foot orthoses and management

1. FOOT ORTHOSES

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

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

4. Regional classification
• Cervical orthosis
• Head cervical orthosis
• Head cervical thoracic orthosis
• Lumbo sacral orthosi
• Upperextrimity orthosis
• Lower extremity orthosis

5. Principle of jordan
• Three point system of Jodan
• F1=F2+F3
f1
DEFORMITY
f2 f3

6. Lower limb orthoses
• Foot orthoses
• Ankle foot orthoses
• Knee ankle foot orthoses
• Hip knee ankle foot orthoses

7. • 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

8. 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

9. 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

10. 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

11. • 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

12. • 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

13. 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

14. • Foot and ankle muscle strength
• Pulses : dorsalis pedis, posterior tibial
• Achilles’ tendon reflex
• Special tests : homan’s sign (DVT), plantar fascia
test (heel spur)

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

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

18. 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

19. • 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

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

22. 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

24. 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

25. • 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

26. • 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

30. 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

32. 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

33. • 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

34. 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

35. 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

36. • 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

37. 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

38. 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

40. 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

42. 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

43. 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

44. • 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

45. • 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

46. • 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

47. • 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

48. • 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

49. • 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

50. • 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

51. Pediatric foot orthoses
• Dennis Browne Splint
• Hinged shoe

52. 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

53. • 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

54. • 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

55. • To stabilize knee during early stance
• 1 resilient heel
• 2 beeveled heel
• To facialiate mid and late stance
• Rocker bar

56. 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

57. Thank You