New Technology for Management of PTTD and TMA · New Technology for Management of PTTD and TMA •...
Transcript of New Technology for Management of PTTD and TMA · New Technology for Management of PTTD and TMA •...
© Allard USA 20082008Canadian Federationfor Podiatric Medicine © Allard USA 2008
New Technology for Management of PTTD and TMA
• Orthotic management of patients with severe ankle instability, flatfeet, partial foot amputations or proximal neuromuscular weakness.
• Improving patient compliance incorporating the dynamics of a floor reaction orthosis with a customized foot orthotic.
© Allard USA 20082008Canadian Federationfor Podiatric Medicine © Allard USA 2008
• Scott Fisher, PTGary Gray PT Clinic, Brooklyn, MI
• Ted Trower, CPOASC O&P Jackson, MI
• Dan Cipriani, PhDDirector, Gait Biomechanics LabSan Diego State University
Course Consultants
© Allard USA 20082008Canadian Federationfor Podiatric Medicine © Allard USA 2008
Acknowledgements• Justin Wernick, DPM
• Function of foot lever arms
• David Carmine, PhD • Neuro anatomy – stretch reflex
• Gary Gray, PT, ATC • Integrated closed chain function
• Jeff Falkel, PT, PhD • Functional Anatomy/Physiology
Acknowledgements
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Foundation PrinciplesCore principles - the foundation upon
which everything is built
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Components of functional stability• Appropriate motion
– All three planes– Appropriate amounts– Appropriate pathways
• Adequate strength• Adequate proprioception
Foundation Principles
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Normal function• Calcaneal ROM (Right posterior view)
20° Inversion(Swing)
Sub-talor neutral 10 ° Eversion(Stance)
Foundation Principles
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Normal function• Calcaneal ROM• Trigger mechanism
Foundation Principles
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PTTD
• Factors contributing to PTTD
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• Normal Biomechanics of PTTD
PTTD
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• Normal Closed Chain Function of the Tibial Posterior Muscle Through Stance Phase of Gait
PTTD
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• Classification of PTTD Dysfunction
PTTD
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• Treatment Protocol for Stages 1-3
PTTD
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• Current FO, SMO, and AFO Treatment – Static Alignment
PTTD
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• Foot Orthotic Selection– Selection of Optimum Prefabricated Foot
Orthotic– Fabrication of Custom Foot Orthotic
PTTD
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Customization• Pre-fab shell• Custom orthotic
PTTD
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Customization• Pre-fab shell• Custom orthotic
– Control medial tibial rotation
PTTD
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• Integration of Dynamic Controlled Stress with Foot Orthotics
PTTD
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Shoe selection– Shank & counter– Toe-to-heel – Rocker sole
• Facilitate 3rd rocker
PTTD
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Orthotic
Shoe
AFOIntegrated FunctionFoot
Customization summary
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• Retrospective Case Study
PTTD
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TMA & Partial Foot
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Various techniques…
TMA & Partial Foot
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Objectives: • Limb preservation
– Friction– Pressure– Shearing forces
TMA & Partial Foot
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Objectives: • Limb preservation• Gait restoration
– Biomechanical function• Stretch reflex• Muscle activation
– Center of gravity– Limb length– Propulsion with proximal stability
TMA & Partial Foot
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• Friction– Shoe size
• Too large
TMA & Partial Foot Limb Preservation
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• Friction– Shoe size
• Too large
– Socket • Too large
TMA & Partial Foot Limb Preservation
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• Friction• Pressure
– Shoe size• Too small
TMA & Partial Foot Limb Preservation
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• Friction• Pressure
– Shoe size• Too small
– Integrity of socket• Too small
TMA & Partial Foot Limb Preservation
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• Friction• Pressure
– Shoe size• Too small
– Integrity of socket• Too small
– Break point • At shoe break
TMA & Partial Foot Limb Preservation
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(Foot) Ball Break
• Friction• Pressure• Shearing forces
lever arm
TMA & Partial Foot Limb Preservation
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(Foot) Ball Break
Shearing forces• “Normal” functional balance
lever arm
TMA & Partial Foot Limb Preservation
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Shear• Normal• Abnormal balance = Shear
lever arm
TMA & Partial Foot Limb Preservation
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Shear• Normal• Shear
lever arm
TMA & Partial Foot Limb Preservation
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Shear• Normal• Sheer
lever arm
TMA & Partial Foot Limb Preservation
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Shear• Normal• Sheer• Partially lengthened
lever arm
TMA & Partial Foot Limb Preservation
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Shear• Normal• Sheer• Partially lengthened• Fully lengthened
lever arm
TMA & Partial Foot Limb Preservation
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TMA pressure analysis
Amputation level
Carbon footplate
Tamarac joints
Blue Rocker
TMA & Partial Foot Limb Preservation
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Summary • Limb preservation
FrictionPressureShearing forces
TMA & Partial Foot Gait Restoration
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Objectives: • Limb preservation• Gait restoration
– Biomechanical function • Proprioceptive stretch reflex • Muscle activation • Proximal stability
TMA & Partial Foot Gait Restoration
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Functional closed chain summary:• Biomechanical event triggers• Proprioceptive stretch reflex, triggers• Muscle activation, leading to• Proximal stability during gait
TMA & Partial Foot Gait Restoration
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Objectives: • Limb preservation• Gait restoration
– Biomechanical function• Stretch reflex• Muscle activation
– Center of gravity• Toward sound side
TMA & Partial Foot Gait Restoration
© Allard USA 20082008Canadian Federationfor Podiatric Medicine © Allard USA 2008
Objectives: • Limb preservation• Gait restoration
– Biomechanical function• Stretch reflex• Muscle activation
– Center of gravity– Limb length
TMA & Partial Foot Gait Restoration
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• Limb length – Correlation to calcaneal angle
Neutral Plantarflexed
TMA & Partial Foot Gait Restoration
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20° dorsiflexion• Limb length
– Normal ankle ROM (1/3 : 2/3 ratio)
40° plantarflexion
(1/3)
(2/3)
Neutral
TMA & Partial Foot Gait Restoration
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20° dorsiflexion• Limb length
– Normal ankle ROM– Normal calcaneal angle
40° plantarflexion
40°
TMA & Partial Foot Gait Restoration
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40°• Limb length
– Normal ankle ROM– Normal calcaneal angle
TMA & Partial Foot Gait Restoration
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40°• Limb length
– Normal ankle ROM– Normal calcaneal angle
• Transmetatarsal
TMA & Partial Foot Gait Restoration
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40°• Limb length
– Normal ankle ROM– Normal calcaneal angle
• Transmetatarsal• Lisfrank
TMA & Partial Foot Gait Restoration
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40°
• Limb length– Normal ankle ROM– Normal calcaneal angle
• Transmetatarsal• Lisfrank• Chopart
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
Maximum dorsiflexion
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM
1/3
2/3
Maximum dorsiflexion
Functional posture
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM
Maximum dorsiflexion
Functional posture
Terminal plantarflexion
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM• Create socket
Functional posture
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM• Create socket
Plaster impression Functional posture
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM• Create socket
Negative Positive model Socket
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM• Create socket• Post to casting angle
Posted to functional posturePosted to residual LLD
Posted for function
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM• Create socket• Prosthesis
– Length– Width– Profile
TMA & Partial Foot Gait Restoration
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• Closed chain max dorsiflexion
• Establish functional ROM• Create socket• Prosthesis• Break
TMA & Partial Foot Gait Restoration
© Allard USA 20082008Canadian Federationfor Podiatric Medicine © Allard USA 2008
Objectives: • Limb preservation• Gait restoration
– Biomechanical function• Stretch reflex• Muscle activation
– Center of gravity– Limb length– Propulsion with proximal stability
TMA & Partial Foot Gait Restoration
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Propulsion with proximal stability• Blue Rocker
– Anterior shell • Proximal stability
TMA & Partial Foot Gait Restoration
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Propulsion with proximal stability• Blue Rocker
– Anterior shell – Open calcaneous
• Biomechanics • Stretch reflex • Muscle activation • Proximal stability
TMA & Partial Foot Gait Restoration
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Propulsion with proximal stability• Blue Rocker
– Anterior shell – Open calcaneous– Graded energy reflection
• Body weight• Proximal deficits• Activity level
TMA & Partial Foot Gait Restoration
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Propulsion with proximal stability• Blue Rocker
– Anterior shell – Open calcaneous– Graded energy reflection– Completed system
TMA & Partial Foot Gait Restoration
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Socket& Filler
Shoe
AFOIntegrated FunctionResidual
Limb
Customization summaryPartial Foot & TMA
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Integrated Function
TMA & Partial Foot
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• Case Study
TMA & Partial Foot
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Primary References• Gait Analysis, Jacquelin Perry, SLACK Inc.• Muscles Alive, Basmajian & De Luca, Williams &
Wilkins• Chain Reaction Seminar Series, Gary Gray, Wynn
Marketing• Atlas of Clinical Anatomy, Netter, Novartis • LifeART, Williams & Wilkins• Primal Pictures
References
© Allard USA 20082008Canadian Federationfor Podiatric Medicine © Allard USA 2008
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