Outlines

1
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Outlines

• What Orthotics and Prosthetics are
• History of Orthotics and Prosthetics
• Orthotics and Prosthetics in Iran
• What we are going to get on todays and
  tomorrows sessions

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What Orthotics and Prosthetics are

• Orthotics, Orthosis, and Orthoses
• Brace, Splint
• Eponyms
• Milwaukee Brace
• Miami Brace
• ISO terminology 1989
• Acronyms
• Cervical Orthosis CO
• Ankle Foot Orthosis AFO
• Prosthetics, Prosthesis, and Prostheses
• Terminology

4
History of Orthotics and Prosthetics

• A Persian soldier 486 B.C.
• A Mummy 250 B.C.
• A Knight in Germany 1840
• Pirates
• 1st and 2nd World Wars
• Orthotics and Prosthetics is rapidly evolving

5
Orthotics and Prosthetics in Iran

• Establishment process
• Education
• Problems

6
What we will have in the next 3 sessions

• Spinal orthoses
• Lower limb orthoses
• Upper limb orthoses

7
Few points on orthotic prescription

• Optimal setting
• Physician, Orthotist, therapist are available for
  evaluation as well as follow-ups.
• Prescription
• Name, DoB, Functional deficit, Reason of
  orthosis, Area of coverage, Action on each joint
  in each plane, Materials, Concerns, Need for
  consultation, and etc.

8
Different classification styles

• Function
• Area of the body
• Material
• Manufacturing method
• Objectives

9
Classification based on function

• Prophylactic
• Rehabilitive
• Functional

10
Classification based on area of the bady

• Upper limb
• Lower limb
• Foot
• Spine
• Head

11
Classification based on the used materials

• High temperature thermoplastics
• Low temperature thermoplastics
• Leather
• Metal
• Electronics? Particularly in sport!

12
Classification based on manufacturing method

• Prefabricated
• Custom made
• Prefabricated custom fitted

13
Classification based on objectives

• Pain relief
• Deformity correction
• Enhance range of motion
• Immobilisation
• A counterforce

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Spinal orthoses

• Reasons
• Abdominal support
• Pain management
• Motion/Position control
• Level
• SO
• LSO
• TLSO
• Structure
• Semi rigid
• Rigid

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Semi rigid spinal orthoses

• Some degree of immobilisation
• Lordosis reduction? lumbo-sacral strain
• Intracavitary pressure? reduced axial load
• Management of pain caused by muscle strain
• Long term use? Atrophy? Increased chance of
  reinjury

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Semi rigid spinal orthoses (cont.)

• Sacroiliac corset
• Provides assistance to pelvis only
• The main indication is hyper mobility of
  sacroiliac joints.
• Slight increase to abdominal pressure
• Lumbosacral corset
• Increases abdominal pressure
• Acute back pain
• Thoracolumbar corset
• Shoulder straps provide a posteriorly directed
  force
• Kinesthetic reminder

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Rigid spinal orthoses

• Prescription considerations
• Patient gadget tolerance
• Donning and doffing
• Categories
• Conventional or Metal
• Contemporary equivalents

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LSO

• Chairback style
• Reduction of gross motion in sagittal plane
• Knight style (Knight, 1884)
• Sagittal-coronal control
• Williams style
• Extension-coronal control
• Dynamic orthosis
• By Willimas in 1937 for spondylolisthesis

20
TLSO

• Jewett style
• Flexion control (hyper extension orthosis)
• Jewett 1937
• Taylor style
• Sagittal control (equivalent to chairback)
• Knight taylor
• Sagittal-coronal control (equivalent to knight)
• Cowhorn style
• Triplanar control

21
Contemporary spinal orthosis

• LSO
• TLSO
• Custom molded body jacket
• Maximum control
• The bivalve design ? patients with variable volume

22
Jewett brace

• Indications
• Symptomatic relief of compression fractures
  not caused by osteoporosis
• Immobilization after surgical stabilization of
  thoracolumbar fractures
•  Motion restrictions
• Limits flexion between T6-L1
• Ineffective in limiting lateral bending and
  rotation of the upper lumbar spine
• Contraindications
• Three-column spinal fractures involving anterior,
  middle, and posterior spinal structures
• Compression fractures above T6, because segmental
  motion increases above the sternal pad
• Compression fractures caused by osteoporosis

23
Cervical orthoses

• Reasons
• Pain management
• Motion/Position control
• Level
• CO
• CTO
• Structure
• Semi rigid
• Rigid

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Cervical orthoses

• Foam collars
• Kinesthetic reminder
• Semi rigid collars
• Philadelphia collar
• Little control of lateral bending and rotation
• Poster style orthoses

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Cervicothoracic orthoses

• Sternal Occipital Mandibular Immobiliser (SOMI)
• More effective in control of flexion than
  extension
• Halo
• Provides triplanar control
• Fixed to skull with pins
• Intersegmental snaking

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Indications for the use of a soft collar

• Warmth
• Psychological comfort
• Head support when acute neck pain occurs
• Relief from minor muscle spasm associated with
  spondylolysis
• Relief from cervical strain
• The soft collar provides some motion limitations
  for the patient, including the following
• Full flexion and extension are limited by 5-15.
• Full lateral bending is limited by 5-10.
• Full rotation is limited by 10-17.

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Indications for the use of a semi rigid collar

• Head support when acute neck pain occurs
• Relief of minor muscle spasm associated with
  spondylosis
• Psychological comfort
• Interim stability and protection during halo
  application
• Motion restrictions associated with the hard
  collar include the following
• Full flexion and extension are limited by 20-25.
  
• The hard collar is less effective in restricting
  rotation and lateral bending.
• It is better than a soft collar in motion
  restriction.

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Indications of Philadelphia

• Anterior cervical fusion
• Halo removal
• Dens type I cervical fractures of C2
• Anterior diskectomy
• Suspected cervical trauma in unconscious patients
  
• Teardrop fracture of the vertebral body (Note
  Some teardrop fractures require anterior
  decompression and fusion.)
• Cervical strain

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Indications for immobilization with the SOMI

• Atlantoaxial instability caused by rheumatoid
  arthritis (Note that ligamentous disruption in
  rheumatoid arthritis affects flexion more than
  extension, because extension is held in check by
  the intact dens.)
• Neural arch fractures of C2, because flexion
  causes instability
• Motion restrictions associated with the SOMI
  include the following
• Cervical flexion and extension are limited by
  70-75
• Lateral bending is limited by 35
• Rotation is limited by 60-65

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Indications for immobilization with a halo device

• Dens type I, II, or III fractures of C2 (Note
  Dens type III fractures of C2 are treated more
  successfully with surgery.)
• C1 fractures with rupture of the transverse
  ligament
• Atlantoaxial instability from rheumatoid
  arthritis, with ligamentous disruption and
  erosion of the dens
• C2 neural arch fractures and disc disruption
  between C2 and C3. (Note Some patients may need
  surgery for stabilization.)
• Bony, single-column cervical fractures
• Cervical arthrodesis - Postoperative
• Cervical tumor resection in an unstable spine -
  Postoperative
• Debridement and drainage of infection in an
  unstable spine - Postoperative
• Spinal cord injury (SCI)
• Contraindications for the use of a halo device
  include the following
• Concomitant skull fracture with cervical injury
• Damaged or infected skin over pin insertion sites

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Orthoses for spinal deformity

• Milwaukee brace CTLSO
• TLSO
• Boston
• Prefabricated, custom fitted
• Miami
• One piece, posterior opening, custom molded
• Wilmington
• Risser frame
• Charleston Bending brace
• Night time use

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Main features of an spinal orthosis

• Weight
• Adjustability
• Functional use
• Cosmesis
• Cost
• Durability
• Material
• Ability to fit patients of various sizes
• Ease with which the device can be put on (donned)
  and taken off (doffed)
• Provision of access to a tracheostomy site, peg
  tube, or other drains
• Provision of access to surgical sites for wound
  care
• Provision of aeration in order to avoid skin
  maceration from moisture

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Indications for recommending the use of orthoses

• Pain relief
• Mechanical unloading
• Scoliosis management
• Spinal immobilization after surgery
• Spinal immobilization after traumatic injury
• Compression fracture management
• Kinesthetic reminder to avoid certain movements

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Duration of orthosis use

• Where spinal instability is not an issue, until
  he/she can tolerate discomfort without the brace.
  
• When employed for stabilisation after surgery or
  acute fractures, 6-12 weeks of use should be
  allowed to permit ligaments and bones to heal

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The use of an orthosis is associated with several
drawbacks

• Discomfort
• Local pain
• Osteopenia
• Skin breakdown
• Nerve compression
• Ingrown facial hair in men
• Muscle atrophy with prolonged use
• Decreased pulmonary capacity
• Increased energy expenditure with ambulation
• Difficulty in donning and doffing the orthosis
• Difficulty with transfers
• Psychological and physical dependency
• Increased segmental motion at the ends of the
  orthosis
• Unsightly appearance
• Poor patient compliance

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The successful use of an orthosis may lead to

• Decreased pain
• Increased strength
• Improved function
• Increased proprioception
• Improved posture
• Correction of spinal curve deformity
• Protection against spinal instability
• Minimized complications
• Healing of ligaments and bones

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Lower limb orthoses

• FO is a foot orthosis.
• AFO is an ankle-foot orthosis.
• KO is a knee orthosis.
• KAFO is a knee-ankle-foot orthosis.
• HO is a hip orthosis.
• HKAFO is a hip-knee-ankle-foot orthosis.
• THKAFO is a trunk-hip-knee-ankle-foot orthosis.

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Shoe Modifications

• Heel modifications
• A cushioned heel A wedge of compressible rubber
  is inserted into the heel to absorb impact at
  heel strike. Often with a rigid ankle
• A heel wedge A medial wedge is used to promote
  inversion, and a lateral wedge is used to promote
  eversion.

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Other heel modifications

• A heel flare
• A medial flare is used to resist eversion.
• A lateral flare is used to resist inversion.
• Both flares are used to provide heel stability.
• Extended heel The Thomas heel projects
  anteriorly on the medial side to provide support
  to the medial longitudinal arch.
• Heel elevation A shoe lift is used to compensate
  for fixed equinus deformity.

41
Sole modifications

• A rocker bar is a convex structure placed
  posterior to the metatarsal head. The rocker bar
  is used to shift the rollover point from
  metatarsal head to metatarsal shaft to avoid
  irritation of ulcers along the metatarsal head in
  patients with diabetes mellitus.
• A metatarsal bar is a bar with a flat surface
  placed posterior to the metatarsal head. The
  metatarsal bar is used to relieve the pressure
  from the metatarsal heads.
• A sole wedge A medial wedge is used to promote
  supination, and a lateral wedge is used to
  provide pronation.

42
Foot orthosis

• UCBL (University of California at Berkeley
  Laboratory) insert This insert is made of rigid
  plastic fabricated over a cast of the foot held
  in maximal manual correction. The UCBL
  encompasses the heel and midfoot, and it has
  rigid medial, lateral, and posterior walls.
• 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.

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Orthotic ManagementFor Athletic Injuries 1

• Turf Toe
• Common in athletes playing on firm, artificial
  turf
• Forceful extension of the 1st MTP joint
• Injury to the joint capsule
• Untreated, can lead to Arthritic Joint Changes
• Hallux limitus
• Hallux rigidus

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Orthotic ManagementFor Athletic Injuries 2

• Turf Toe
• Goal of Orthotic Treatment
• Limit Great Toe Extension
• Helping joint capsule to heal
• Carbon Footplates
• Total Contact FO

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Orthotic ManagementFor Athletic Injuries 3

• Heel Pain
• Severs disease
• Active adolescents
• Girls 8 to 10 yrs of age
• Boys 10 to 12 yrs of age
• Strong pull of Achilles tendon

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Orthotic ManagementFor Athletic Injuries 4

• Heel Pain
• Conservative Treatment for Severs Disease
• Rest
• Stretches
• Soft heel cups
• FO with heel cushion
• Walking boot in slight equinus / heel wedge

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Orthotic ManagementFor Athletic Injuries 5

• Heel Pain
• Plantar Fasciitis
• Repetitive strain of the plantar fascia

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Orthotic ManagementFor Athletic Injuries 6

• Plantar Fasciitis Treatment
• Stretches
• Heel Cushions / Gel cups
• Nocturnal dorsiflexion splints
• AFO (custom) Total contact day night

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Orthotic ManagementFor Athletic Injuries 7

• Ankle Sprains
• Treatment corresponds to degree of instability
• Walking boot
• Ankle lacer, stirrup, sleeve
• Chronic sprains, instability
• Foot orthotics
• Ankle lacer during sport
• Medial or lateral support

50
Orthotic ManagementFor Athletic Injuries 8

• Achilles Tendon Injury
• Immobilization
• Custom made AFO
• Floor reaction AFO
• Walking Boot
• Reduce Stress on Injured Site
• Allow Healing

51
Orthotic ManagementFor Athletic Injuries 9

• Metatarsal Fractures
• Dancers fracture
• Jones fracture
• 5th Metatarsal fracture
• March Fracture
• High rate of 2nd and 3rd MT stress fractures

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Orthotic ManagementFor Athletic Injuries 10

• Metatarsal Fractures
• Orthotic Treatment
• Walking boot
• AFO (custom made)
• Prevention
• Foot orthotics addressing the shock absorbing
  and/or functional needs of the individual

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Thermoplastic AFOs

• Posterior leaf spring (PLS) For compensating for
  weak ankle dorsiflexors , no mediolateral
  control.
• Spiral AFO Allows for rotation in the transverse
  plane while controlling ankle dorsiflexion and
  plantar flexion, as well as eversion and
  inversion.

54
Thermoplastic AFOs (Continued)

• Solid 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 for
  valgus, varus control.
• Hinged AFO The adjustable ankle hinges can be
  set to the desired range of ankle dorsiflexion or
  plantar flexion.

55
Metal AFO

• Free motion ankle joint allows free ankle motion
  and provides only mediolateral stability.
• Dorsiflexion assist spring joint This joint has
  a coil spring in the posterior channel and helps
  to aid dorsiflexion during swing phase.
• Varus or valgus correction straps (T-straps)
  valgus, varus correction.

56
Knee Ankle Foot Orthosis

• Free motion knee joint
• to prevent hyperextension.
• for patients with recurvatum but good strength of
  the quadriceps
• Offset knee joint
• is located posterior to ground reaction force
  thus,
• provides great stability
• joint flexes the knee freely during swing phase
• is contraindicated with knee or hip flexion
  contracture and ankle plantar flexion stop.
• Drop ring lock knee joint
• is the most commonly used knee lock to control
  knee flexion.
• gait is stiff without knee motion.

57
Knee Ankle Foot Orthosis

• Adjustable knee lock joint (dial lock) It allows
  knee locking at different degrees of flexion. in
  patients with knee flexion contractures that are
  improving gradually with stretching.
• Ischial weight bearing

58
Knee Orthoses

• Knee orthoses for patellofemoral disorder to
  control tracking of the patella during knee
  flexion and extension.
• Knee orthoses for knee control in the sagittal
  plane to control genu recurvatum with minimal
  mediolateral stability.
• Knee orthoses with adjustable knee joint fpr
  flexion contracture.
• Knee orthoses for knee control in the frontal
  plane The knee joint usually is polycentric and
  closely mimics the anatomic joint motion.
• Knee orthoses for axial rotation control These
  orthoses can provide angular control of
  flexion-extension and mediolateral planes, in
  addition to controlling axial rotation. This
  orthosis is used mostly in management of sports
  injuries of the knee. This type of KO includes
  Lenox-Hill derotation orthosis and Lerman
  multiligamentous knee control orthosis.

59
Hip Knee Ankle Foot Orthoses

• Reciprocating Gait Orthosis

60
Sport related orthoses

• Prophylactic
• Yes
• To prevent excessive forces
• To prevent sudden impact
• No
• It increases energy expenditure
• It can harm others
• Anatomical and mechanical correspondence

61
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62
Lower limb orthoses

• FO is a foot orthosis.
• AFO is an ankle-foot orthosis.
• KO is a knee orthosis.
• KAFO is a knee-ankle-foot orthosis.
• HO is a hip orthosis.
• HKAFO is a hip-knee-ankle-foot orthosis.
• THKAFO is a trunk-hip-knee-ankle-foot orthosis.

63
Materials

• Plastics
• Low-temperature thermoplastics Mainly in low
  stress activities.
• High-temperature They are ideal for high stress
  activities.
• Leather It conducts heat and absorbs water well.
  
• Rubber Rubber is used for padding in body
  jackets and limb orthoses.
• Metal
• Metals, such as stainless steel and aluminum
  alloys can be used for joint components, metal
  uprights, sprints, and bearings.

64
Shoe Modifications

• Heel modifications
• A cushioned heel A wedge of compressible rubber
  is inserted into the heel to absorb impact at
  heel strike. This cushion often is used with a
  rigid ankle to reduce the knee flexion moment by
  allowing for more rapid ankle plantar flexion.
• A heel wedge A medial wedge is used to promote
  inversion, and a lateral wedge is used to promote
  eversion. The heel counter should be strong
  enough to prevent the hindfoot from sliding down.

65
Other heel modifications

• A heel flare A medial flare is used to resist
  eversion, and a lateral flare is used to resist
  inversion. Both flares are used to provide heel
  stability.
• Extended heel The Thomas heel projects
  anteriorly on the medial side to provide support
  to the medial longitudinal arch. The reverse
  Thomas heel projects anteriorly on the lateral
  side to provide stability to the lateral
  longitudinal arch.
• Heel elevation A shoe lift is used to compensate
  for fixed equinus deformity or for any leg-length
  discrepancy of more than one centimeter.

66
Sole modifications

• A rocker bar is a convex structure placed
  posterior to the metatarsal head. The rocker bar
  is used to shift the rollover point from
  metatarsal head to metatarsal shaft to avoid
  irritation of ulcers along the metatarsal head in
  patients with diabetes mellitus (DM).
• A metatarsal bar is a bar with a flat surface
  placed posterior to the metatarsal head. The
  metatarsal bar is used to relieve the pressure
  from the metatarsal heads.
• A sole wedge A medial wedge is used to promote
  supination, and a lateral wedge is used to
  provide pronation.
• A steel bar The steel bar is placed between the
  inner sole and outer sole. This bar is used to
  reduce forefoot motion to reduce the stress from
  phalanges and metatarsals.
• Combination of sole and heel modifications If
  heel elevation is more than one half an inch, a
  sole elevation should be added to avoid equinus
  posture.

67
Foot orthosis

• UCBL (University of California at Berkeley
  Laboratory) insert This insert is made of rigid
  plastic fabricated over a cast of the foot held
  in maximal manual correction. The UCBL
  encompasses the heel and midfoot, and it has
  rigid medial, lateral, and posterior walls.
• 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.
• 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.

68
Thermoplastic AFOs

• 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 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.

69
Thermoplastic AFOs (Continued)

• 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.

70
Metal AFO

• Free motion ankle joint The stirrup has a
  completely circular top, which allows free ankle
  motion and provides only mediolateral stability.
• Dorsiflexion assist spring joint This joint has
  a coil spring in the posterior channel and helps
  to aid dorsiflexion during swing phase.
• 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.

71
Knee Ankle Foot Orthosis

• Free motion knee joint
• to prevent hyperextension.
• for patients with recurvatum but good strength of
  the quadriceps
• Offset knee joint
• is located posterior to ground reaction force
  thus,
• provides great stability
• joint flexes the knee freely during swing phase
• is contraindicated with knee or hip flexion
  contracture and ankle plantar flexion stop.
• Drop ring lock knee joint
• is the most commonly used knee lock to control
  knee flexion.
• gait is stiff without knee motion.

72
Knee Ankle Foot Orthosis

• Adjustable knee lock joint (dial lock) It allows
  knee locking at different degrees of flexion. in
  patients with knee flexion contractures that are
  improving gradually with stretching.
• Ischial weight bearing

73
Knee Orthoses

• Knee orthoses for patellofemoral disorder to
  control tracking of the patella during knee
  flexion and extension.
• Knee orthoses for knee control in the sagittal
  plane to control genu recurvatum with minimal
  mediolateral stability.
• Knee orthoses with adjustable knee joint fpr
  flexion contracture.
• Knee orthoses for knee control in the frontal
  plane The knee joint usually is polycentric and
  closely mimics the anatomic joint motion.
• Knee orthoses for axial rotation control These
  orthoses can provide angular control of
  flexion-extension and mediolateral planes, in
  addition to controlling axial rotation. This
  orthosis is used mostly in management of sports
  injuries of the knee. This type of KO includes
  Lenox-Hill derotation orthosis and Lerman
  multiligamentous knee control orthosis.

74
Hip Knee Ankle Foot Orthoses

• Hip joints and locks The hip joint can prevent
  abduction and adduction as well as hip rotation.
• Single axis hip joint with lock This joint is
  the most common hip joint with flexion and
  extension. The single axis hip joint with lock
  may include an adjustable stop to control
  hyperextension.
• Two-position lock hip joint This hip joint can
  be locked at full extension and 90 of flexion
  and is used for hip spasticity control in a
  patient who has difficulty maintaining a seated
  position.
• Double axis hip joint This hip joint has a
  flexion-extension axis and abduction-adduction
  axis to control these motions.

75
Sport related orthoses

• Prophylactic
• Yes
• To prevent excessive forces
• To prevent sudden impact
• No
• It increases energy expenditure
• It can harm others
• Anatomical and mechanical correspondence