Show modifications

and AFOs
Dr Sonal (MPT I) and Dr Akanksha (MPT II)
Under Dr. ANKITA
anatomy & biomechanics

• Two ankle joints- talocrural

subtalar

• Three parts of foot – rearfoot/hindfoot

midfoot
forefoot

• Arches of foot – medial longitudinal arch

lateral longitudinal arch
transverse MT arch
SHOE MODIFICATIONS

• Leg length discrepancy

• Diabetes
• Severe pronation
• Severe supination
• Plano valgus
• Osteoarthritis
Goals of shoe modifications

• Provide ankle & foot stability in stance

• Control biomechanical alignment of foot & ankle in locomotion (pronation & supination)
• Aid in adaption to surfaces
• Redistribute pressures on the foot
• Resist external forces on foot & ankle
• Limit excessive movements in foot & ankle
• Protect the foot & ankle
• Provide shock absorption
• Produce a more energy efficient gait pattern
Intrinsic & extrinsic modifications

• Intrinsic : changes made to the positive mould of foot & ankle

• Extrinsic : accommodative padding & wedging added to the shoe.
• Exs of accommodative padding:
• Metatarsal pad Scaphoid pad
• 2-5 bar Malleolar padding
• MT head cutout Shoe raise
• Mortons extension Rocker bottom
• Heel cushion Buttress
• Forefoot extension
• Shoe modifications work best when used within a neutral
shoe with an appropriate heel counter.
• Shoe modifications cannot be switched between shoes.
Permanent footwear modifications

Not temporary but are substantive & result in a shoe that cannot be easily
returned to its original condition. Once modified, this footwear would not be
appropriate for someone without the medically indicated deformity.
Either on their own or combined with custom-made orthoses &/or orthopaedic
shoes
Can be simple or complex, with price & impact varying accordingly.
Can be made to everyday footwear as well as athletic shoes.
Some modifications are not appropriate for all types of footwear & options
should be discussed with trained Pedorthist.
Reducing ground reaction forces:
Indications : heel spur, heel ulcer, plantar fasciitis, muscular skeletal degeneration ( neck, back,
hip, knees)

Objectives: improve heel base stability, alternate shock & reduce GRF to rearfoot.

Internal :
Heel cradle, cups, wedges, pads, etc.

External :
Thomas heel
Extended lateral (reverse ) Thomas heel
Bevel (rock up) heel at contact to slow foot slap
Thomas heel(a) reverse Thomas heel (B)
Medial / lateral stability modifications :
Indications :
Excessive or inadequate pronation/supination
Peroneal paralysis /weakness (stroke, polio)
Extreme genu valgum/varus
Post tibial tendon ruptures or dysfunction
Poor stability (ankle sprains)
Extreme medial or lateral instability
Peroneal muscle atrophy ( Charcot Marie Tooth syndrome)

Objectives :
Reinforce the structure of shoe to prevent excessive inversion/eversion forces of foot & ankle
when the vertical forces fall laterally or medially to the position of foot & ankle.

Heel flare( outrigger)design

Heel & sole wedges:
Controlling pronation/supination

Indications :
Excessive or inadequate pronation/supination
Peroneal paralysis/weakness
Post. Tibial tendon dysfunction/rupture
Ankle sprains
Extreme medial /lateral instability
Faulty frontal plane mechanics
Stabilization of weak counter

Objectives:
Augment eversion/inversion (pronation/supination)forces not being fully addressed by footwear
&/or orthotic devices.
Elevations :
Improving balance.

Indications :
Structural asymmetry
Gait inefficiencies
Functional /anatomical leg length discrepancies
Equinus influences

Objectives :
To help improve balance, alignment& gait.
To relieve discomfort & pain.

Internal : heel only

External : heel only
heel & sole
Metatarsal bars:
Alleviating pressure.

Indications :
Metatarsalgia, plantar flexed MT- overuse injury,pain & inflammation in the ball of foot.
IPK( Intractable Plantar Keratosis)-focused, painful lesion, in the form of a discrete, focused
callus, usually about 1 cm on plantar aspect of forefoot.

Objectives :
Relieve /reduce pressure on MT heads by placing MT bar proximally to MT heads.
Allowing propulsion with some reduction of MPJ dorsiflexion, midfoot, subtalar & ankle
motions.

Thomas bar:
Supports shank area (midfoot)
Sole modifications :
Accommodating foot shapes.

Indications:
Unusual shape & size of feet.
When custom made shoes are not within patients budget.
An economical approach to customised footwear.

Objectives:
Modify size & fit within shoe to accommodate out of ordinary foot shape & volume.
Effective solution for fashion shoe wearer.

Techniques: fit alterations- widening , stretching, shoe surgery, relasting (remodelling)

Excavations, Dispersions & Pads.
Diffusing pressures

Indications :
Dorsal exostosis- distinct,painful bump on top of foot.
Plantar flexed 1st ray
Dropped MT head
Calcaneal spur
Haglund's deformity- bony enlargement on the back of heel.
Any sensitive area or lesion that would benefit by relief of pressure.

Objectives :
Diffuse pressure
Plantar accommodations
Deformities accommodation
Redistribute weight to more tolerant areas.
Examples :
1. Plantar relief in dress(fancy heeled ) shoes
2. Excavation of forefoot
3. Filled with soft foam or liquid gel
4. Arch support covered with upper matched leather.
5. Optional MT pad for pressure relief.
6. Optional heel wedge for more correction.
7. Inside of shoe covered with leather insole
8. ¼’” forefoot rocker.

 MT pad
 MT bar
 Scaphoid pad
 Sesamoid pad/dancers pad
 Mortons extension
 Heel spur excavations
 Neuroma pad
Enclosures :
Improving access.

Indications :
Geared to pts with manual dexterity limitations.
Rigid ankle,knee,hip & back disabilities.
Paralysis.

Objective :
To create an easier way to allow foot entry & closure.

Techniques :
Velcro addition hook & loop
Lace to toe opening
Rear-entry closures
Rocker- bottoms
Reducing painful motions.

Indications :
Address painful or immobile joints that function on the sagittal plane.

Objectives :
Reduce pressure motion in painful joints.
Prevent compensation to rigid joints.
Reduce ground reaction forces.

Techniques :
Heel to toe rocker
Healing/negative rocker
MPJ rocker
MT head rocker
Ankle joint rocker
Lisfranc’s rocker
Rigid rocker bottoms
Reducing painful motion.

Indications :
Hallux rigidus
Charcot arthropathy

Objectives :
Maintain a fulcrum to control sagittal plane ground reactive forces.

Techniques :
Adding an integral rigid steel or carbon graphite plate to shoe.
Providing a rigid fulcrum for the foot to pass over.
MT rocker.
Definition
• Any externally applied device used to modify structural or functional
characteristics of the neuromuscular skeletal system
(International Standards Organisation of International society for
Prosthetics and Orthotics)
Uses
• Assist gait
• Decrease pain
• Control movement
• Minimize progression of a deformity
PRINCIPLE USE
• Lower limb orthoses assist non ambulatory patients with transfer and
mobility skills and help ambulatory patients in becoming safe walkers
AFO (Ankle Foot Orthosis)
• Also known as short leg braces
• To control excessive ankle motion
• Provide mediolateral stability as a safety feature
• The most frequently prescribed device used to control the lower
extremity during each phase of the gait cycle
 Click icon to add picture
Parts of the
AFO
• Foot plate
• Trim line
• Ankle joint-plastic or
metal
• Varus-valgus control by
3 point pressure system
Principle of 3 Point pressure Mechanism
 • Prohibit motion in any plane (Solid AFOs,
Sta Anterior floor reaction AFOs)
tic
Dy • Allow some degree of movement int the
na sagittal plane (posterior leaf AFO and
mi articulating AFO)
c
Static AFOs
• Restrict ankle and foot motion in all three planes to provide
significant stance stability and swing limb clearance
• There is a benefit of greater stability against the cost of lost mobility
1.Solid Ankle foot orthosis
2.Anterior floor reaction orthosis
Solid ankle
foot orthosis
(SAFO)
• Control ankle position
throughout the stance
phase.
• Provides stance phase
stability via ankle- knee
coupling
• Assist in limb clearance
in swing phase
• Preposition foot for IC by
heel
• Indications: Significant hypertonicity with seriously impaired motor
control at ankle and knee
• Contraindications: LMN paralysis (flaccidity) or hypotonicity as
primary problem (wont be able to lift the leg with weight of the (AFO)
• Other options:
• Made up of thermoplastic material
• Forms the basis for KAFO and HKAFO
• Requires cushion heel and rocker bottom shoe
Anterior floor
reaction AFO
It is fabricated to hold
the ankle in a few
degrees of
plantarflexion, this
creates an extensor
moment that stabilizes
the knee during the late
stance phase
• Most commonly used for children with CP (spastic diplegia) who
demonstrate crouch gait (GMFCS level- 2and 3) or in
myelomeningocele and in post polio syndrome
• Indications: Weakness or impaired motor control at ankle and knee
• Contraindications: Ligamentous insufficiency at the knee, genu
recurvatum
• Made up of thermoplastic or carbon composite (to provide maximum
stiffness)
Dynamic AFOS
• Allow some degree of sagittal plane motion at ankle, dorsiflexion
durig stance phase (facilitate 2nd rocker), but restrict plantarflexion
motion during swing phase to facilitate swing limb clearance
1. Supramalleolar orthosis
2. Posterior leaf spring AFO
3. Articulating AFO
Supramalleolar
Orthosis (SMO)
• Proximal trimlines are just
superior to the ankle joint
and the distal encase most of
the foot forefoot.
• This limits the movement of
the midfoot and forefoot and
gives stability, thereby giving
a more functional alignment
(preventing navicular drop)
SMO
• Indications: Flexible pes planus, Correct foot alignment
1. CP diplegic children- redistribute the plantar pressures of spastic
equinovarus from the anterior of the foot to the heel,
2. In stance phase- stable base, swing phase improve the limb clearance
and self- selected walking speed, upright posture
Posterior leaf
spring AFO
• Support the weight of
the foot during swing
phase as a means of
enhancing swing limb
clearance
• Assist with lowering of
the foot during loading
response in stance
phase (1st heel rocker)
Posterior leaf spring AFO
• Indications: dorsiflexion weakness, impaired motor control, LMN
flaccid paralysis of dorsiflexors
• Contraindications: Moderate to severe hypertonicity (poor
mediolateral stability)
Articulating AFO
(Hinged)
• Allows sagittal plane
motion at the ankle by
incorporating a
mechanical ankle joint
between the foot and the
calf sections.
• This allows the tibia to
roll over the weight
bearing foot during stance
(2nd rocker)
Hinged AFOs
• In CP and stroke, these orthoses reduce the energy cost of walking as
well as improve stride length, cadence and walking speed.
• Also improves mobility in functional activities ( rising from the floor,
ascending and descending stairs, walking up and down on inclines as
compared to SAFO)
• Hinged AFOs can be fabricated to allow free motion at the ankle, to
allow limit range of motion
Hinged AFOs
• Indications: Impaired motor control of ankle musculature, potential recovery of
neuromotor function
• Contraindications: LMN paralysis (flaccidity) or hypotonicity as primary
problem
• Other options: Thermoplastic or metal uprights.
• Dorsiflexion assist
• Plantarflexion stop
• Adjustable range into dorsiflexion can be incorporated often requires shoe with
cushion heel
Static vs Dynamic AFOs
• Static AFOs • Dynamic AFOs
• No mobility at the ankle joint. • Some range of motion at ankle
joint
• Difficulty in mid stance and
• Facilitate dorsiflexion and
push off phases
plantarflexion
• Conditions- quadriplegic CP or • Posterior leaf spring AFOS- (foot
SCI (complications like drop, stroke)
contractures are avoided), • Dynamic AFOs- Stoke cases, CP
MND or DMD) (Diplegic)
Combinations
• SMO+ dynamic AFOs – CP (diplegic or triplegic), Stroke cases
• SAFO: Basis of KAFO or HKAFO (SCI)
QUIZ
A) B)
C) D)