Complete Orthotic Study Guide Bundle

Orthotic Practicum

Chapter 2

In this section we will review the main points of range of motion (ROM) and manual muscle testing (MMT). I will only be covering the fundamentals that I believe to be useful to the examination. If you are unfamiliar with any of the terminology used here please do not be lazy, LOOK IT UP! You will need to know this material.

Range of Motion

Measurement Review:

You will be required to use a goniometer if asked to measure a patient’s ROM. So let’s make sure you understand how to properly use the device before we begin. The goniometer is made up of an axis (the hinge), a stable arm, and the mobilizing arm.

1. Axis (AX): The center of the goniometer should always be placed next to the axis of the anatomical joint.
2. Stable arm (SA): Placed proximal to the anatomical joint-the part of the body that will not be moving (i.e. for knee flexion, stable joint will be along the femur).
3. Mobile arm (MA): placed distal to the joint and as the name refers will be moving (mobile arm will be along the fibula).

Always assure that the patient is in a stable position and to support the extremity being tested.

Before preforming the actual measurement ensure the patient is in a favorable and safe position. Then assist them through the desired motion (PROM), while explaining what you would like them to do. Don’t be afraid to show them how you would like them to move. Once you have your goniometer in place, have the subject perform the desired motion unassisted.

The chart below will walk you through the starting position (SP) to have the patient in, as well as, how to position the goniometer.

Orthotic Written Study Guide

1. Which of the following is not a component of the Knight-Taylor TLSO?

a. Paraspinal Bars
b. Lateral Bars
c. Pelvic Band
d. Sternal Extension
e. Thoracic Band

2. After receiving an Rx for a KAFO, you evaluate an elderly patient. You find that the patient presents with poor hip extensors and genu recurvatum and poor upper body strength. Which of the following knee joints should you utilize?

a. Drop locks
b. Ratchet
c. Posterior offset
d. Bail lock

3. The obturator nerve innervates all of the following except:

a. Adductor brevis
b. Adductor longus
c. Gracillis
d. Vastus medialis

4. Where is the origin and insertion of the Anterior Cruciate Ligament?

a. O – Medial wall of femoral condyle; I – the middle of the tibial intercondylar area
b. O – Lateral wall of femoral condyle; I – the anterior aspect of the tibial intercondylar area
c. O – the middle of the tibial intercondylar area; I – Medial wall of femoral condyle
d. O – the anterior aspect of the tibial intercondylar area; I – lateral wall of femoral condyle

5. A patient presents with Trendelenburg gait pattern. What muscle is affected?

a. Gluteus medius/minimus of stance phase limb
b. Gluteus medius/minimus of swing phase limb
c. Gluteus maximus of stance phase limb
d. Gluteus maximus of swing phase limb

6. You have received a Rx for a corrective scoliosis orthosis. After examining the provided radiograph, you discover a double major curve. The superior curve has an apex of T5. Traditionally, which type of orthosis would have been the suggested?

a. Minerva
b. Milwaukee
c. “Boston brace” type TLSO
d. SOMI

7. Ideally orthotic treatment of plageocephaly should begin by what age?

a. 1-3 months of age
b. 4-6 months of age
c. 7-8 months of age
d. 9-12 months of age

8. A patient comes in to your office with a diagnosis of Posterior Tibial Tendon Dysfunction. What is a simple test used to diagnose this condition?

a. Thomas Test
b. Posterior Drawer Sign
c. Single Limb Heel Rise
d. Trendelenburg Test

9. A patient has a SCI at level C7. What functions does he have remaining?

a. Independent Breathing
b. Bladder/Bowel Control
c. Complete function of the elbow, wrist, and hand
d. Neck flexion and extension
e. Some shoulder movement

10. Ligaments connect __________ to _________ while tendons connect __________to ___________?

a. Bone to bone; muscle to bone
b. Muscle to bone; muscle to muscle
c. Muscle to muscle; bone to bone
d. Muscle to bone; bone to muscle

11. The term thrombotic when referring to a stroke, means what?

a. Blood flow is blocked by a clot in an artery leading to the brain
b. Blood clot forms elsewhere in the body, breaks free, and lodges in the brain
c. Blood clot forms directly in a brain vessel
d. Vessel in the brain ruptures causing blood to fill around the brain causing pressure

12. A 75 year old post-polio patient comes in to your office wearing a right conventional style KAFO with double uprights, drop lock knee joints, klenzak ankle joints, and split caliper that attaches to multiple shoes. She states that her leg has atrophied and that the brace is too loose. She is worried about getting a new brace because she is on a fixed income. She has also noticed that her ankle is rolling out more. Inspection of her skin reveals a callous along her lateral malleoli and fifth met. Head. Her equinovarus position is still flexible to neutral. What type of orthotic would you recommend for this patient?

a. Double upright conventional KAFO with drop locks, double action ankle joints, split calipers, and a lateral T-strap.
b. Single upright conventional KAFO with the bar on the medial side with drop lock, klenzak joint, and a UCBL footplate
c. Double upright thermoplastic KAFO with drop locks, lateral sabolich tab, and solid ankle
d. Double upright conventional KAFO with drop locks, klenzak joint, and UCBL style footplate

Answer Key w/ Explanations
Be prepared & Pass your first time!

1. D) The components of a Knight-Taylor TLSO include thoracic band, pelvic band, paraspinal bars, lateral bars, interscapular band, and axillary straps.

2. D) The genu recruvatum is likely a secondary condition due to the poor hip extensors. From the list provided the bail lock would be the ideal choice for the following reasons.

• The posterior offset joint would be great to treat the genu recurvatum but would not provide any security for the poor hip extensors and could lead to the patient overall feeling unstable as the genu recruvatum is likely her stabilizing force in stance phase.
• While both the ratchet lock and drop locks would provide her increased security with her weak hip extensors while better supporting her genu recruvatum, they would be difficult for her to disengage. Furthermore, the ratchet lock would be excessive and require more work from her hip extensors to fully engage. The ratchet lock would be excessive and unnecessarily difficult for an elderly patient to disengage, as well as, the drop locks.
• The bail lock provide sufficient control and is much more convenient to operate .

3. D) The obturator nerve runs through the obturator foramen and innervates the adductor of the thigh. The vastus medialis is part of the quadriceps muscle group and is innervated by the femoral nerve.

4. A) The ACL originates along the medial wall of the femur and inserts into the middle of the intercondylar area of the tibia. It prevents anterior translation of the tibia in relation to the femur. (change all of the answer options on this question).

5. A) Trendelnburg gait is when there is weakness of the hip abductor muscles (gluteus medius/minimus). During gait, the when the affected side is in stance phase, the “sound side” limb is in swing and there is a noticeable drop of the pelvis.

6. B) The Milwaukee CTLSO was traditionally used to treat an Apex of T6 and Superior.

7. B) Documented in the AAOS Atlas of Orthoses and Assistive Devices (edition 4) orthotic treatment should begin within 4 and 8 months of age and should not be used longer than 12 months of age.

8. C) Single Limb Heel Rise test is used to help diagnose PTTD. Patient is asked to stand up on his toes. A patient with positive PTTD often cannot or has pain with performing this task.

9. A, D, and E) Patient will be able to breathe on his own (C3, C4, C5 keep the diaphragm alive). Writst and elbow extension are likely maintained but not motions of the hand and flexion motions making C not an option. Neck flexion and extension still controlled. Some shoulder movement available due to C5-C6 being intact.

10. A) Ligaments connects bone to bone while tendons connect muscle to bone.

11. C) A thrombotic stroke is the most common type of ischemic stroke.

12. D) One of the most important things of working with a post-polio patient is to keep the brace as close as possible to the original. While (A) would be a possible option, double action joints would be heavier and a lateral T-strap would be required to be added on to every shoe, and she is already concerned about finances. (D) is a better option as the brace remains almost the same, she can continue to switch shoes as she is accustomed to, and she will have the needed support of the equinovarus deformity.

Orthotic Written Simmulation

Scenario

A 5-year-old male patient and his mom comes in to your office for evaluation for bilateral orthotics. The patient has been diagnosed with myelodysplasia at level L4. The mom states that the patient has been undergoing OT/PT and is going to begin kindergarten in the fall.

Part A

You begin your evaluation:

A. Ask about allergies
B. Take height and weight
C. Inspect patients skin
D. Check the patients ROM/MMT
E. Have the patient ambulate between the parallel bars with a gait belt donned
F. Check the patients tone
Part B
Your evaluation finds the following answers:

A – The patient has a latex allergy
B – Ht: 44” Wt: 41lbs.
C- No signs of skin breakdown or concerns but mom states that patients skin is sensitive to pressure
D – Bilateral ROM – WNL bilaterally Bilateral MMT – Hip flexion/extension – 5/5, Knee flexion – 4-/5, knee extension 3-/5, DF 1/5, PF 2/5, Inv/Ev – 2/5
E – Patient presents with crouch gait and foot drop in swing phase, and a hindfoot varus deformity throughout stance phase bilaterally.
F- Mild spastic response with quick stretch

Now that your evaluation is complete, you formulate your treatment plan.

A. Custom single upright thermoplastic KAFOs
B. Single axis knee joints
C. Locking knee joints
D. Oklahoma ankle joints
E. Klenzak joints
F. UCBL style trim footplate
G. Custom semi-solid AFOs
H. Custom articulated AFOs
I. Custom GRAFOs
J. Molded inner boot
K. Full length footplate
L. Met length footplate
M. Sulcus length footplate
N. Soft interface

Part C
The patient comes in for a fitting of his custom made GRAFO with molded inner boot and soft interface. The patient ambulates in the brace and complains of pain along his patella, discomfort along the inside of his foot, and a slight valgum deformity that worsens at midstance. How will you address these issues?

A. Tell the patient’s mom that if he follows the break-in schedule, the areas of pain will go away
B. Evaluate the fit of the orthotic
C. Check the patient’s skin for signs of redness
D. Add a lateral heel wedge
E. Add a medial heel wedge
F. Bring the trimline of the GRAFO below the tibial tubercle
G. Heat and relieve along the patella
H. Add more padding to the entire molded inner boot to decrease skin breakdown

Answers

Part A – Correct Selections – A, B, C, D, E, F
Part B – Correct Selections – I, J, K, N

*Note – depending on whatever orthotic you select in this section, it will lead you down a different path. The “correct selections” in this Part are based off what is the best answer, though other options are potentially also partly correct.

Incorrect Selections:
A, B, C, D, E, F – Because the patient is so young, the goal is to avoid over bracing. Furthermore, none of these options would address the crouch gait except the locking knee joints, and that would be uncessary bracing for this patient. Both the Oklahoma and Klenzak joints would only further promote the crouch gait.

G – While this a viable answer, it would not be the optimal way to address the crouch gait and weakened knee muscles because a semi-solid AFO comes posterior to the malleoli and would likely hold up to the amount of stress that would be applied – if it was a solid AFO, this would potentially be a good answer
H – Potential problem with the articulated would be the spastic response while ambulating that could lead to skin breakdown and cause difficulty while walking. It also would not address crouch gait
L/M – These lengths are not recommended for patients with tone, and it is not the correct length footplate length for a GRAFO.

Part C – Correct Selections – B, C, E, G

Incorrect Selections –
A – While some discomforts may go away after a break-in schedule, if he is already complaining of pain, it is important to check his skin for redness and breakdowns that are already happening
D – A lateral heel wedge increases the pain along the inside of his foot and the valgum deformity
F – This will compromise the effectiveness of the GRAFO and may lead to increased pressure along the tibia