Unicompartmental osteoarthritis of the knee is one of the most common forms of arthritis that affects millions of people today. Osteoarthritis, which is the degeneration of either the medial or lateral compartment of the knee, can result from an injury to the knee that occurred earlier in life or it may be genetic.

While there is no cure for osteoarthritis, the symptoms which include pain, swelling and stiffening of the knee, can be decreased in a variety of ways. One way to alleviate the pain and other symptoms of osteoarthritis is to wear a knee orthosis.

Many times, a neoprene sleeve with metal uprights is prescribed for patients with osteoarthritis of the knee. This type of brace offers some relief, but most patients need more help to alleviate the pain. The pain from osteoarthritis occurs when there is degeneration of the articular cartilage which covers the joint. The degeneration causes there to be areas of the joint where bone rubs against bone.

An alternative to a neoprene sleeve would be one of the many different types of Osteoarthritis Knee Orthoses. An Osteoarthritis Knee Orthosis (OA KO) is more effective than a neoprene sleeve because it is designed to apply a combination of forces to certain areas of the knee and keeps the two bones from contacting one another. The OA KO applies either a valgus or varus force depending upon which compartment of the knee is affected and, therefore, more joint space is created and the pain is alleviated.

Patients wearing an OA KO versus a neoprene sleeve have seen great results. However, patients should wear the brace for at least 3-4 weeks before they may notice any significant pain relief.

While an OA KO may be larger than a neoprene sleeve, it is still very lightweight and also may be worn while a patient is participating in most any type of work or recreational activity. Depending on what a physician prescribes, a patient may wear the brace all day or only while participating in certain activities.

An orthotist is a person who measures, designs, fabricates, fits, or services orthoses, and/or assists in the formulation of orthoses.

An orthosis is a device that is intended to be fitted to a person to correct a disability, or to support the person who has a disability. Orthoses are usually prescribed by a licensed physician. Orthotists take referrals from these physicians. A Certified Orthotist or CO is an Orthotist who has passed the certification standards of The American Board of Certification in Orthotics & Prosthetics, Inc. and maintains certification through mandatory continuing education program and adherence to the Board's Code of Professional Responsibility.

A BOC Certified Orthotist or BOCO is an Orthotist who has passed the certification standards of The Board for Orthotist/Prosthetist Certification and maintains certification through mandatory continuing education program and adherence to the Board's Code of Professional Responsibility.

WHAT SHOULD YOU EXPECT FROM YOUR ORTHOTIST?
Whether your particular orthotic requirements are the result of disease, congenital anomalies or trauma, your rehabilitation program is individually prescribed. The prescription from your physician will be utilized by your orthotist and, if necessary, will consult your physical or occupational therapist. In many cases, particularly with custom fabricated devices, your orthotist will suggest follow-up visits to ensure continued proper fit and ultimate success in your rehabilitation program. Your orthotist should provide proper answers to all your questions and you should feel secure in the decision making. In many cases, your orthotist will follow your care with your physician in the form of written correspondence or oral conversations.

Ankle-foot orthosis (abbreviated: AFO) is a brace, usually plastic, worn on the lower leg and foot to support the ankle, hold the foot and ankle in the correct position, and correct foot drop. Also known as a foot-drop brace. AFOs are commonly used in the treatment of disorders that affect muscle function such as stroke, spinal cord injury, muscular dystrophy, cerebral palsy, polio and multiple sclerosis. AFOs can be used either by providing support to weak or wasted limbs or by positioning a limb with tight, contracted muscles into a more normal position. AFOs are also used to immobilize the ankle and lower leg in the presence of arthritis or fracture.

AFOs

The method of obtaining a good fit with an AFO involves one of 2 approaches:

1. provision of an off-the-shelf or prefabricated AFO matched in size to the end user

2. Custom manufacture of an individualized AFO from a positive model obtaining by means of a negative cast or the use of computer assisted imaging, design, and milling. The plastic used to create a durable AFO must be heated to +/- 400 degrees Fahrenheit, making direct molding of the material to the end user impossible.

AFO's generally refer to lightweight ploypropylene based plastic braces. The devices are attached to the calf with a strap and a piece runs up under the foot, fitting inside an accomodative shoe. The "L" effect of the plastic shell counteracts foot drop and allows those suffering to better control their movement. The use of generic descriptions of orthopedic braces, such as ankle foot orthosis, began in the late 1970s as the result of work done by the American Academy of Orthopedic Surgeon in order to make classification of such braces easy. The initial description in the literature of the device now referred to as an ankle foot orthosis was made by York, et al in the late 1960s. Prior to that time, braces that affected the lower leg were limited to metal and leather designs attached to the shoe or plaster casts, called short leg braces or short leg casts.

The effects of an ankle-foot orthosis (AFO) on ankle and knee biomechanics during walking.

Therapists often recommend, and physicians frequently prescribe the ankle-foot orthosis (AFO) for patients with gait deviations that relate to muscle weakness. The AFO substitutes for weak dorsiflexors during swing and, more importantly, for weak plantar flexors during stance.

The AFO's effect on supporting the forefoot and preventing plantar flexion or "foot drop" during swing is straightforward. Less obvious is the AFO's role as a substitute for plantar flexor muscles. The plantar flexors must be active during midstance and terminal stance to counter the dorsiflexor moment that is produced by the ground reaction force. If the plantar flexors are weak, the ankle dorsiflexes too rapidly and, because the lower extremity is positioned in a closed chain, the knee flexes.

Midstance knee flexion threatens the person's stability. Someone with weak plantar flexors must compensate, or must wear an external device (an orthosis) that substitutes the force that the plantar flexors ordinarily provide.

When a person bears weight on an AFO that he or she wears inside the shoe, the AFO's rigid walls transfer the ground reaction force (black arrow) in the direction indicated by the red arrow. Thus, the AFO directs a force posteriorly against the anterior tibia during midstance and terminal stance, and prevents or controls tibial advancement. In this way, the AFO's force produces a plantar flexion moment that counters the ground reaction force's (GRF) tendency to dorsiflex the ankle.

The AFO's ability to redirect the ground reaction force, and thereby produce a plantar flexor moment, depends on its rigidity. An AFO that is flexible or articulated (hinged at the ankle) does not serve this purpose.

In addition to producing a force that pushes posteriorly on the tibia, in the direction of ankle plantar flexion, an AFO can influence the ground reaction force's effect on the knee.

 • If the orthotist aligns the AFO in plantar flexion, the alignment inclines the tibia posteriorly during stance. This ankle alignment causes the knee joint's lateral axis to lie more posteriorly. In this location, the knee joint axis lies posterior to the ground reaction force's line of application throughout a longer period of time during the walking cycle. Therefore, this plantar flexed alignment increases the time during which the ground reaction force lies anterior to the knee joint axis, and produces knee extension.

The diagram illustrates an AFO that is aligned in five degrees of plantar flexion.

• Alternatively, when the orthotist aligns the AFO in dorsiflexion, the tibia is inclined more anteriorly during stance. This tibial position causes the knee joint axis to lie further anterior, and increases the period of time during which the ground reaction force lies posterior to the knee joint axis, and produces knee flexion.

The diagram illustrates an AFO that is aligned in five degrees of dorsiflexion.

A brace designed to aid in controlling the motion of the ankle joint and give stability to the foot giving control of both major joints of the foot.  The AFO can be fabricated with various materials including polypropylene plastic or metal and leather design. 

Molded plastic is most commonly used for the AFO, but in the event of edema (swelling) or skin integrity issues, metal and leather design attached to a shoe can be used successfully.

The molded plastic AFO can be solid ankle or the use of joints at the ankle can be incorporated.  This design fits inside an extra depth shoe, preferably lace up style.

ASSOCIATED CONDITIONS

Drop Foot

Peroneal Nerve Injury

Posterior Tibial Tendon Dysfunction

Ankle Sprains, Strains

Tendonitis

Lateral Ankle Instability

Flatfoot

Arthritis

Polio

Charcot-Marie-Tooth

Charcot Joint

Cerebral Palsy

Muscular Dystrophy

Tibial or Fibular Fracture

Amyotrophic Lateral Sclerosis

WEARING PROTOCOL

Your physician will give specific instructions as to your particular protocol, but normally the brace is to be worn when active and ambulating if a functional design. 

If non-ambulatory, the AFO can be used to prevent ankle contractures and keep the ankle and foot in a proper position.

DON AND DOFF INSTRUCTIONS

The plastic design should be placed in the shoe and the foot slipped into the brace securely.

The metal and leather design is attached to a shoe with a receptacle called a caliper.

The boot-type walkers can be provided in a fixed mode or with ankle joints to provide articulation.  Pneumatic support is also available.

The brace has a lightweight, durable, semi-rigid shell that will support the limb and provide protection.  Incorporated are medial and lateral uprights, SACH heel and rocker sole.  Closure is achieved with Velcro.

The strapping system provides full circumferential compression of the limb.  The breathable fiber liner is washable.

The articulated boot allows range of motion (ROM) usually from approximately 20 degrees dorsiflexion to 40 degrees plantar flexion.

ASSOCIATED CONDITIONS

§          Sprain/Strain

§          Distal Tibial Fracture

§          Distal Fibular Fracture

§          Ankle Instability

§          Arthritis

§          Fractures of the Foot

WEARING PROTOCOL

Follow your physicians instructions as to wearing protocol.  Normally, use device when up and ambulating.

DON AND DOFF INSTRUCTIONS

Bend the knee and place the foot firmly back in the heel of the boot.

Start by placing the strap around the ankle tightly and then snug remaining straps.  Remember that a loose strap can cause pistoning and could result in a blister.

CARE

The lining of the boot can be washed.  Follow the manufacturers instructions.  Depending on the length of wearing time, a new liner can be purchased and replaced by your orthotist

SUGGESTIONS

The brace has a rocker bottom on the sole which allows for easier ambulation.  A tennis shoe worn on the opposite side helps eliminate some of the leg length discrepancy. 

Changing of socks and foot care is a must if wearing the brace 24/7.

Scoliosis is the abnormal curvature of the spine. The normal spine has natural curves that round the shoulders and make the lower back curve inward.  Scoliosis involves a three-dimensional deformity of the spinal column and rib cage. To varying degrees, the spine curves from side-to-side, and some of the spinal bones may rotate slightly, making the hips or shoulders appear uneven.  Hippocrates gave a name to scoliosis.

The purpose of bracing is to keep the curve from progressing as a child grows. While the curve will demonstrate improvement during the time the child is braced, it will typically revert to its original degree of severity when the use of the brace is eventually discontinued at the cessation of growth. Some individuals do achieve permanent correction, but holding the curve to an acceptable level, thus avoiding surgery, should be deemed a success.

In the early seventies, the most popular of the TLSO systems, the Boston Brace, was developed by Dr. John Hall and Dr. William Miller of The Boston Children's Hospital. The Boston Brace was the first brace to utilize symmetrical standardized modules eliminating the need for casting. It was also the brace used in the Scoliosis Research Society's bracing study. The Boston Brace extends from below the breast to the beginning of the pelvic area in front and just below the scapulae to the middle of the buttocks in the back. It is designed to keep the lumbar area of the body in a flexed position by pushing the abdomen in and flattening the posterior lumbar contour. Pads are placed to provide pressure to the curve, and areas of "relief" or "voids" are provided opposite the areas of pressure.

ASSOCIATED CONDITIONS

Scoliosis

WEARING PROTOCOL

Your physician will determine the appropriate wearing protocol,

DON AND DOFF INSTRUCTIONS

Normally, written instructions will be provided by your Orthotist.

While in the supine position (lying down on back), spread the brace enough to slip into the orthosis.

CARE

Use alcohol on liner every day to remove odor inside brace.

Use alcohol on areas of skin that may involve irritation.

SUGGESTIONS

Wearing a clean cotton shirt under brace will help with odor and skin issues. 

Your physician and orthotist will give specific instructions as to wearing time and follow-up.

To understand how AFOs work, one must first understand two standard motions that occur at the ankle joint – “dorsiflexion” and “plantarflexion”. Plantarflexion is the motion the ankle joint makes when the toes point downward. Dorsiflexion is the motion the ankle joint makes when the foot points upward. This motion needs to occur when the foot comes off the ground so that the patient does not drag their toes. Patients with dropfoot usually have a partial or complete weakness of the muscles that dorsiflex the foot at the ankle joint.

Sometimes carbon graphite devices that provide some ground reaction energy return are used for drop foot. This is curious since most cases of drop foot do not include corresponding plantar flexion weakness. Like an energy-storing prosthetic foot, the benefit of these carbon graphite AFOs is that the spring is compressed by body weight as the tibia travels over the foot. Then, late in stance phase, the energy is released by the material the brace is composed of and returned for use in toe-off. This energy return may be desirable for the flail foot, but the typical drop foot case does not need this feature.

ASSOCIATED CONDITIONS

Drop foot

Peroneal nerve injury

Posterior tibial tendon dysfunction

Ankle sprains, strains

Tendonitis

Lateral ankle instability

Flatfoot

Arthritis

Polio

Charcot-Marie-Tooth

Charcot joint

Cerebral palsy

Muscular dystrophy

Tibial or fibular fracture

Amyotrophic lateral sclerosis

WEARING PROTOCOL

Your physician and your certified orthotist will give specific instructions as to your particular protocol, but normally the brace is to be worn when active and ambulating if a functional design.

DON AND DOFF

This design should be placed in a shoe and the foot slipped into the brace securely.

CARE

Normally, alcohol on a clean cloth can be used.

The Charcot Restraint Orthotic Walker (CROW) orthosis is a custom fabricated brace which maintains the foot in a plantigrade position for ambulation and protection of the joints and skin by the uniform transfer or distribution of weight over the foot until the time when the pathology reaches the stage of coalescence (the fusion or blending of parts).

A cast mold is taken of the patient’s foot and the brace is custom made from this cast.  It is a rigid, full-foot enclosure, total contact ankle foot orthosis (AFO).  A rocker bottom is applied to the sole of the orthosis to facilitate a more functional gait pattern.

ASSOCIATED CONDITIONS

Charcot Foot

Diabetes

WEARING PROTOCOL

The CROW is to be worn which up and ambulating during the day.

DON AND DOFF

§          The CROW orthosis is a two piece design (clam shell type)

§          Place foot in back of brace making sure your heel is well seated.

§          Attach front with straps snugly.

SUGGESTIONS

§          Frequent checking of skin areas for redness, blisters, or any skin changes.

§          White socks should be worn.  If there is a pressure sore even beginning on the bottom of the foot, this would demonstrate itself on the sock.

§          Any skin changes should be reported to your physician and Orthotist immediately.

The CASH brace provides a high level of stabilization and hyperextension capabilities and offers a lightweight design providing easier application by the patient and better compliance with wearing protocol.

The brace is fit anteriorly (front of the body) and provides a three-point pressure system.  The hyperextension capabilities keep the body in an upright position and prevent bending forward.

CASH with Sternal Extension

The sternal extension design extends to the subclavicular areas, bilaterally, to distribute the pressure more evenly over the chesst area.

ASSOCIATED CONDITIONS

Compression fracture of the spine

WEARING PROTOCOL

It is important to follow your physician’s instructions as to wearing protocol.  Normally, the brace is used when up and ambulating.

DON AND DOFF INSTRUCTIONS

While lying down on back or sitting, position the brace on your chest with the pectoral pads (see photo) placed below the collarbone.

If sternal pads are used, position the pad marked TOP on chest just below the notch at the bottom of the neck.

The pubic pad is marked BOTTOM and should be placed just above the pubic bone.

The strap should be fed through the side pad slot, velcro side up and fasten the strap by pressing the Velcro hook into the pile strap.

CARE

Clean with mild soap and water.

Clean the end parts of the strap (hook) with a toothbrush.

SUGGESTIONS

You may shower, bathe or sponge clean while wearing the brace.

If the chest pads feel uncomfortably tight at first, you may place a folded washcloth or sponge under the pads for more comfort.

Wear a cotton shirt under the brace for additional comfort and protection.

Do not loosen the screws and attempt to readjust the brace yourself.  Your orthotist should be contacted for adjustments.

Keep the brace away from excessive heat.

To avoid snagging your clothes, cover the end parts of the strap.