Checkout Principles of lower

limb Orthoses
Kunal Y. Chandra
MPO

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 Checkout (evaluation)
 Checkout may be defined as a systematic
examination of the patient with the orthosis
as a biomechanical entity.
 The checkout procedure provides for the
systematic evaluation of an orthosis. The
purpose of checkout is to ascertain that the
orthosis is satisfactory and to call attention
to any modifications or adjustments that
may be requiered.

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 Initial checkout

 Initial checkout is accomplished before the

initiation of training. It is generally performed with
the appliance in the unfinished state so that minor
improvements may be introduced at minimum
cost. It is important for two reasons- 1. to provide
assurance that the prescription has been followed
precisely. 2. to evaluate the biomechanical
adequacy of the device.
 if the orthosis is found satisfactory at Initial
checkout, orthotic training is started.

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 Final checkout

 Final checkout is done after completion of orthotic

training.
 It assures the clinic that the patient is not in
immediate need of any further orthotic, medical, or
surgical attention.
 In Final checkout, the biomechanical adequacy is
reviewed, and evaluation is made of the extent
and effectiveness of the patient`s use of the
orthosis, as well as his physical and psychological
status.

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 At the initial checkout, attention will be directed to
comfort, stability and the fit of the appliance.
 At final checkout, in addition to these items, the
patient`s ability to use the orthosis effectively
should be carefully evaluated.
 Checkout is designed to ensure that the orthosis
fits appropriately and wearer has adequate
stability, and is satisfied with the device.

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Checkout of lower limb Orthoses
 Checkout of lower limb Orthoses involves a static
and a dynamic examination.
 Static evaluation consists of obeserving the
orthosis on the patient as the individuals stands
and sits, as well as examining the device of the
patient.
 Dynamic evaluation is performed while the patient
walks.
 Generally, checkout clinic team members includes
orthotist, physical therapist and physian.

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 Static evaluation
 Conformance with prescription- prior to static
evaluation, examiner should ascertain that the
plan developed in the prescription has been
carried out.
 Construction of the orthosis- the clinic team should
examine the construction of the device, paying
particular attention to smoothness of the edges
and enterior and exterior.
 Donning and doffing of the orthosis- patient/
caregiver should apply and remove orthosis easily
and correctly.

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 Comfort of the orthosis
 Regardless of its purpose, the orthosis must
be comfortable, otherwise, the patient is
unlikely to wear it.
 A major element in ensuring comfort is
minimizing pressure by maximizing the area
covered by the orthosis. Another way to
improve comfort is to proviode sufficient
leverage through which the longitudinal
segments of the orthosis apply force.

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 Checking with the patient standing
 Fitting of the shoe- regardless of its purpose, the
shoe should fit properly after all modification are
complete and any insert is installed. Each foot
should be checked separately.
 Fitting and alignment of the orthosis- it includes
conformity to contour, free from pressure points
and irritation, correct width and depth of metal
bands and plastic shell, correct positioned
mechanical joints, correct location of straps and
metal bands, stability of the patient.

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 Fitting of the shoes
 Every shoe should be judged for proper fit.
The final determination of fit is made on the
wt. bearing foot after all internal shoe
modification have been completed.
 The shoe should be at least ½ inch longer
than the longest toe, in order to facilitate toe
off action.
 Shoe is snug from the heel to the ball of the
foot.

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Evaluation of shoe modification and
foot orthoses
 At the initial examination, the placement and
dimensions of the shoe modification should
be checked with fitting if shoe.
 At initial and follow up examinations, a gait
analysis should be performed and causes of
any gait deviations are identified.
 In examining the foot, any signs of irritation
should be noted.

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Fitting and alignment of the orthosis

Objectives-
1.Flat heel and sole contact of the shoe with
the ground.
2.Anatomical –mechanical joints congruency.
3.Horizontal orientation of the joint axis
4.Conformity to anatomical contours and land
marks.

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 Alignment of hip, knee, and ankle
orthotic joint
plane hip knee ankle
frontal Horizontal Horizontal Horizontal
&perpendicular &perpendicul &perpendicul
to sagittal line ar to sagittal ar to sagittal
line line

sagittal 1 inch sup. ¾ inch Distal tip of

and ½ inch proximal to medial
ant. to G.T tibial plateau malleolus
and ½ the centre
A.P.dia.of
knee
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 Alignment of hip, knee, and ankle
orthotic joint
plane hip knee ankle
tranceverse Parellel to Perpendicular Rotated in
axis of the to the plane of accord with
knee joint motion of the measured
shank: amount of
Approximately torsion:
parallel to Usually 20 -
plane of 30˚ of
popliteal area external
when knee is rotation in
flexed 90 relation
to knee axis.
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Checking with the patient sitting and
after removal of the orthosis
 Comfortable sitting
 Maintaining the alignment and fitting
 Limb should be free from signs of irritation
immediately after removal of the orthosis.
 Satisfactory general workmanship
 Satisfactory appearance or cosmesis
 Patient`s performance and opinion - The patient
should consider the orthosis satisfactory as to
weight, comfort, function and appearance.

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 Checking with the patient walking
(Dynamic evaluation)
 Assuming the orthosis fits well, the team
should proceed to the dynamic phase of
evaluation during which the patient walks
with the orthosis.
 Gait analysis should be related to the
purpose of which the orthosis was
prescribed.
 Any gait deviation and causes shoud be
noted.

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 Training

 The orthotist educates the patient about donning,

doffing, caring for and using the orthosis. A
wearing schedule is often provided for the patient
to gradually grow accustomed to the orthosis.
Donning and doffing an orthosis can be a
challenge at first, especially for children. The
orthotist provides specific instructions for donning
and doffing with the least difficulty. In addition, he
or she provides instructions regarding the need to
monitor skin for possible breakdown.

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 Maintenance
of orthoses
 Orthotic maintenance may include resetting joint
angles, which is usually done by an orthotist or a
physical therapist under the direction of an
orthotist. Screws in joint mechanisms also may
loosen occasionally, and tightening can usually be
done by the patient or caregiver at home with
directions from the orthotist. As with operation,
maintenance may vary depending on the type of
orthosis, and users should follow the instructions
of their orthotists.

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 At the end of the checkout, team should
ascertain that patient/ caregiver has
received oral and written instruction
regarding: 1. name and contact no. of the
orthotist, 2. purpose of the orthosis,
 3. wearing shedule, 4. care of the orthosis,
5. special instructions, 6. precautions.

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 Conclusion

 One of the problems of judging the effectiveness

of orthotic treatment has been the lack of
evaluation techniques and instrument that can
readily be applied in routine clinical situations.
Therefore, a simplified and standard method of
evaluation technique should be developed for
testing the effectiveness of the orthoses in routine
clinical practice.

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