In this post I will briefly discuss types of orthoses.
Please note there will be subsequent posts that go into finer detail.
Foot orthoses (FO)
Also known as arch supports and commonly referred to as foot “orthotics” (incorrect grammar). Foot orthoses come in different shapes and sizes, and can treat things from ligament laxity to posterior tibial tendon dysfunction. Foot orthoses can be either prefabricated or custom made. Depending on what your diagnosis is and its severity, an orthotist may choose to use a prefabricated foot orthosis (one you can purchase “off the shelf. i.e.: the ones you see in a chemist) or a custom made orthosis. There are varying ways to create custom orthoses and different features i.e.: metatarsal dome, rear foot posts, etc. There are also a number of materials that can be used, including plastic (polypropylene, co polymer, and polyethylene), pelite, and ethyl vinyl acetate (EVA).
Both podiatrists and orthotists are qualified to assess for, manufacture, fit and review foot orthoses.
Congenital talipes equino varus (CTEV, also known as “clubfoot”) boots and bars also fall under the category of FOs however they are not considered as your regular FO. These boots made from leather, silicon and plastic and are joined via a bar of metal. Picture a snowboard and it’s a similar idea. The positioning of the foot inside the boot in combination with the amount of external rotation (how much the toes are pointing outwards like a ballerina) set on the boots in relation to the bar, treat the CTEV.
Ankle foot orthoses (AFO)
One of the most commonly used orthosis is the ankle foot orthosis (AFO). There are many styles, materials that can be used, features and techniques that AFOs can employ. Here is a short list of AFOs and their possible uses (please note that there are more AFO styles, “hybrid” styles, and a plethora of diagnoses that and AFOs can be used to treat)
- Solid AFO. These are commonly made from polypropylene, co polymer, polyethylene, and carbon fibre. They can be used to control a person’s shank in walking, maintain foot clearance in swing (the part of the gait cycle where your leg moves from behind you to in front of you), and prevent contractures. They are used amongst cerebral palsy patients, stroke victims, spina bifida patients, spinal cord injury patients, and patients with a neuromuscular diagnosis just to name a few.
- CAM boot. CAM stands for controlled ankle motion and is also referred to as “moon boots”. These are used to treat lower limb fractures or ligamentous injuries. They can also be used for diabetic patients in conjunction with offloading foot orthoses.
- Hinged AFO, much similar to a solid AFO, however a hinged AFO allows for movement at the ankle joint. A hinged AFO can be free (no restriction on dorsiflexion (moving foot up at ankle joint) or plantar flexion (moving foot down at ankle joint)), plantarflexion stop /restricted, or dorsiflexion stop/restricted.
- Posterior leaf spring (PLS). Although this AFO does not have hinges, because of its posterior trimlines (where the AFO finishes) it offers a small amount of energy return allowing a person to adequately clear their foot in swing. PLS should not be used for complex patients with muscle weaknesses that extend to their calf musculature or quadriceps. It is commonly made from polypropylene and copolymer.
- GRAFO (ground reaction ankle foot orthosis). I find this title to be very odd as it implies that this style of AFO is the only AFO that manipulates the ground reaction force (ground reaction force is the equal and opposite force of your body weight going down through your body and into the ground), which is not true because every orthosis modifies external forces. Traditionally, these are set in some amount of plantarflexion (i.e.: the foot is pointing down) and then wedged (when material like EVA is used to realign an orthosis) so that the shank is vertical or inclined. There is a section of the GRAFO where it swoops from behind and comes into contact with the leg just bellow the knee cap. This aims to get the knee into extension. Please note: the concept of plantarflexing the angle of the ankle in the AFO and wedging is part of a process called tuning. I hope to soon release a detailed post dedicated to just tuning.
Knee orthoses (KO)
Knee orthoses can be used for a variety of reasons. In paediatrics it is more common for a knee orthosis to be used whilst resting or long legged sitting, to promote knee extension. In adults, knee orthoses can be used whilst mobilising or at rest. A knee orthosis is mainly used among adults to stabilise floating patella, treat osteoarthritis or rheumatoid arthritis, and treat injuries to anterior/ posterior cruciate ligaments and collateral ligaments.
Knee ankle foot orthoses (KAFO)
KAFOs are similar to AFOs except they pass the knee joint and half a section for the thigh. Most KAFOs have some sort of knee joint (free swing, locking, stance control (locks when you stand on it, is free in swing phase)) and may have an ankle joint depending on what the goals are that the KAFO must achieve. They can be made form the same materials as AFOs.
Hip knee ankle foot orthoses (HKAFO)
These orthoses are the same as a KAFO except now they extend to the pelvis and cross over the hip joint. The hip joints can be free, locking or partially locked. The knee and ankle joints (if any) can also be free, lock partially or completely – this all depends on the patient’s diagnosis, weaknesses and range of motion.
Reciprocal gait orthoses (RGO) are a type of HKAFO, but they use an interesting component that allows one leg to swing in front of the other when weight is placed on the contra-lateral limb. These are used amongst paediatrics with spinal cord injuries and some adults with partial or incomplete paralysis.
Hip orthoses (HO)
There is a large array of hip orthoses to treat a number of different conditions. Some are used by adults post surgically to immobilise a joint after surgery, however the most common types of hip orthoses are used in paediatrics to treat developmental dysplasia of the hip (DDH). Hip orthoses in paediatrics are normally prefabricated.
There are a number of different spinal orthoses that can treat an array of diagnoses from scoliosis in teenagers to broken backs in adults. Below is a short list of spinal orthoses:
- COs: cervical orthoses (also known as collars). These are mainly used to immobilise the cervical spine (the neck) post injury. Keep your eyes peeled in movies and television shows as these are seen often.
- CTOs: cervical thoracic orthosis. These are used to immobilise both the cervical and thoracic (chest region) spines post injury.
- TLSO: thoracic lumbar sacral orthosis. These are also used to immobilise the thoracic lumbar (lower back) and sacral (tail bone) regions of the spine post injury. They can also be used for disc herniation. Please note that scoliosis and kyphosis bracing in paediatrics falls under this category.
- CTLSO: cervical thoracic lumbar sacral orthosis. More commonly used in adult spinal fractures, however there are some scoliosis and kyphosis orthoses that fall under this category (although rarely seen nowadays).
- Scoliosis TLSO. Scoliosis is a condition where the spine deviates from its regular anatomical alignment and can look like the letter “S”. Scoliosis is a fascinating condition and most of the time it is idiopathic (unknown cause), and is a final result of the spine’s irregular growth where the front portion of the vertebral body (spine bone) grows faster than the back portion. It can also be caused by muscle imbalances in neuromuscular, cerebral palsy and spinal cord injury patients. There are so many options for shapes, trimlines, and forces depending on the location and severity of the scoliosis. The two most common types used today are called the Cheneau TLSO with Rigo modifications and the Boston Brace.
- Kyphosis TLSO. Everyone has kyphotic curve (slight bump in the spine in the high chest region) and a lumbar cure (inward curving part of the lower back). Kyphosis TLSOs are used to treat hyperkyphosis.
Head orthoses (helmets)
Helmets can be used in adult and paediatric cases. In adults they are used post surgically or for head protection. In paediatrics they can also be used for these reasons, but are more commonly used to treat plagiocephaly and scaphiocephaly.
These orthoses are normally prefabricated, made from a fabric (elastic, cotton and polyester blend, Velcro) and used to treat rotator cuff injuries. They are also fit by Occupational therapists.
Upper limb orthoses
As the name suggests, this title is technically an umbrella under which shoulder, elbow and wrist hand orthoses come under. However upper limb orthoses normally refer to braces that encapsulate the upper arm. These are mainly fracture braces that immobilise and protect the humerus (upper arm bone) and some parts of the shoulder.
They are also fit by Occupational therapists.
Elbow orthosis (EO)
Similar to knee orthoses, these can have a joint and have free motion, partially motion or be locked. They can treat things like tennis elbow, golfer’s elbow, overuse injuries, arthritis, and prevent contractures in cerebral palsy, brain injury and neuromuscular patients. They are also fit by Occupational therapists.
Wrist hand orthoses (WHO)
Wrist hand orthoses can be made from a variety of materials (plastics, fabrics and laminated materials) and used in the treatment of almost anything from contracture prevention to immobilisation in carpal tunnel syndrome. They are also fit by Occupational therapists.