Shoes Module 9

Shoes

• Protection & Support

• Fashion statement - not effectively serving its original purpose

  • Blisters, calluses, ulcers, deformities and serious injuries

• Function in lower extremity orthosis

1. The upper (the part of the shoe over the dorsum of the foot)

2. The sole

3. Reinforcements

Three General Parts of the Shoe

Upper

Covers the dorsum, side and the back of the foot

Shoe Depth

Determined by the shoe last as well as the type of insole

Extra-____-shoes - specially manufactured,

additional ¼ inch -> 2x ¼ inch inserts

Height of the Toe Box

• Important for hammer toes and claw toes, diabetic neuropathies and arthritis

• Toe region of the shoe should have adequate length and width (½ inch longer than the longest toe in WB) (width must accommodate the widest part of the foot)

Height of the Quarters (side and Back of the Shoe)

• Usually distal to the malleoli (low-top)

• High top (boots), extend over malleoli

  • Provides additional medio-lateral stability to the rearfoot

  • Footdrop without spasticity

Slip-on

• Not suitable for use with orthosis or accommodating foot deformities

• Laces -> preferable 4-5 eyelets or multiple wide straps for securing foot or orthoses

• Best for accommodating varying foot girth

• Velcro -> for impaired hand function

Throat

Portion of the shoes where the foot enters and the shoe closure attaches to the quarters

BLUCHER

What throat style

• Most preferred for most orthoses

• Allows greater adjustability

• Tongue is an extension of the vamp

BAL OR BALMORAL

What throat style

Tongue is separate and sewn to the vamp and quarters

OPEN-TO-THE-TOE (SURGICAL)

What throat style

• Quarters and tongue extends up to the toe of the shoe

• For severe spasticity, rigid deformities, healing ulcers or wounds

Reinforcements

Strengthens the shoes in areas of high stress

Toe box

What reinforcement

steel among manual laborers

Saddle or arch bandage

What reinforcements

added to the quarters to support medial longitudinal arch

Counter

what reinforcement

of the posterior aspect of the quarters that cups the heel and stabilizes the hindfoot

• Medial ___often extends further anteriorly, supports midfoot in px with excessive pronation

• Most athletic footwear have reinforced ___to provide additional hindfoot stabilization during high impact activities

• From stiff to soft natural leathers to lightweight synthetic fabrics

• Must be durable but soft enough to form the foot and appliance without exerting excessive pressure on the foot

• Breathable (thermoplastics)

Materials for the Upper

Sole

Where the upper is attached to; located under the foo

1. Outsole

2. Welt

3. Midsole

4. Heel

5. Shank

Parts of the Sole

Outsole

1. Durability
2. Flexibility - toe break or toe extension

3. Weight - energy cost

4. Resilience - shock absorption

5. Ability to provide traction - falls/limb advancement

material that contacts the ground

Features that are important for orthotic application:

1

2

3

4

5

Insole

• “Sock liner”

• Lies in contact with the plantar aspect of the foot

• Removable -> more appropriate for orthotic appliance

Midsole

• Between outsole and insole

• Most often present in athletic shoes

• Foamed polymers, serves to increase shock absorption and improve foot stability

Shank

• Longitudinal reinforcement of the midportion of the non-athletic shoes

• Extends from heel to metatarsal heads

• Determines where the sole flexes during late stance for the toe extension and rollover

• Role of shank with conventional double upright orthosis

Heel

• Height -> increase in ht -> pressure on forefoot and metatarsal heads (metatarsalgia, bunions and hammer toes)

  • More than 2 ½ inch -> muscular effort to maintain balance

• Size -> balance and traction

• Resiliency or compressibility - orthosis that restrict ankle motion should have resilient heel

  • Rigid orthosis with stiff or hard heel -> promotes early stance phase knee instability or buckling

• component added to the outsole, directly under the anatomical heel

• Important Factors:

  • 1

  • 2

  • 3

  • 4

  • 5

Internal modifications

• Usually provide cushioning and shock absorption, relieve pressure sensitive areas or LLD

• Do not permanently alter shoe, inexpensive

• Can be used as trial devices

External modification

• Added to the outsole by the pedorthist

• Permanent and cannot be moved from shoe to shoe

• Wear and tear -> periodic replacement

• Balance LLD, relieve pressure sensitive areas on the plantar aspect of the foot, shift center of pressure on WB foot

Lifts to balance LLD

• Up to ⅜ inch heel wedges, otherwise external modification

• Do not extends under the metatarsal

Heel Wedges

lateral

medial

• For rearfoot problems, fixed or functional hindfoot varus, valgus or equinus deformities

• ________ - flexible hindfoot varus

• ______ - fixed hindfoot varus

• Equinus deformity

Thomas Heel

• anterior edge or breast is curve anteriorly on the medial side to provide support on the posterior portion of the medial longitudinal arch

Relief Pad

pressure relief additions
heel insert with void -> plantar fasciitis

• Medial and lateral forefoot wedges -> forefoot varus and valgus

• Relief pads - relieve pressure for metatarsal heads

• External forefoot shoe modification ○ Metatarsal bar ○ Forefoot rocker

Forefoot Shoe Modification

Rocker Soles

• Curved external shoes modification that allows the foot to roll from heelstrike to toe off without requiring the foot to bend

• Used to reduce pressure on the metatarsal heads

• Simulate or substitute for ankle DF/PF or toe extension during stance phase

ANKLEF-OOT ORTHOSIS (AFO)

Consists of a shoe attachment, ankle control, uprights and a proximal leg band

Conventional AFOs

●Molded AFOs

● Specialized AFOs

Uprights and Attachments

Conventional AFOs

• They have metal uprights (aluminum, carbon graphite or steel) and a hinged ankle joint allowing PF and DF

• Provides maximum support

• May be easier to alter to accommodate changes than molded AFOs

Molded AFOs

• Posterior leaf spring (PLS)

• Modified AFO

• Solid ankle AFO

• Spiral AFO

• Hinged plastic AFO

• Made of molded plastic and lighter in weight and cosmetically more appealing

• Contraindicated for individuals with changing leg volume

• 5 types:

Posterior Leaf Spring

What Molded AFO is this

• Has a flexible, narrow posterior shell

• Functions as dorsiflexion assist

• Holds foot at 90° angle during swing

• Provides no medial-lateral stability

Modified AFO

What Molded AFO is this

• Has wider posterior shell with trimlines just posterior to malleoli

• Foot plate includes more of medial and lateral borders of foot

• Provides more medial-lateral stability (control of calcaneal and forefoot inversion and eversion)

Solid ankle AFO

What Molded AFO is this

• Has widest posterior shell with trimlines extending forward to malleoli

• Controls DF, PF, inversion and eversion

Spiral AFO

What Molded AFO is this

• Winds around the calf

• Provides limited control of motion in all planes

Patellar-tendon-bearing brim

What Specialized AFO is this

• Allows for weight distribution on the patellar shelf

• Reduces weight bearing forces through the foot

Tone-reducing orthosis

What Specialized AFO is this

• Applies constant pressure to spastic or hypertonic muscles (plantarflexors and invertors)

• Snug fit essential to achieve the benefits of reciprocal inhibition

FOOT PLATE

What shoe attachment is this

• A molded plastic shoes insert

• Allows application of the brace before insertion into the shoe

• Ease of changing shoes of same heel height

STIRRUP

Split Stirrup

Solid Stirrup

What shoe attachment is this

A metal attachment riveted to the sole

___ - allow for shoe interchange

___ - fixed permanently to the shoe and provide for maximum stability

Free motion

provides mediolateral stability that allows free motion in DF and PF

Solid ankle

allow no movement; indicated with severe pain or instability

Limited motion

○ BiCAAL

○ Anterior stop

○ Posterior stop

○ Solid AFO

allows motion to be restricted in one or both directions

examples:

Spring assist (Klenzak housing) ○

Posterior leaf spring (PLS)

Dorsiflexion assistance ankle controls

Bichannel adjustable ankle lock (BiCAAL)

What limited motion is this

• An ankle joint with the anterior and posterior channels that can be fit with pins to reduce motion or springs to assist motion

Posterior Stop (Plantarflexion Stop)

What limited motion is this

• Determines the limits of ankle PF

• If the stop is set to allow slight PF (5°), knee extension results (can be used to control unstable knee)

• If the stop is set to allow to much PF, recurvatum or knee hyperextension occurs

Anterior Stop (Dorsiflexion Stop)

What limited motion is this

• Determines the limits of ankle DF

• If the stop is set to allow slight DF (5°), knee flexion results (can be used for knee hyperextension)

• If the stop is set to allow to much DF, knee buckling could result

Solid AFO

What limited motion is this

Limits all foot and ankle motion

Spring assist (Klenzak housing)

What dorsiflexion assistance is this

• Double upright metal AFO with a single anterior channel for a spring assist to aid dorsiflexion

Posterior leaf spring (PLS)

• A plastic AFO that inserts into the shoe

• Widely used to prevent foot drop

Medial strap

What Varus or valgus correction straps (T-straps) is this

• Buckles around the lateral upright

• Corrects for valgus

Lateral strap

What Varus or valgus correction straps (T-straps) is this

• Buckles around the medial upright

• Corrects for varus

KNEE ANKLE FOOT ORTHOSIS (KAFO)

What Varus or valgus correction straps (T-straps) is this

• Consists of a shoe attachment, ankle control, uprights, knee control and bands or shells for the calf and thigh

Hinge joint

what knee control is this

• Provides mediolateral and hyperextension control while allowing for flexion and extension

Offset

• The hinge is placed posterior to the weight-bearing line (trochanter-knee-ankle TKA line)

• Assists extension

• Stabilizes knee during early stance

• Patients may have difficulty on ramps where knee may flex inadvertently

Drop ring lock

what type of lock is this

• Drops over joint when knee is in full extension to provide maximum stability

• A retention button may be added to hold the ring lock up

• Permit gait training with knee unlocked

Pawl lock with bail release

• The pawl is a spring-loaded posterior projection (lever) that allows the patient to unlock the knee by pulling up or hooking the pawl on the back of a chair and pushing it up

• Adds bulk and may unlock inadvertently with posterior knee pressure

Sagittal stability

What knee staiblity is this

• achieved by bands or straps used to provide a posteriorly directed forced

• Anterior band (knee cap)

  • Attaches by four buckles to metal uprights

  • May restrict sitting ○ Increases difficulty in putting KAFO

  • Can be pretibial or suprapatella

Frontal plane controls

What knee staiblity is this

• For control of genu varum or genu valgum

  • Posterior plastic shell

  • Older braces utilize valgum (medial) or varum (lateral) correction straps which buckle around the opposite metal upright

Craig-Scott KAFO

What specialized KAFO is this

• Commonly used appliance for individuals with paraplegia

• Consist of shoe attachments with reinforced foot plates, BiCAAL ankle joints set in slight DF, pretibial band, pawl knee locks with bail release and single thigh band

Oregon Orthotic System

What specialized KAFO is this

• A combination of plastic and metal components allows for triplanar control in three planes of motion

Articulated KO

What specialized KO is this

• Controls knee motion and provides added stability

• Protects repaired ligaments from overload; post-surgery

• Ex: Lenox Hill, Pro-AM, Can-Am, Don Joy

Swedish Knee Cage

What specialized KO is this

• Provides mild control for excessive hyperextension of the knee

Patellar Stabilizing Braces

What specialized KO is this

• Improve patellar tracking

• Maintain alignment

• Lateral buttress or strap often positions patella medially

• A central patellar cutout may help positioning and minimizes compression

Neoprene Sleeves

What specialized KO is this

• Provide compression, protection and proprioceptive feedback

• Provide little stabilization unless metal or plastic hinges are added

• Retains body heat, which may increase total circulation

HIPKNEEANKLEFOOT ORTHOSIS HKAFO

What specialized KO is this

• Contain a hip joint and pelvic band added to a KAFO

• Hip joint

  • Typically a metal hinge joint

  • Controls abduction, adduction and rotation

  • Controls hip flexion when locked, typically with a drop ring lock

  • A locked hip restricts gait pattern to either swing-to or swing-through

• Pelvic attachments

SPECIALIZED TRUNK-HIP -KNEE- ANKLE- FOOT ORTHOSIS (THKAFO)

What specialized KO is this

• Contains a trunk band added to a HKAFO

Reciprocating gait orthosis (RGO)

what type of THKAFO is this

• Utilizes plastic molded solid-ankle orthoses with locked knees, plastic thigh shells, a hip joint with pelvic and trunk bands

• The hips are connected by steel cables which allow for reciprocal gait pattern (either two-point or four-point)

• When the patient leans on the supporting hip, it forces into extension, while the opposite leg is pushed into flexion, allows limb advancement

Denis Browne Splint

what pediatric orthosis is this

• A bar connecting two shoes that can swivel

• Use for correction of club foot or pes equinovarus in young children

“A”-frame orthosis

what pediatric orthosis is this

• Same purpose as Denis Browne splint

• Calf and thigh bands and pressure pads are added for proximal abnormalities

Congenital Hip Dysplasia Orthoses

• Maintain the femoral head within the acetabulum

• Hold the hip in flexion and abduction

Von Rosen

what Congenital Hip Dysplasia orthosis is this

• Plastic frame

• Easily conformed to child’s body

• Vertical straps hold thigh in position

Ifeld

what Congenital Hip Dysplasia orthosis is this

• Two thigh bands holds the limb in abduction

• Length of cross bar adjusts the degree of abduction

• Waist band is used to secure the splint

Pavlik harness

what Congenital Hip Dysplasia orthosis is this

• Chest strap

• Shoulder harness

• Anterior and posterior straps

• Permits greatest activity

Frejka pillow

what Congenital Hip Dysplasia orthosis is this

• Keeps hip abducted

• Used for hip dysplasia or other conditions with tight adductors in young children

Legg-Calve Perthes Disease (LCPD) Orthoses

• Maintain the femoral head in the acetabulum

● Hold the hip in abduction

Trilateral orthosis

what Legg-Calve Perthes Disease (LCPD) Orthoses is this

• Rotates femur internally

• Lateral wall of plastic brim is cut away to reduce ABD forces

• Usually unilateral

Toronto orthosis

what Legg-Calve Perthes Disease (LCPD) Orthoses is this

• Rotates femur internally

• Single vertical tube connected to thigh cuffs

• Spreader bar

• Angled shoes blocks attached to high-top shoes -> maintain foot ankle alignment

Scottish Rite Orthosis

what Legg-Calve Perthes Disease (LCPD) Orthoses is this

• Maintains hip flexion and abduction

• Horizontal telescoping spreader bar

• Lightest and least restrictive

• Does not hold hip in IR

• Proper alignment of subtalar joint is not achieved

Standing frame orthosis

what Severe Paralytic Disorder is this

• To train standing balance and swing-through gait pattern

• Worn over clothing

Parapodium

what Severe Paralytic Disorder is this

• Worn over clothing

• Allows standing without crutches

• Permits child to sit and stand

Reciprocating-gait orthosis

• Extends from thorax to the feet

• Provides lower limb support

• Allows reciprocal walking

• Permits sitting

• Can be used by adults