Download - New Technology for Management of PTTD and TMA · New Technology for Management of PTTD and TMA • Orthotic management of patients with severe ankle instability, flatfeet, partial

© 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.


• 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


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


Foundation PrinciplesCore principles - the foundation upon

which everything is built


Components of functional stability• Appropriate motion

– All three planes– Appropriate amounts– Appropriate pathways

• Adequate strength• Adequate proprioception

Foundation Principles


Normal function• Calcaneal ROM (Right posterior view)

20° Inversion(Swing)

Sub-talor neutral 10 ° Eversion(Stance)



Normal function• Calcaneal ROM• Trigger mechanism



PTTD

• Factors contributing to PTTD


• Normal Biomechanics of PTTD

PTTD


• Normal Closed Chain Function of the Tibial Posterior Muscle Through Stance Phase of Gait

PTTD


• Classification of PTTD Dysfunction

PTTD


• Treatment Protocol for Stages 1-3

PTTD


• Current FO, SMO, and AFO Treatment – Static Alignment

PTTD


• Foot Orthotic Selection– Selection of Optimum Prefabricated Foot

Orthotic– Fabrication of Custom Foot Orthotic

PTTD


Customization• Pre-fab shell• Custom orthotic

PTTD


Customization• Pre-fab shell• Custom orthotic

– Control medial tibial rotation

PTTD


• Integration of Dynamic Controlled Stress with Foot Orthotics

PTTD


Shoe selection– Shank & counter– Toe-to-heel – Rocker sole

• Facilitate 3rd rocker

PTTD


Orthotic

Shoe

AFOIntegrated FunctionFoot

Customization summary


• Retrospective Case Study

PTTD


TMA & Partial Foot


Various techniques…

TMA & Partial Foot


Objectives: • Limb preservation

– Friction– Pressure– Shearing forces

TMA & Partial Foot


Objectives: • Limb preservation• Gait restoration

– Biomechanical function• Stretch reflex• Muscle activation

– Center of gravity– Limb length– Propulsion with proximal stability

TMA & Partial Foot


• Friction– Shoe size

• Too large

TMA & Partial Foot Limb Preservation


• Friction– Shoe size

• Too large

– Socket • Too large



• Friction• Pressure

– Shoe size• Too small





– Integrity of socket• Too small





– Integrity of socket• Too small

– Break point • At shoe break



(Foot) Ball Break

• Friction• Pressure• Shearing forces

lever arm



(Foot) Ball Break

Shearing forces• “Normal” functional balance

lever arm



Shear• Normal• Abnormal balance = Shear

lever arm



Shear• Normal• Shear

lever arm



Shear• Normal• Sheer

lever arm



Shear• Normal• Sheer• Partially lengthened

lever arm



Shear• Normal• Sheer• Partially lengthened• Fully lengthened

lever arm



TMA pressure analysis

Amputation level

Carbon footplate

Tamarac joints

Blue Rocker



Summary • Limb preservation

FrictionPressureShearing forces

TMA & Partial Foot Gait Restoration



– Biomechanical function • Proprioceptive stretch reflex • Muscle activation • Proximal stability



Functional closed chain summary:• Biomechanical event triggers• Proprioceptive stretch reflex, triggers• Muscle activation, leading to• Proximal stability during gait





– Center of gravity• Toward sound side





– Center of gravity– Limb length



• Limb length – Correlation to calcaneal angle

Neutral Plantarflexed



20° dorsiflexion• Limb length

– Normal ankle ROM (1/3 : 2/3 ratio)

40° plantarflexion

(1/3)

(2/3)

Neutral



20° dorsiflexion• Limb length

– Normal ankle ROM– Normal calcaneal angle

40° plantarflexion

40°



40°• Limb length




40°• Limb length


• Transmetatarsal



40°• Limb length


• Transmetatarsal• Lisfrank



40°

• Limb length– Normal ankle ROM– Normal calcaneal angle

• Transmetatarsal• Lisfrank• Chopart



• Closed chain max dorsiflexion

Maximum dorsiflexion




• Establish functional ROM

1/3

2/3


Functional posture




• Establish functional ROM


Functional posture

Terminal plantarflexion




• Establish functional ROM• Create socket

Functional posture





Plaster impression Functional posture





Negative Positive model Socket




• Establish functional ROM• Create socket• Post to casting angle

Posted to functional posturePosted to residual LLD

Posted for function




• Establish functional ROM• Create socket• Prosthesis

– Length– Width– Profile




• Establish functional ROM• Create socket• Prosthesis• Break





– Center of gravity– Limb length– Propulsion with proximal stability



Propulsion with proximal stability• Blue Rocker

– Anterior shell • Proximal stability




– Anterior shell – Open calcaneous

• Biomechanics • Stretch reflex • Muscle activation • Proximal stability




– Anterior shell – Open calcaneous– Graded energy reflection

• Body weight• Proximal deficits• Activity level




– Anterior shell – Open calcaneous– Graded energy reflection– Completed system



Socket& Filler

Shoe

AFOIntegrated FunctionResidual

Limb

Customization summaryPartial Foot & TMA


Integrated Function

TMA & Partial Foot


• Case Study

TMA & Partial Foot


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


Thank you!