Orthoses for Pediatric Population

Approximate Age Gross and Fine Motor

Skill
Purpose:
The goals of orthotic intervention for children are similar Birth to 2 months Physiological Flexion
to those for adults. Goals may include:
● Support the upper extremity 2 months Grasp reflex
● Protect during healing 3 months Hands together in supine
● Position for improved function
● Assist weaker muscle groups to improve function 4 months Objects held in midline
● Facilitate or maintain tissue length and joint bears weight on forearm
alignment
5 months Two-handed approach to
● Prevent deformity
objects, extended arm
weight-bearing, displays
Orthotic fabrication for a child is different from orthotic some supination of
fabrication for an adult in several key areas, including the forearm
following:
● Different proportions between the palm and 6 months Weight shifts on extended
arms in prone, sits with
length of fingers in the growing hand versus the
straight back, elbows fully
adult hand exist. extend
● Children are constantly growing and therefore
require more frequent orthotic adjustments 7 months Purposeful release, may
and/or new orthoses to accommodate for growth. pull to stand
● The parents or teachers are responsible for
8 months Creeps on hands and
applying and removing the orthosis.
knees
○ They must understand the importance of
the orthosis, wear and care schedule, 9 months Reaches with active
and precautions. supination
● Foundational movement patterns are set during
the first 2 to 3 years of life. 10 months Pokes with index finger
○ Interventions with orthoses assist the 12 months One hand stabilizes while
child to develop more typical movement one hand manipulates
patterns.
15 months Develops release with
Gross and Fine Motor Skill Development precision
● Considers:
○ infant or child’s current level of fine motor Common Pediatric Upper Extremity Conditions
skills 1. Common congenital hand anomalies
○ thinks about how the orthotic intervention a. Radial deficiency/radial clubhand
impacts future hand skill development b. Hypoplastic thumb
● Through sensory exploration and play, children c. Congenital trigger finger
learn about their environments. d. Syndactyly
● Wearing an orthosis interferes to some degree e. Camptodactyly
with the ability to explore and play. f. Clinodactyly
● The therapist provides appropriate scheduling 2. Brachial plexus palsy
of orthotic wear to ensure ample opportunities for 3. Arthrogryposis
play and development of grasp and release 4. Juvenile idiopathic arthritis
patterns. 5. Cerebral palsy

Radial Deficiency/ Radial Clubhand

● refer to all congenital hand anomalies with failure
of formation along the radial border of the upper
extremity
 ● includes deficient or absent thenar muscles;
shortened, unstable, or absent thumb; and
shortened or absent radius, commonly referred
to as radial clubhand
ORTHOTIC INTERVENTION
● typically initiated immediately
after birth
● a program of passive
stretching along with orthoses is
introduced
● molded on the radial border of
the forearm and places the hand in a
central position relative to the forearm
● worn full-time until the baby
begins to use the hands
● padding or lining the orthosis with moleskin or
Neoprene is important due to the increased
prominence of the ulnar styloid
● full arm casting may be utilized to correct the
positioning of the hand, wrist, and elbow
● radial gutter type wrist orthoses, forearm
orthoses, resting hand orthoses, and elbow
orthoses
Hypoplastic Thumb
● Spectrum of thumb disorders ranging from mild
underdevelopment of the thumb anatomy to
complete absence of the thumb.
● Children with congenital thumb aplasia (total
absence of the thumb) or hypoplasia are
severely impaired functionally.
● They lack an active thumb, which plays a key
component in hand function.
● Surgical procedures:
○ Tendon transfers to enhance thumb
function (for mild cases of thumb
hypoplasia)
○ Pollicization (creating a thumb from the
index finger when the thumb is absent)
ORTHOTIC INTERVENTION
Thumb orthoses for children with thumb hypoplasia
include:
● carpometacarpal (CMC)
● metacarpal (MP)
● interphalangeal (IP) joints as needed

Serial static and static progressive mobilization orthoses Such orthoses maintain:
stabilize and position the wrist. ● adequate first web space
● align the wrist in a more neutral position and ● hold the thumb in a functional position
maximize function ● correct or prevent deformity
● Children benefit from nighttime resting hand
orthoses once full passive motion is achieved. Appropriate thickness of
● Resting hand orthoses maintain digital thermoplastic material is
alignment and prevent flexion contractures of the based on the size of the
digits. child’s hand.
● As the child grows and when orthoses can no For small children and
longer maintain the correction, surgical infants- 1⁄16-inch thick
intervention may be necessary to enhance thermoplastic material
function may be too heavy.

Challenges:
● Lack of a thumb to hook the thermoplastic
Indications for Orthotic Fabrication for Thumb
material around during fabrication and wear. Hypoplasia
● Tendency of the orthosis to migrate proximally
and/or distally. Preoperatively Postoperatively
● Frequent serial adjustments of the orthosis are
necessary with gains in passive range of motion 1. Preserve and/ 1. Protect the
increase the first tendon transfers
(PROM)
web space during healing
● Wrist orthosis should allow full digital motion. 2. Protect
● Children may develop a scissoring pattern of pollicization of the
prehension with the index and middle digits for index finger (new
function when the thumb is absent. position)
● Elbow may need to be included in the orthosis for
leverage and mechanical length.
Congenital Trigger Finger Camptodactyly
● a congenital pediatric condition of the thumb that ● non-traumatic, flexion contracture of the proximal
results in abnormal flexion at the interphalangeal (PIP) joint that typically affects
interphalangeal joint the little finger
● orthotic intervention and stretching exercises can ● Intervention:
be successful ○ mobilization or immobilization orthoses
● includes full-time hyperextension orthotic and stretching regimens, especially
intervention for 6 to 12 weeks followed by during growth spurts.
nighttime wear ○ surgery may be a treatment option
● surgical release of the A-1 pulley may occur
when there is no resolution after 1 year of
conservative management

Syndactyly
● refers to the webbing of fingers
● classified as complete (full length of the fingers)
or incomplete
● may involve the skin only (simple syndactyly), or
it may involve fusion of the bones (complex
syndactyly)
● treated by surgical release for functional and
cosmetic improvement.; Surgery- performed
before patterns of prehension are established
Types of orthoses for camptodactyly:
● PIP extension orthoses
○ Immobilization
○ Mobilization
○ Static progressive orthoses
● Typically worn full-time at night until skeletal
maturity is reached.
● Serial casting and/or static progressive orthoses
may be more effective for rigid deformities.
● Younger children may require a forearm based
orthosis to prevent removal.

Brachial Plexus Palsy

● weakness or paralysis in parts of the arm as a
result of significant injury to the brachial plexus,
ORTHOTIC INTERVENTION
which can happen during childbirth
● Postsurgical syndactyly release
● typical posture:
○ web spacer or finger separator is formed
○ shoulder- adducted and internally rotated
from silicone or elastomer putty to
○ extended elbow
maintain pressure on the surgically
○ pronated forearm
corrected interdigital web space
○ flexed wrist and digits
● Highly conforming thermoplastic material is
○ thumb- flexed in the palm
utilized.
● Most babies recover spontaneously within the
○ Web creep or the repeated fusion of the
first 2 months
skin between the released digits may
● Those babies who do not recover by 3 months
reoccur and is a significant complication
have:
that may require an additional surgical
○ permanent impairments of ROM
release.
○ decreased strength
● The type of orthoses used in the treatment of
○ smaller upper extremity
syndactyly include:
○ resting hand orthosis with finger
separators made from pellets of
thermoplastic material or elastomer.
○ another option: finger orthosis in
extension
INITIAL INTERVENTION ORTHOTIC INTERVENTION:
● PROM to all joints ● Multiple surgical procedures may be considered
● Children may have limitations in ROM at every for children with arthrogryposis including:
joint and may develop contractures of the elbow, ○ tendon transfers
forearm, and wrist. ○ posterior elbow capsulotomy
● Orthoses are used for positioning, preventing ○ wrist arthrodesis or carpectomy
deformities, and enhancing function. ○ thumb procedures
● Orthotic intervention prior to surgery to increase
Soft Orthoses: passive joint ROM or stretch tight contractures
If an infant shows signs of: may be necessary.
● muscle weakness ● Postsurgical protective and positioning orthoses
● limited active range of movement are often provided.
● Serial static and static progressive orthoses
Immobilization or static progressive orthoses ○ fabricated for maximal passive stretching
Signs of contracture development at: of tight joints and contractures
● Elbow
● Forearm
● Wrist
● Thumb
● Digits

ORTHOTIC INTERVENTION:
● Immobilization orthoses
○ elbow positioning
○ wrist extension Juvenile Idiopathic Arthritis
○ forearm supination ● used to be called juvenile rheumatoid arthritis
○ thumb positioning ● chronic, potentially lifelong disease causing joint
○ nighttime resting orthoses inflammation
● Static progressive and/or mobilization orthoses
○ used to lengthen tight structures ORTHOTIC INTERVENTION:
○ release joint contractures ● Goals: to preserve normal joint function and to
● Soft elastic orthoses prevent deformity and disability
○ supinate the forearm ● Types of orthoses:
○ promote thumb opposition ○ Immobilization orthoses for the elbow,
○ used to improve functional skills forearm, wrist (dorsal or volar based)
fingers and thumb.
Arthrogryposis ● These orthoses:
● A term describing a number of conditions that ○ Protect the joints during flare-ups
affect the joints ○ Prevent further deformity
● Often times both the arms and legs are affected. ○ Support weak and inflamed joints
A pronounced lack of muscle mass and flexion ○ Improve function of grasp and reach
creases are apparent.
● Joints have decreased ROM with an inelastic
end range.
● Typical posturing includes:
○ internally rotated and adducted shoulders
○ extended elbows
○ pronated forearms
○ flexed and ulnarly deviated wrists
○ partially flexed fingers
○ adducted thumbs
Cerebral Palsy ● Orthoses for Function
● a lifelong disorder of sensory-motor development ○ Enable existing function to continue
that originates from insult to the developing brain ○ Improve existing function
CP ○ Substitute for weak or absent muscles
● Characterized by ○ Augment benefits of therapy
○ impaired ability to move ● Orthoses for Hygiene
○ maintain posture and balance ○ Improve or prevent a hygiene problem
● Hallmarks: ● Orthoses for Protection
○ Spasticity ○ Keep the child safe
○ fluctuating muscle tone ○ Prevent undesired behaviors
○ muscle weakness
○ reflex-dominated movement Approaches to Pediatric Orthotic Fabrication
● To encourage motivation and acceptance of the
ORTOTHIC INTERVENTION: orthosis, engage the child in design and color
● Different purposes: selections.
○ assist children to develop more typical ● Monitor the orthosis frequently due to growth.
movement patterns ● Consider not only the physical growth, but also
○ block unwanted motion while allowing psychomotor and mental growth.
function ● Children have unique hands that require custom
○ reduce contractures designs and individualized intervention plans.
○ maintain ROM ● It is essential that family/caregivers are invested.
○ protect skin integrity
Safety Tips and Precautions
● Place sharp tools and scissors out of reach.
● Do not leave scissors or other equipment
unattended on the counter or table.
● When using hot water for orthotic fabrication,
avoid splashing.
● Always cover the hydrocollator or fry pan when in
use.
General Principle for Orthotic Fabrication ● Children’s skin may be sensitive to heat and may
react to thermoplastic materials
After a thorough initial evaluation and interview with the ● Allow the material to cool adequately before
child and parents or caregivers, the key to successful placing on the skin.
orthotic fabrication is prioritizing the needs of the child. ● Sharp edges on the orthosis’ corners can scratch
● Create a list of the abilities and deficits. or cut skin. Smooth sharp edges and round
● Prioritize the needs in accordance to age and corners on the orthosis and strapping materials.
ability to perform. ● Securely attach straps and other small pieces to
● Incorporate the family’s stated outcomes and the the orthosis so that they cannot be pulled off and
child’s stated outcomes. swallowed.
● Fabricate an orthosis that first addresses one or ● Verify that the thermoplastic material does not
two primary needs. contain toxic ingredients.
● Fabricate other orthoses to meet additional ● Use latex-free Neoprene.
needs, and schedule alternate wear among the
various orthoses. Steps for Orthotic Fabrication
● Reassess the fit of each orthosis and need for it ● Prepare the Child
frequently. ● Prepare the Environment
● Design
Goals of Pediatric Orthoses ● Selection of Orthotic Materials
● Orthoses for Positioning ● Pattern Making
○ Mobilize joints, reduce contractures ● Heating the Thermoplastic Material
○ Provide stability -Rest the extremity ● Hastening the Process
○ Provide proper alignment ● Padding
 ● Strapping
● Providing Instruction for Orthotic Application
Prepare the Child
● Position the child so that the effects of abnormal
tone and postural reflexes on the arm and hand
are at a minimum
○ spend time to allow the child to warm up
○ provide a brief time is provided to allow
the child to acclimate to the equipment
and setup for orthotic intervention
○ to establish a reciprocal interaction with
the child before starting the fabrication
process (may use toys, music, books,
stickers, or other materials)
○ Infant: talks in a soothing voice and
touches the child in a playful manner
before fabrication.
○ Older child: shows the child what to
expect by first fabricating an “orthosis” on
a doll or stuffed animal or by making
“thermoplastic jewelry,” or other play
objects
● Child is given the opportunity to touch and feel
the material: warm and soft; cool and hard
● Child’s response to tactile stimuli is noted
○ if signs of tactile defensiveness occur:
the therapist follows sensory processing
guidelines for improving sensory system
modulation
● If colored thermoplastic material is available, the
child is encouraged to select a color.
● For some children, decorating the orthosis with
stickers or leather stamps encourages
acceptance.
Prepare the Environment
● have a second pair of adult hands to help with
the fabrication
(might be a parent, teacher, paraprofessional, or
another therapist)
○ this usually involves:
■ maintaining the child’s overall
position
■ Calming
■ entertaining the child
■ holding the arm just proximal to
the joint being positioned
■ stabilizing the material once in
place and while it is cooling
Design
● Orthoses can be fabricated on the volar, dorsal,
ulnar, radial borders, or circumferentially
● Circumferential orthoses:
○ do not migrate distally
○ cover both the dorsal and volar surfaces
○ more comfortable to take on and off
○ strong and supportive
Selection of Orthotic Materials
● Thermoplastic materials are commonly used for
the fabrication of static orthoses, or those that
require restricting motion at certain joints.
○ skin may breakdown from the high
resistance and unyielding shape
○ larger limbs: ⅛-inch thick thermoplastic
material
○ smaller hands: 1⁄12 inch and 1⁄16 inch
● Soft orthoses:
○ commonly made of materials such as
Neoprene
○ may not totally immobilize a joint, but
they provide support and allow greater
freedom of movement
■ 3.0 mm - commonly used,
consider 1.5 mm thickness
because it is less bulky in a small
hand be alert to the possibility of
skin irritation or rash
Pattern Making
● Older children can be encouraged to participate
in the process by having them trace their own
hands on the paper
● Infants and toddlers might best be approached
while napping or feeding
● Younger children can be enticed to play a game
where their hands are placed on the table
● Making a photocopy of the child’s hand may be
helpful
● It may be helpful to plan on extending the
thermoplastic material beyond that of the finished
product to give leverage to help hold joints in
position.
● For patterns that tear, masking tape is used for
repairs or to reinforce contours
Heating the Thermoplastic Material
● Before placing the plastic on a child’s extremity,
the therapist dries off the hot water and makes
sure the plastic is not too hot
● Some children may be hypersensitive to
temperature and react negatively, even though
the temperature does not feel hot to the therapist
 ● Therapist- watches the child’s facial expressions
and listens for vocalizations that indicate
discomfort
● The child’s arm and hand can be moistened with
cold water prior to molding.
● Another option is placing a wet piece of paper
towel over the extremity, or waiting longer for the
plastic to cool.
● Some therapists use a stockinette to protect the
extremity
Hastening the Process
● Time is of the essence when one is working with
a moving target, a rebellious little one, or a
difficult-to-position extremity
● Once the plastic is in place on the extremity, an
ice pack can be rubbed on the orthosis to hasten
the setting process.
● A rubber glove filled with ice chips can easily
serve the purpose.
● After being partially hardened, the orthosis is
carefully removed and put into a pan of ice water
or placed under a faucet of cold running water.
● A spray coolant may be used, but only with great
care to spray after the orthosis is off the child.
● Spray- directed away from the child.
● Coolant spray- avoided with children who are
unable to keep their heads turned away from the
direction of the spray and those who have
frequent respiratory problems.
Padding
● form of pressure relief
● may be necessary over bony areas to prevent
skin problems
● includes closed- and open-cell foam and gel
products
● To ensure proper fit, the therapist lays the
padding on the child’s extremity before molding
the plastic or places it on the thermoplastic
material before molding the orthosis
Strapping
● The therapist considers:
○ Strength
○ Durability
○ Elasticity
○ Texture when the strap is against the skin
● Strapping with sharp edges is avoided with
younger children and those with sensitive skin.
● Wider the strap = more force is dispersed if the
entire strap width is in full contact with the skin.
● Strap material may need to be cut narrower,
especially around the wrist and fingers, to be
proportionate to the size of the child’s hand.
Providing Instruction for Orthotic Application
● Those responsible for applying the child’s
orthosis (i.e., teachers, nursing staff, or parents)
should be part of the assessment process and
provide input on the orthotic design and agree
with the need for the orthosis.
● They must understand the orthosis’ purpose,
rationale, precautions, and risks of incorrect
usage.
● The therapist provides written instructions along
with a phone number and/or email address to
contact for questions or concerns.
● A demonstration of the steps involved in donning
the orthosis are provided, followed by an
opportunity for the caretaker to practice applying
the orthosis under supervision
Wearing Schedules
● worn for long or short intervals during the day, at
night, during functional activities, or a
combination
● gradually increase the wearing time initially to
build up the child’s tolerance for the orthosis and
to make any modifications that become apparent
with use
● purpose of the orthosis is to increase functional
use- wearing during times when the child is
engaged in occupations
● purpose is tone reduction, the orthosis is worn
prior to activities or occupations
● purpose is to prevent a contracture- worn when
the child is not engaged in occupations.
● if the orthosis is used to treat an existing
contracture, wear it for prolonged periods of time
Precautions
● The skin is inspected frequently during the initial
wearing phase.
● A distinct red area or generalized redness that
does not disappear within 15 to 20 minutes after
removal indicates excessive pressure and the
need for revision.
● During periods of monitoring, the therapist should
be aware of any problems associated with joint
compression, pressure on nerves, compromised
circulation, and dermatologic reactions
Lower Limb Orthoses:
Anatomic and Biomechanical Principles related to Arches of the Foot
Orthotic Provision & its Different Types

Lower Limb Orthoses

● the most commonly prescribed biomechanical
devices intended to assist walking in individuals
with gait dysfunction, caused by musculoskeletal
or neuromuscular diseases
● Walking is one of the most desirable
self-reported goals for patients entering a
rehabilitation program

Anatomic Principles Related to Orthotic Provision

Hip Joint

● Medial arch - higher of the two longitudinal

arches
○ Formed by: calcaneus, talus, navicular,
three cuneiforms and first three
metatarsal bones
● Lateral arch- flatter of the two longitudinal
arches, and lies on the ground in the standing
position.
○ Formed by: calcaneus, cuboid and 4th
Knee Joint and 5th metatarsal bones
● Transverse arch - llocated in the coronal plane of
the foot.
○ Formed by: metatarsal bases, the cuboid
and the three cuneiform bones

Biomechanical Principles Related for Orthotic

Intervention

Principles of Lower Limb Orthosis

● Most orthoses utilize a three-point system to
ensure proper positioning of the limb within the
orthosis
○ used to change the alignment of a joint
through the application of two forces
Ankle Joint
working in opposition to a counterforce
(or fulcrum)
○ counterforce is positioned on the convex
side of the joint deviation, close to the
joint requiring the angular change
○ opposite two forces are positioned
proximally and distally to the
counterforce, on the side of the joint
concavity
 ● orthotic ankle joint - centered over the tip of the
Observational gait Functional testing to
medial malleolus. assessment identify specific functional
● orthotic knee joint - centered over the challenges
prominence of the medial femoral condyle.
● orthotic hip joint - in a position that allows the
Clinical Assessment
patient to sit upright at 90°
● Physical Examination
● Patient compliance will be enhanced if the
○ Strong working knowledge of the major
orthosis is comfortable, cosmetic, and functional.
joints and structures that contribute to LE
movement
Orthotic Design Principles
● Gait Analysis
○ key joints and structures contributing to
Abbreviation Name lower limb movement:
■ the oblique midtarsal (Chopart)
FO Foot orthosis ■ Subtalar
AFO Ankle-foot orthosis ■ Ankle
■ Knee and hip joints
KO Knee orthosis ○ when in contact with the ground, these
joints work in concert to facilitate efficient
KAFO Knee-ankle-foot orthosis movement patterns.
HO Hip orthosis ○ When a single joint is deficient in strength
or motion to perform a functional task,
HKAFO Hip-knee-ankle-foot adjacent joint segments are often
orthosis affected as well.

Clinical Assessment Clinical Objectives of Lower Extremity Orthotic

Treatment

Personal history (initial Areas of pain/ discomfort

presentation of disease) Relieve pain Manage abnormal
neuromuscular function
Medical Background Neurologic profile
Manage deformities Protect tissues
Comorbid conditions that Sensation
affect orthotic Prevent excessive ROM Promote healing
management (diabetes,
neurological impairment) Increase the ROM Provide other effects
(placebo, warmth,
Current and previous Proprioception postural feedback)
orthotic use
Compensate for -
Individual goals and Range of available joint abnormalities of segment
expectations motion length and shape

Daily activity level Spasticity/ tone

(current and anticipated)
Sitting & standing posture
and balance
Description of body size
and habitus
Skin integrity
Presence of edema
Control Options for Modification of Joint Motion by
Muscle strength an Orthosis
1. Free
a. Permit free motion in a
Cognitive abilities
plane or direction
b. free motion about the
Static and dynamic knee would allow
alignment of joints flexion and extension
of the knee through
Transfers and self-care the full arc of motion
tasks
 2. Stop
a. To limit motion in a
particular direction or
plane
b. a plantar flexion stop
mechanically blocks
plantar flexion of the
ankle but does not
impede dorsiflexion
3. Hold
a. To limit motion of a joint in
both directions of a single
plane of motion
b. a rigid orthosis preventing
any motion at the ankle joint
would be considered a hold
4. Hold-variable
a. To limit motion of a joint in
both directions of a single
plane of motion without the
joint being fixed
b. an orthosis made from a
thin strut of flexible plastic
posterior to the ankle can
limit both plantar flexion
and dorsiflexion without
completely blocking all movement
5. Assist
a. To encourage or facilitate
motion in a specific
direction for a plane of
motion. Note assisting a
motion will resist the
opposing motion
b. dorsiflexion assist joint
assists dorsiflexion
movement while resisting
plantar flexion movement
Orthotic Components
1. Interface components
a. are in direct contact with
the orthosis user, are
responsible for
transmitting the forces
required for function,
and help hold the
orthosis in place on the
body.
b. Examples: shells, pads, straps and, when
used with an orthosis that encompass the
feet, shoes
2. Articulating components
a. used to allow or control
the motion of
anatomical joints
b. further defined by the
joint that they are
intended to control, the
permissible motion of
the joint in the final
orthosis, the form of articulation
c. either by motion between parts, as in a
hinge, or deformation of a part of the joint
d. These components control the axis of
rotation (i.e., monocentric or polycentric)
and the type of motion control
3. Structural components
a. connect the interface and
articulating components,
acting to maintain the
alignment of the orthosis
b. metal uprights and plastic
shells
4. Cosmetic components
a. means of providing shape,
color, and texture to
orthoses.
b. Examples may include:
fillers, covers, sleeves,
and patterns or pictures
embedded into plastic
shells
Other Considerations:
● Prefabricated vs custom fabricated orthosis
● Height
● Weight
● Activity level
○ ensure that the components are robust
enough to function optimally and be
durable without being excessively heavy
or bulky
Lower Limb Orthosis 2. High-quarter shoe
a. the quarters may
Shoes extend up to barely
● an integral part of any cover the malleoli,
lower limb orthosis or extending to the
that includes the foot lower third of the
● serves as the tibia or higher, as
foundation for the in boots
device and directly b. prevents piston action during walking and
impacts its function back-and-forth sliding of the foot
● Factors to consider when selecting a shoe: size, c. provides some degree of medial-lateral
shape, fit, and function stability at the ankle and subtalar joints,
● Good pair of shoes- eliminate the need for foot and some restriction of
orthoses and should be considered before plantar/dorsiflexion ankle motion
orthotic prescription.
● The foot may swell with prolonged sitting or 3. Bluncher
activity and is often best fitted at the end of the a. most common opening
day and after walking around. style in which the lace
● Sole - pliable, so as not to interfere with the stay is not directly
normal biomechanics of the foot fastened to the vamp
● Shoe is of adequate length = index finger can be b. gives a wide opening
placed between the tip of the great toe and the for the foot for easy
toe box insertion and greater
● Leather shoes- good choices for all types of adjustability over the
activity. mid foot
○ Durable c. For ease of access the surgical opening
○ allow ventilation shoe allows exposure of the entire foot
○ mold to the feet with time by opening up to the toes
● Plastic brace = longer or wider shoe
4. Bal-type (Balmoral)
Shoe Parts a. has the face stay attached
● Blucher directly to the vamp
○ recommended-orthosis b. does not provide such easy
● Bal foot access
c. Shoe closure usually is
accomplished by cotton laces,
which thread through two or
more pairs of eyelets,
although closure can also be achieved by
buckles, zippers, Velcro flaps, or elastics

Shoe Types & Styles Foot Orthoses

1. Low-quarter shoe ● those devices that encompass all or part of the
a. known as Oxford foot but terminate distal to the ankle joint
shoe ● benefit the foot primarily in stance and are held in
b. characterized by the position against the foot by shoes
quarters finishing ● may be used to:
approximately 1 in. ○ treat foot instability or deformity caused
below the malleoli with no restriction of by muscle weakness and/or imbalance
ankle or subtalar movement
 ○ structural malalignment, and loss of
structural integrity due to ligamentous Gait Analysis & Different Types of Pathologic Gait
laxity or rupture
● Alignment of the foot can affect: Anatomy LE
○ plantar pressure distribution 1. Hip flexors except:
○ center of pressure progression a. Psoas Major
○ moments occurring at proximal joints by b. Psoas Minor
altering the orientation of the joint axes c. Iliacus
d. Pectineus
Three broad categories e. Gluteus Maximus
1. Accommodative or soft f. Rectus Femoris
FOs 2. Hip extensors except:
a. made from soft or a. Gluteus Maximus
flexible materials, b. Gluteus Medius
such as closed and c. Biceps Femoris (long head)
open cell foams d. Semitendinosus
b. accommodate and e. Semimembranous
protect rigidly deformed or dysvascular 3. Hip Adductors except:
feet a. Adductor Magnus
c. attempt to: b. Adductor Longus
i. increase the weight-bearing c. Adductor Brevis
surface area d. Piriformis
ii. redistribute the plantar pressures e. Gracilis
iii. decrease the forces applied to f. Pectineus
the tissues at risk for ulceration 4. Hip Abductors/ Internal Rotators except:
and breakdown a. Gluteus Medius
2. Intermediate or semirigid Fos b. Gluteus minimus
a. made by layering c. Tensor Fascia Latae
different density foam d. Semitendinosus
materials 5. Hip External Rotators except:
b. the composition of a. Gluteus Maximus
the layers dictate the b. Gemellus Superior
degree of support c. Gemellus Inferior
and biomechanical control d. Obturator Externus
3. Corrective or rigid FOs e. Obturator Internus
a. correct flexible f. Quadratus Femoris
deformities, g. Psoas Major
especially those h. Piriformis
that include hind 6. Knee Extensors except:
foot varus or a. Rectus femoris
valgus b. Gastrocnemius
b. generally made from high-temperature c. Vastus lateralis
thermoplastic materials and require a d. Vastus intermedius
heat resistant positive model of the foot e. Vastus medialis
7. Knee Flexors except:
Clinical Considerations for the Occupational a. Hamstrings
Therapist b. Gracilis
● OTs educate clients with insensate feet about c. Sartorius
visual skin inspection d. Gastrocnemius
● Checking the skin’s color and temperature is e. Tibialis anterior
essential for clients with major vascular issues f. Plantaris
and neuropathy g. Popliteus
8. Plantar Flexors excepts:
 a. Gastrocnemius c. is useful for identifying and measuring
b. Soleus asymmetry between the two sides of the
c. Plantaris body in pathologic conditions
d. Tibialis anterior 3. Stride Length
e. Posterior tibialis a. is the distance measured between the
9. Dorsiflexors excepts: heel points of two consecutive footprints
a. Tibialis anterior of right foot
b. Extensor hallucis longus 4. Stride Period
c. Extensor digitorum longus a. time from an event of one foot until the
d. Gracilis recurrence of the same event for the
10. Foot Evertors except same foot; most often, initial contact to
a. Fibularis brevis initial contact is used to define the stride
b. Fibularis longus period
c. Extensor digitorum longus 5. Cadence
d. Flexor digitorum longus a. refers to the number of steps in a period
11. Foot Invertors except of time (commonly - expressed as
a. Tibialis posterior steps/minute).
b. Tibialis anterior
c. Psoas Major
d. Flexor digitorum longus
e. Flexor hallucis longus

Gait Cycle
● basic unit of walking
● recorded from the time one foot strikes the
ground until that episode recurs and starts the
next repeating cycle

Gait Cycle
● Each lower limb supports the body during its
stance phase and then leaves the floor for its
swing phase, during which it advances (or steps).
● The beginning and the end of the stance phase
mark the period of double support, during which
both feet are in contact with the floor, allowing
the weight of the body to be transferred from one
limb to the other
● broadly divided into 60% for the stance phase
and 40% for the swing phase, with approximately
10% overlap for each double support time

Stance Phase
1. Heel Strike
Terminologies a. the Instant the foot contacts the ground
1. Step Length i. 30° flexion of the hip full
a. length measured from the heel of left extension in the knee
foot to the heel of right foot ii. ankle moves from dorsiflexion to
2. Step Period a neutral (supinated 5°) position
a. the time measured from an event in one iii. Extension of the knee is caused
foot to the subsequent occurrence of the by a contraction of the
same event in the other foot quadriceps
b. there are two steps in each stride or gait
cycle
 iv. Flexion of the hip is caused by
the contraction of the rectus
femoris
2. Foot Flat (loading response)
a. Body absorbs the impact of the foot by
rolling in pronation
b. From flat foot position until the opposite
foot is off the ground for swing
i. Hip moves slowly into extension,
caused by a contraction of the
adductor magnus and gluteus
maximus muscles
ii. Knee flexes to 15° to 20° of
flexion
iii. Ankle plantarflexion increases to
10-15°
3. Midstance
a. Body is supported by one single leg
which begins to move from force
absorption at impact to force propulsion
forward
b. From the time the opposite foot is lifted
until the ipsilateral tibia is vertical
i. Hip moves from 10° of flexion to
extension by contraction of the
gluteus medius muscle.
ii. Knee reaches maximal flexion
and then begins to extend.
iii. Ankle becomes supinated and
dorsiflexed (5°), which is caused
by some contraction of the triceps
surae muscles
4. Heel off (terminal stance)
a. From heel rise until the opposite foot
contacts the ground (contralateral initial
contact)
i. 10° of hip hyperextension, which
then goes into flexion.
ii. Knee becomes flexed (0-5°)
iii. Ankle supinates and plantar
flexes.
Swing Phase
1. Toe Off (pre-swing)
a. transition phase between stance and
swing, in which the foot is pushed and
lifted off of the ground
i. Hip becomes less extended.
ii. Knee is flexed 35-40°
iii. Plantar flexion of the ankle
increases to 20°
2. Initial Swing
a. the hip, knee, and ankle are flexed to
begin advancement of the limb forward
and create clearance of the foot over the
ground
i. Hip extends to 10° and then
flexes due to contraction of the
iliopsoas muscle
ii. 20° with lateral rotation
iii. Knee flexes to 40-60°
iv. Ankle goes from 20° of plantar
flexion to dorsiflexion, to end in a
neutral position
3. Mid-Swing
a. limb advancement continues and the
thigh reaches its peak advancement.
b. Begins when the foot is aligned with the
opposite foot and ends when the tibia is
vertical
i. Hip flexes to 30° (by contraction
of the adductors)
ii. ankle becomes dorsiflexed due to
a contraction of the tibialis
anterior muscle
iii. Knee flexes 60° but then extends
approximately 30° due to the
contraction of the sartorius
muscle (caused by the
quadriceps muscles).
4. Terminal Swing
a. the final advancement of the shank takes
place and the foot is positioned for initial
foot contact to start the next gait cycle
b. Begins when the tibia is vertical and ends
when the foot contacts the ground (initial
contact)
i. Hip flexion of 25-30°
ii. Locked extension of the knee
iii. Neutral position of the ankle

Pathologic Gait
● Abnormal base of support
● Joint instability
● Limb clearance and advancement dysfunction
Abnormal Base of Support
● Equinus foot deformity
● Equinovalgus/varus foot
● Flexion deformity of the toes
● Hitchhiker's great toe
Equinus foot deformity
● frequently seen after an upper or lower motor
neuron injury
● a result of tightness in the Achilles tendon or calf
muscles (the soleus muscle and/or
gastrocnemius muscle)
● Limb contact with the ground occurs first with the
forefoot; weight is borne primarily on the anterior
and lateral border of the foot and may be
concentrated in the area of the fifth metatarsal
● Limited ankle dorsiflexion during midstance
prevents forward progression of the tibia over the
stationary foot, increasing pressure over the
metatarsals, promoting ankle instability, and
causing knee hyperextension.
● Swing phase- sustained plantar flexion of the foot
may result in a limb clearance problem unless
proximal mechanisms of compensation such as
increased hip and knee flexion are used
Equinovalgus Foot
● Upper or lower motor neuron injury, bony and
ligamentous injuries, surgery, and prolonged
immobilization with loss of ankle range of motion
can all contribute to this deformity
● plantarflexed that the base of the heel is rotated
away from the midline of the foot (eversion) and
abduction of foot
● During gait, contact with the ground occurs with
the forefoot, and weight is borne primarily on the
medial aspect of the foot. This position is
maintained or worsened during the stance phase
and interferes with weight bearing. Antalgic gait
may be present if the navicualr is overloaded. •
● During the swing phase, sustained plantar flexion
of the foot may result in a limb clearance problem
unless proximal mechanisms of compensation
such as increased hip and knee flexion are used
Equinovarus Foot
● commonly seen in pediatric patients with cerebral
palsy, spina bifida, and Duchenne muscular
dystrophy
● inverted heel with a supinated forefoot, often
associated with pain and callous formation along
the lateral border of the foot
● invertors overpower the evertors
● painful weight bearing over the lateral border of
the foot
● Instability during stance phase
● results in shortened single limb stance
Flexion Deformity of the Toes
● Likely causes are neurologic injuries, reflex
sympathetic dystrophy, prolonged immobilization,
and contractures.
● The toe may be held in flexion during the swing
and stance phase
● When wearing shoes, the patient complains of
pain at the tip of the toes and also over the
dorsum of the phalangeal joints, which is
worsened by weight bearing. Callus formation in
these areas is frequently seen.
● The gait pattern will demonstrate gradual loading
of the affected limb and shortening of the step
length and stance time.
Hitchhiker’s Great Toe
● notable problem in patients with upper motor
neuron problems
● The great toe is held in extension during stance
and frequently during swing phases.
● Equinus and varus posture of the ankle may
accompany this deformity.
 ● When wearing shoes, the patient frequently
complains of pain at the dorsum and the tip of
the big toe and, during the weightbearing phase
of the gait cycle, under the first metatarsal head.
● During gait, big toe extension can interfere with
the weightbearing phase of locomotion.
● Overactivation of the extensor hallucis longus
and reduction or lack of activation of flexor
hallucis longus frequently contribute to this
deformity
Joint Instability
● Ankle Instability
● Knee Instability
● Hip Instability
● Trunk Instability
Ankle Instability
● This deviation is caused by excessive untimely
forward progression of the tibia in mid to late
stance phase.
● This is usually the result of insufficient calf
musculature, which is intended to provide control
for the forward progression of the tibia over the
stationary foot.
Knee Instability
● Refers to either knee buckling or hyperextension
● can occur when the expected early stance-phase
knee flexion is combined with quadriceps
weakness
● may be seen in persons with lower motor neuron
syndrome, knee extensor weakness, quadriceps
tendon rupture, or tears of the cruciate ligaments
● The lack of full knee extension in terminal swing
limits limb advancement and reduces step
length.
Hip Instability
● Excessive hip flexion during stance phase is a
less common gait deviation
● This deformity is characterized by sustained hip
flexion that interferes with limb positioning during
gait.
● During the stance phase, excessive hip flexion
interferes with contralateral limb advancement
and results in a shortened step length. \
● Possible causes include:
○ degenerative changes of the hip joint
○ bony deformities such as:
■ heterotopic ossification
■ knee extensor, weakness and
ankle plantar flexor posture
■ hip flexion contractures, and
flexor spasticity
● Hip adduction can occur during the swing phase,
and this can interfere with limb clearance and
advancement.
● During stance phase, this deviation results in a
narrow base of support with potential balance
impairment.
Limb Clearance and Advancement Dysfunction
● Stiff knee gait
● Excessive pelvic obliquity (pelvic drop)
● Inadequate hip flexion
● Drop foot
Stiff Knee Gait
● most commonly seen in the patient with spastic
hemiplegia
● the knee and hip maintain an extended attitude in
the swing phase instead of flexing up to the
average normal 60° for the knee and 30° for the
hip
● even if the ankle-foot system has an appropriate
dorsiflexed position, the lack of limb clearance
can result in a foot drag
Excessive Pelvic Obliquity (Pelvic Drop)
● Overactive stance phase hip abductor weakness
can compromise limb clearance and
advancement
● Normally, hip abductors help to counter gravity's
pull in the swing side pelvis by producing an
abductor moment to help keep the pelvis level
● Weakness may allow the pelvis to sag (more
obliquity)
Inadequate Hip Flexion
● another cause of abnormal limb clearance
● this problem effectively prevents physiologic
'shortening’ of the limb, producing a swing phase
toe drag or early foot contact
Drop Foot
● lack of ankle dorsiflexion during the swing phase
● can result in impairment of limb clearance unless
appropriate compensation is afforded in other
anatomic segments such as:
○ knee and hip (steppage gait)
○ by the contralateral limb (vaulting)
● The frequent cause of this problem is lack of
activation of the tibialis anterior and may be
secondary to a peroneal nerve injury