SHOES, FOOT ORTHOTICS, ANKLE FOOT ORTHOTICS

Shoes
Shoes are the important foundation of the lower limb orthosis. Shoes are used to protect and warm the feet, transfer body weight while walking, and reduce pressure or pain through redistributing weight. Shoes should be comfortable and properly fitted.
They should be at least 1 cm longer than the longest toe and correspond to the shape of the feet.
The shoe can be divided into lower and upper parts. The lower parts consist of the sole, shank, ball, toe spring, and heel. The upper parts include the quarter, heel counter, vamp, toe box, tongue, and throat.

Rocker Shoe

Blucher style orthopedic shoe

Diabetic shoe

Foot orthosis
The foot orthosis extends from the posterior border of the foot to a point just posterior to the metatarsal heads. This device is used to accommodate the abnormal foot to help restore more normalized lower limb biomechanics.

  1. Custom Foot Orthotic Shoe insert: This insert is made of rigid plastic fabricated over a cast of the foot held in maximal manual correction. It encompasses the heel and midfoot, and it has rigid medial, lateral, and posterior walls.
  2. Heel cup: The 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. The heel cup is used to prevent lateral calcaneal shift in the flexible flat foot.
  3. Sesamoid insert: This addition to an orthosis is an insert amounting to three quarters of an inch with an extension under the hallux to transfer pressure off the short first metatarsal head and onto its shaft.

ANKLE-FOOT ORTHOTICS (AFO)
An AFO is commonly prescribed for weakness or paralysis of ankle dorsiflexors, plantar flexors, invertors, and evertors. AFOs are used to prevent or correct deformities and reduce weight bearing. The position of the ankle indirectly affects the stability of the knee with ankle plantar flexion providing a knee extension force and ankle dorsiflexion providing a knee flexion force. An AFO has been shown to reduce the energy cost of ambulation in a wide variety of conditions, such as spastic diplegia due to cerebral palsy, lower motor neuron weakness of poliomyelitis, and spastic hemiplegia in cerebral infarction.

  1. Thermoplastic AFOs: These devices are plastic molded AFOs, consisting of the following 3 parts: (1) a shoe insert, (2) a calf shell, and (3) a calf strap attached proximally. The rigidity depends on the thickness and composition of the plastic, aswell as the trim line and shape. Thermoplastic AFOs are contraindicated in cases of fluctuating edema and insensation.
  • Posterior leaf spring (PLS): The PLS is the most common form of AFO with a narrow calf shell and a narrow ankle trimline behind the malleoli. The PLS is used for compensating for weak ankle dorsiflexors by resisting ankle plantar flexion at heel strike and during swing phase with no mediolateral control.
  • 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 rotation in the transverse plane while controlling ankle dorsiflexion and plantar flexion, as well as eversion and inversion.
  • 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.
  • 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.
  • 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.
  • Hinged AFO: The adjustable ankle hinges can be set to the desired range of ankle dorsiflexion or plantar flexion.
  • Tone-reducing AFO (TRAFO): The broad footplate is used to provide support around most of the foot, extendingdistally under the toes and up over the foot medially and laterally to maintain the subtalar joint in normal alignment.

The TRAFO is indicated for patients with spastic hemiplegia.

Modular ankle-foot orthosis with ankle foot double adjustable hinged joint

Double uprightmetal AFO

Carbon plastic orthosis with footplate.

REFERENCES

  1. Braddom RL, Dumitru D, Johnson EW, et al, eds. Lower limb orthoses. In: Physical Medicine and Rehabilitation. 1st ed. WB Saunders Co;1995:333-358.
  2. Merritt JL. Knee-ankle-foot orthotics: long leg braces and their practical applications. In: Physical Medicine and Rehabilitation: State of the Art Reviews. Vol 1. 1987:67-82.
  3. Molnar GE, Alexander MA. Orthotics and assistive devices. In: Pediatric Rehabilitation, Rehabilitation Medicine Library. Lippincott Williams & Wilkins;1985:157-177.
  4. Tan JC. Orthoses. In: Practical Manual of Physical Medicine and Rehabilitation. 1st ed. Mosby-Year Book;1998:178-228.
  5. Rubin G, Bonarrigo D, Danisi M. The shoe as a component of the orthosis. Prosthet Orthot Int.1976;30(2):13-25

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