-
Craig metal KAFO.
 The plastic designs are indicated for closer fit and maximum control
of the foot, including supracondylar plastic KAFO, supracondylar
plastic-metal KAFO and plastic shells with metal uprights KAFO.
 A KAFO is more difficult to don & doff than an AFO, so it is not
recommended for patients who have moderate-to-severe cognitive
dysfunction.

 This is an AFO with two/single metal uprights extending proximally
to the thigh to control knee motion & alignment.
 This orthosis consists of mechanical knee joint and 2 thigh bands
between 2 uprights.
Single/Double Bar KAFO
KAFO

 This design is intended for standing &
ambulation of paraplegic adults based
on eliminating unnecessary structural
elements to make it more functional
and easier to don & doff.
 It consists of a cushioned heel with a
T-shaped foot plate for mediolateral
stability, ankle joint with anterior and
posterior adjustable stops, double
uprights, a pretibial band, a posterior
thigh band and knee joint with pawl
locks and bail control.
Scott-Craig orthosis
KAFO

Hyperextension of the hip
allows the center of gravity
falling behind the hip joint
and in front of the locked
knee and ankle joint.
With 10° of ankle
dorsiflexion alignment, it
allows a swing-to-or
swing-through gait with
crutches.
Scott-Craig orthosis
KAFO

Oregon orthotic system:
a combination of plastic and metal components allows
for triplanar control in three plans of motion(sagittal,
frontal, and transverse)
KAFO

KAFO
Supracondylar plastic orthosis
Resists hyperextension at the knee without hindering
flexion, thus is used to eliminate the need for a
mechanical knee lock.
It also resists genu recurvatum and provides
mediolateral knee stability.

KAFO
Plastic shell & metal upright orthosis:
Consists of a posterior leaf
spring AFO with double
metal uprights extending up
to a plastic shell in the thigh
with an intervening knee
joint

KAFO
Bilateral KAFO:
Typically used 2ry to spinal cord
injury when paraplegia or
paraparesis is present.
A “spreader bar” can be added to
lock a pair of KAFOs together.
The functional use of this
orthosis entails training in the
swing-to & swing-through type
of ambulation.

 Fracture braces: a KAFO device with a calf or thigh shell that encompasses
the fracture site and provides support.
 More customizable - Better load distribution.
 Includes Sarmiento Style Fracture Bracing.
Total Contact KAFO- fracture brace:
KAFO

 Ischial containment or Quadrilateral style brims with high trimlines.
 Generally used with paralytic limbs.
 Not as effective with larger or obese individuals.
Ischial Weight Bearing (unweighting) KAFO
KAFO

Functional electrical stimulation (FES) orthosis:
Orthotic use and functional
ambulation is facilitated by
the addition of electrical
stimulation to specific
muscles; the pattern and
sequence of muscle activation
by portable stimulators is
controlled by an externally
worn miniaturized computer
pack; requires full passive
range of motion good
functional
KAFO

Functional electrical stimulation (FES) orthosis:

KAFO
Knee cap & strap:
The knee cap can be placed in front of the knee
in the orthosis to prevent flexion of the knee.
A medial strap is used for genu valgum and a
lateral strap is used for genu varum.
These buckles wrap around the upright on the
opposite side.

KAFO
Knee Controls
Hinge joints provides mediolateral and
hyperextension control while allowing for
flexion and extension.

1-Free motion knee joint:
 This joint has unrestricted knee flexion and extension with a
stop to prevent hyperextension.
 The free motion knee joint is used for patients with
recurvatum but good strength of the quadriceps to control
knee motion.
KAFO- Knee Controls

2-Offset knee joint:
 The hinge is located posterior to the knee joint and ground reaction
force; thus, it extends the knee and provides great stability during
early stance phase of the gait cycle.
 This joint flexes the knee freely during swing phase and is
contraindicated with knee or hip flexion contracture and ankle
plantar flexion stop.
KAFO- Knee Controls

3-Drop ring lock knee joint:
 The drop ring lock is the most
commonly used knee lock to control
knee flexion.
 The rings drop to unlock over the knee
joint while the knee is in extension by
gravity or manual assistance.
 This type of joint is stable, but gait is
stiff without knee motion.
 A ball bearing on a spring can be
added just above the drop lock to
keep it from slipping up as the patient
ambulates.
 Patients over 120 pounds usually feel
more secure with both medial and
lateral drop locks.
KAFO- Knee Controls

4-Pawl lock with bail release knee joint:
 The semicircular bail attaches to the knee joint posteriorly,
and it can unlock both joints easily by pulling up the bail or
backing up to sit down in a chair.
 A major drawback is the accidental unlocking while the
patient is pulling his or her pants up or bumping into a
chair.
KAFO- Knee Controls

5-Adjustable knee lock joint (dial lock):
 The serrated adjustable knee joint allows knee locking at different
degrees of flexion.
 This type of knee joint is used in patients with knee flexion
contractures that are improving gradually with stretching.
KAFO- Knee Controls

6-Spring assist knee joint- Ratchet lock:
 The ratchet knee joints lock automatically while standing as long as
the lock mechanism is engaged (catching mechanism).
 Start standing with knee extension knee flexion is achieved by
pressing down the released lever.
 Prevents unstabilities or flexion movements of knee and keep gain
towards extension.
KAFO- Knee Controls

7- The polycentric knee joint:
 It uses a double-axis system to
simulate the flexion-extension
movements of the femur and tibia
at the knee joint.
 Although this concept is
theoretically sound, the
polycentric knee joint has not
proved to be advantageous over
the straight-set knee joint, and it
is less commonly used.
 It also adds bulk to the orthosis.
 It is most frequently used in sport
knee orthoses.
KAFO- Knee Controls

Very restrictive and laborious to swing-to or through in gait
Hip Knee Ankle Foot Orthosis (HKAFO)

Hip joint: typically a metal hinge joint
 Controls for abduction, adduction
and rotation
 Controls for hip flexion when locked,
typically with a drop ring lock; a
locked hip restricts gait pattern to
either a swing to or swing through
gait
Pelvic attachments
 A leather covered, metal pelvic band;
attaches the HKAFO to the pelvis
between the greater trochanter and
iliac crest; adds to difficulty in
donning and doffing; adds weight
and increases overall energy
expenditure during ambulation.
HKAFO

Standing Frames
Allows standing without crutch support may be
stationary or attached to a wheeled mobility base

Parapodium
Allows for standing without crutch support; also allows for ease in
sitting with the addition of hip and knee joints that can be unlocked
can be used on children with myelodysplasia

Utilizes plastic molded solid
ankle orthoses with locked knees,
plastic thigh shell, a hip joint with
pelvic and trunk bands; the hips
are connected by steel cables
which allow for a reciprocal gait
pattern (either 4point or 2point);
when the patient leans on the
supporting hip, it forces it into
extension while the opposite leg
is pushed into flexion allowing
limb advancement
Reciprocating Gait Orthosis (RGO)
Contains a trunk band added to a HKAFO

The RGO is appropriate for children
who have used the standing frame,
developed good trunk control and
coordination, can safely stand and are
mentally prepared for ambulation.
Good upper limb strength, trunk
balance and active hip flexion are
important positive variables.
Commonly used in cases of spina
bifida and spinal cord injury.
Reciprocating Gait Orthosis (RGO)

1- Knee orthosis for patellofemoral disorders:
These orthosis are used to supply mediolateral knee
stability & to control tracking of the patella during
knee flexion & extension.
These orthoses include the :
-Infrapatellar strap KO
-Patellar stabilizer brace (Palumbo KO)

Patellar stabilizing braces (Palumbo KO)
 Improve patellar tracking; maintain alignment
 Lateral buttress or strap positions patella medially
 A Central Patellar cutout may help positioning and minimizes
compression

2- Knee orthosis for knee control in the sagittal plane:
These orthosis are used to control genu recurvatum, which
occurs due to tight calf muscles or weak knee extensors with
minimal mediolateral stabilization.
-Swedish knee cage
-Three – way knee stabilizer

Swedish Knee Cage
 Used to control minor to moderate genu recurvatum due to
ligamentous or capsular laxity.
 The articulated version of the orthosis allows full knee flexion
and prevents hyperextension.

Swedish Knee Cage
 It uses a three point system with two bands placed anterior to
the knee axis (one above and one below the knee) and a third
band posterior to the knee joint in the popliteal area.
 It also has a thigh band with longer uprights to obtain better
leverage at the knee joint.

3- Knee orthosis for knee control in the frontal plane:
These orthosis consist of thigh and calf cuffs joined by
sidebars with mechanical knee joints.
The knee joint is usually polycentric that closely mimics the
anatomic joint motion.
-Traditional metal-leather KO
-Supracondylar KO

Traditional metal-leather knee orthosis with leather
thigh and caffs and metal side bars

Supracondylar knee orthosis
 Resists hyperextension at the knee without hindering
flexion, thus is used to eliminate the need for a
mechanical knee lock.
 It also resists genu recurvatum and provides mediolateral
knee stability.

4- Knee orthosis for axial rotation control:
These orthosis can provide angular control of sagittal
(flexion-extension) & frontal (mediolateral) planes in addition
to controlling axial rotation.
This orthosis is used mostly in management of sports injuries
of the knee.
Articulated hinged knee orthosis

Articulated – hinged KO:
control knee motion and provide added stability.
 Post surgery KO protects repaired ligaments from overload
 Functional KO is worn long-term during selected activities
Examples include: Lenox Hill, Pro-Am, Can-Am, Don Joy

Nylon coated rubber material
Provide compression, protection and
proprioceptive feedback
Provide little stabilization unless metal or
plastic hinges are added
Retains body heat which may increase local
circulation
A central cut out minimizes patellar
compression
Can be used in other areas of the body such
as the elbow and thigh etc
Neoprene sleeves
Specialized KO

Knee Immobilizers KO
Specialized KO

Hip Abduction Orthosis
Standing Walking And Sitting Orthosis (SWASH)
Some Orthoses can intervene at the hip without
crossing the hip.

Hip Abduction Orthosis
Commonly used post-operatively to position the femoral head
optimally within the acetabulum.
Hip Abduction orthoses can be an HO only or can have a KAFO
extension.

Specific Case Hip Orthosis (HO):
S.W.A.S.H Orthosis
Standing Walking And Sitting Hip Orthosis
Maintains femoral abduction in standing, walking and sitting↓
hip dislocation rate in CP,↓ scissoring gait,↑ sitting balance
Plastic pelvic section and malleable cuffs. 115 or 123 °uprights.

Dennis Brown Bars
– static correction
– off shelf
– straight or reverse last boots
– bar maintains external rotation
Aluminium crossbar with rotation adjustable end plates.

Designed to provide adjustable abduction and adduction
control.
Nylon ball and socket joints duplicate the anatomical
motion of the hip. Breathable neoprene liners discourage
limb migration during gait training or limited ambulation.
Indications in Post-surgical hip conditions, or Legg Perthes
Disease.
Hip ABDUCTION BARS

Hip control orthosis
Internal rotation control straps
External rotation control straps

-Angular & rotational deformities
-Congenital hip dysplasia
-Legge-Calve-Perthes Disease
-Spinal cord injury levels

Congenital Talipes Equinovarus (CTEV)
 1:1000 live births, male:female 2:1, 50% bilateral
 hindfoot equinus, Subtalar varus/inversion, cavus, forefoot adduction
Angular & rotational deformities

 Newborn -> 3/12, 85%-95% success, application critical
 safe zone (100-110 flexion, 60-80 abduction) allows movement
within range
 no place for double nappies
Developmental Hip Dysplasia (DDH)

RHINO BRACE
Function:To hold hips in the correct abduction position, but flexible
enough to allow walking.
Description: A moulded plastic orthosis with foam lining. Anterior
velcro closures strap around the abdomen and thigh shells.
Indications:Hip Dysplasia.

VON ROSEN SPLINT
Function: To rigidly maintain the hips in flexion and abduction.
Indications:Congenital dislocation of the hip

PAVLIK HARNESS
Function: To maintain hips in desired degree of flexion and
abduction, whilst encouraging active motion.
Description: The harness fits over the torso and straps embrace the
legs. Pelite booties and chest strap are perforated for ventilation. Leg
straps are adjustable.
Indications: Congenital dislocation or subluxation of the hip.

Scottish Rite orthosis
Custom made for Perthes disease, this brace holds the hips in a
determined degree of abduction whilst permitting flexion and thus
mobility.
Used also following surgical procedures to maintain the hips in the
desired degree of abduction during the healing phase. Hip joints are
now available which permit selection of abduction.

Everything You Need to Know About Orthoses

Everything You Need to Know About Orthoses

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