Orthotics

An orthosis (orthotic) is an external device applied to a body segment to support, align, or improve function, and to prevent or correct deformity. Orthoses range from soft and flexible to rigid, and some are built for sport-specific use.

Watch-out: Prescribing, selecting, or fitting an orthosis, or changing the plan of care, is the PT’s role. Within the established plan of care, the PTA may apply the device, teach donning and doffing and wear schedules, and make minor adjustments (e.g., strap tension, padding). The PTA also monitors gait pattern, skin at contact points, and pain, and reports findings to the supervising PT.

A precaution means extra care is needed (for example, checking an orthotic interface frequently for redness that doesn’t fade within 20 minutes); a contraindication means the action should not be done at all (for example, never lift or reposition a patient using the rods of a halo vest, since this can dislodge the pins and destabilize the cervical spine). Report immediately: new skin breakdown, persistent redness, unusual halo pin-site drainage, or a sudden change in fit.

Lower limb orthotics

Foot orthoses (FO)

• Definition:
  • Foot orthoses are inserts placed inside shoes to support, align, or improve foot function. They help with conditions such as flat feet, plantar fasciitis, and overpronation
• Components:
  • Shell: The main body of the orthotic, made from rigid, semi-rigid, or soft materials
  • Posting: Adjustments to correct alignment (e.g., medial wedge for overpronation)
  • Heel cup: Helps control heel motion and provides stability
  • Arch support: Maintains the natural arch to prevent excessive collapse
• Types:
  • Rigid FO (functional orthotic): Controls foot motion and alignment, typically made of plastic or carbon fiber; used for foot deformities and repetitive stress injuries
  • Semi-rigid FO: Combines soft and rigid materials to balance control and flexibility; often used in sports and for flat feet
  • Soft FO (accommodative orthotic): Offers cushioning for sensitive feet, plantar fasciitis, and diabetic feet, including those with foot ulcers

Ankle-foot orthoses (AFO)

• Definition:
  • Ankle-foot orthoses (AFOs) extend from the foot to just below the knee and are used for conditions affecting foot and ankle stability, such as drop foot, stroke, cerebral palsy, and peripheral neuropathy
• Components:
  • Footplate: Extends under the foot to control foot movement
  • Ankle joint: Can be fixed, hinged, or adjustable to allow varying degrees of movement
  • Calf support: Provides additional control over ankle motion
• Types:
  • Solid AFO: Provides complete immobilization of the ankle joint
  • Hinged AFO: Allows controlled ankle motion while still providing support
  • Carbon fiber AFO: Lightweight and energy-efficient for active users
• Specialized AFOs:
  • Posterior leaf spring AFO: A flexible AFO that helps with foot clearance during walking by providing a spring-like effect
  • AFO with a posterior stop: Limits plantarflexion. This aids toe clearance and produces a knee-flexion moment at initial contact, which helps control knee hyperextension (genu recurvatum). An anterior (dorsiflexion) stop does the opposite: it resists knee buckling into flexion Genu recurvatum is knee hyperextension beyond 5 degrees, and nonoperative management includes bracing the knee or correcting gait patterns.
  • Dynamic ankle foot orthosis (DAFO): Designed for individuals with neurological conditions, often shorter, and with a neurological footplate design
  • Ground reaction force ankle foot orthosis (GRAFO): Designed to reduce instability at the knee joint as well as the foot and ankle
  • Hybrid AFO: A combination of different AFO types, offering a balance of support and flexibility
• Precaution: impaired sensation (e.g., diabetic peripheral neuropathy) and leg edema both raise the risk of a pressure injury under a close-fitting plastic AFO - the patient may not feel a pressure point, and swelling changes the fit. Check the skin at every removal, and report new swelling or a change in fit to the PT.

Knee-ankle-foot orthoses (KAFO)

• Definition:
  • Knee-ankle-foot orthoses (KAFOs) extend from the foot to the thigh, providing support for patients with quadriceps weakness, spinal cord injuries, or post-stroke conditions.
• Components:
  • Footplate: Provides support to the foot like an AFO
  • Ankle joint: Can be rigid, hinged, or free-motion
  • Knee joints: May include locking mechanisms (drop lock, bail lock) or free-motion for controlled knee flexion
  • Thigh cuff: Provides proximal stability to the femur
• Types:
  • Locked KAFO: Prevents knee flexion for complete knee support.
  • Stance control KAFO: Allows free knee flexion during the swing phase but locks during the stance
  • Offset joint KAFO: Reduces knee buckling by shifting the mechanical knee joint posteriorly
  • Microprocessor-controlled KAFO (MPKAFO): Uses microprocessors to regulate swing and stance control, offering stability, stumble recovery, and controlled knee flexion

Hip-knee-ankle-foot orthoses (HKAFO)

• Definition:

  • A hip-knee-ankle-foot orthosis (HKAFO) is a full-leg brace that supports and stabilizes the hip, knee, ankle, and foot. HKAFOs are often prescribed for individuals with significant muscle weakness or paralysis in the lower limbs and hips.

• Components:

  • HKAFO components include the same footplate, ankle joint, knee joints, and thigh cuff as a KAFO, plus:
  • Hip joint and pelvic band: Controls hip motion and connects the orthosis to the pelvis, sometimes using a pelvic girdle for maximum stability

• Types:

  • Conventional HKAFOs: offer basic support with different joint options: single-axis, two-position lock, or double-axis hip joints.
  • Reciprocating gait orthosis (RGO) is a specialized type of HKAFO. It uses a cable or bar system to couple the hip flexion of one leg with the hip extension of the opposite leg.

Spinal orthoses

• Precaution: check the skin under the brace edges and over bony prominences, and watch breathing - a rigid TLSO restricts chest and abdominal expansion, which matters in patients with limited respiratory reserve (e.g., neuromuscular disease). Prolonged wear also weakens the trunk muscles, so follow the wear schedule in the PT’s plan.
• Contraindication: never lift or reposition a patient by the rods of a halo vest.

Lumbar-sacral orthoses (LSO)

• Definition:
  • LSOs provide support and stability to the lumbar and sacral spine, commonly used for low back pain, post-surgical stabilization, herniated discs, and fractures
• Components:
  • Rigid or semi-rigid frame: Provides stability and restricts motion
  • Abdominal panel: Offers compression to reduce lumbar lordosis
  • Pelvic section: Stabilizes the sacrum and lower lumbar spine
• Types:
  • Rigid LSO
    • Restricts lumbar flexion and extension.
    • Commonly used post-surgery or for fractures.
  • Corset-style LSO
    • Provides mild to moderate support.
    • Often used for chronic back pain and muscle strain

Thoracolumbar-sacral orthoses (TLSO)

• Definition:
  • TLSOs provide support to the thoracic, lumbar, and sacral spine, commonly used for post-surgical recovery, scoliosis, and compression fractures
• Components:
  • Rigid or semi-rigid frame: Limits spinal movement
  • Anterior and posterior panels: Provide structural support
• Types:
  • Rigid TLSO
    • Used for scoliosis and spinal fractures.
    • Limits motion in all planes.
  • Hyperextension TLSO (e.g., Jewett, CASH)
    • Limits spinal flexion but allows extension.
    • Common for anterior compression fractures.
  • Soft TLSO
    • Provides mild support and posture correction.
    • Used for mild osteoporosis or muscle strain

Cervical orthoses (CO)

• Definition:
  • Cervical orthoses are designed to support and immobilize the cervical spine, commonly used for whiplash, post-surgical recovery, and cervical fractures
• Components:
  • Collar or shell: Provides cervical stabilization.
  • Anterior and posterior panels (for rigid braces): Limit flexion, extension, and rotation
  • Chin and occipital support: Maintains head position
• Types:
  • Soft cervical collar
    • Provides minimal support and is used for mild strains or whiplash; it should only be worn for a short period of time, since long-term wear may decrease the strength of the neck muscles
  • Rigid cervical brace (e.g., Philadelphia Collar, Miami J, Aspen Collar)
    • Provides moderate to firm immobilization.
    • Common for post-operative care and cervical fractures
  • Halo vest orthosis
    • Provides maximum cervical immobilization
    • Used for unstable cervical fractures or post-surgical fusion
  • Sterno-occipital mandibular immobilizer
    • Limits flexion and extension, often used for C1-C3 fractures

Matching presentation to device

Applying and monitoring orthoses

• Donning and wear schedule: For a rigid AFO, seat the heel fully in the footplate before securing straps distal to proximal. Build wear time gradually - commonly starting around 1 hour and increasing as tolerated - rather than moving straight to full-day wear.
• Skin checks: Inspect skin at every contact point immediately after removal. Redness that fades within 20 minutes is expected; redness that persists past 20-30 minutes needs to be reported to the PT.
• Gait signs of poor fit: Toe drag suggests inadequate dorsiflexion assist, while excessive knee hyperextension suggests too little plantarflexion resistance (or an ankle set in plantarflexion) or a dorsiflexion stop that’s too restrictive; excessive knee flexion at initial contact suggests a plantarflexion stop that’s too restrictive.

Example: Redness that doesn’t resolve

A patient with diabetic peripheral neuropathy wears a solid AFO. After a therapy session, you remove the AFO and see redness over the lateral malleolus that is still present 30 minutes later.

Answer: Stop using the AFO for now, document the location and duration of the redness, and notify the supervising PT. The patient’s neuropathy means they may not feel the early pressure that caused it, so the fit needs to be addressed before the orthosis is worn again.

Upper-extremity and protective devices

• Resting hand splint: Positions the wrist in slight extension and the fingers in a functional grasp to prevent contracture; used after stroke, spinal cord injury, or peripheral nerve injury. Precaution: check for pressure over the ulnar styloid and MCP joints.
• Wrist cock-up splint: Holds the wrist in neutral to slight extension to rest inflamed or weak wrist musculature; used for tendinitis or wrist drop from radial nerve injury, and, set in neutral, for carpal tunnel syndrome. Where the radial nerve is injured changes what the splint has to do: at the axilla (crutch palsy) elbow extension is weak too; at the spiral groove of the humerus (a shaft fracture, or ‘Saturday night palsy’) elbow extension is spared but the wrist drops and the back of the hand is numb; at the radial head (the posterior interosseous nerve) the fingers and thumb drop with no sensory loss.
• Ulnar gutter splint: Immobilizes the 4th and 5th digits (ring and little fingers); used for 4th or 5th metacarpal fractures, angulated or unstable proximal and middle phalanx fractures of those digits, and fractures of the distal ulna.
• Protective helmet: Reduces head injury risk for patients with seizure disorders, balance deficits, or post-craniectomy status. Precaution: monitor for skin breakdown at contact points.
• Compression garment: Used for lymphedema management and DVT prevention. Contraindicated in uncompensated congestive heart failure, acute DVT, and significant arterial insufficiency. Report signs of arterial compromise - increased pain, pallor, or coolness distal to the garment - immediately.