Checking the Orthosis’ Alignment

Step 1/3

Mount the spring units (see also Joint Assembly of System Ankle Joints with plug + go Modularity) according to the configuration recommendation.

Step 2/3

Check the position of the motion limiting screw inside the alignment screw:
A. motion limiting screw is unscrewed as much as possible → correct
B. motion limiting screw is not unscrewed as much as possible so that the spring’s range is limited → unscrew it as much as possible

Step 3/3

Mind the markings indicating the joint angle. Mount the spring units in such a way that the indicator is in the middle so that the alignment corresponds to the cast.

Step 1/1

Check the alignment on the workbench considering the shoe pitch:
A. correct
B. tibia inclination too small → unscrew ventral spring unit until the alignment is correct, then turn the dorsal one until it has contact to the system stirrup again → check again
C. tibia inclination too high → unscrew dorsal spring unit, then screw in the ventral one until the alignment is correct; turn dorsal spring unit until it has contact to the system stirrup again → check again 

Step 1/1

Check the orthosis’ alignment on the patient, while the patient leans forward against the contact area:
A. patient is standing safely (with or without medical devices) and the plumb line falls into the green or yellow marked area → correct
B. patient needs help standing because he falls forward and the plumb line falls into the red marked area →

1. check settings and functionality of the medical device
2. unscrew dorsal spring unit a little and screw in ventral one; make sure there is no play in the system joint and check again from the previous step (On the Workbench) → if the plumb line still falls into the red marked area: mount a stronger spring unit ventrally and leave the alignment as it is for now; check again

Step 1/14

For checking the alignment dynamically on the patient, always examine several step processes.

Step 2/14

If the patient is still insecure, walking assistive devices can be used if necessary. Mind the correct settings, so that checking the alignment dynamically can be carried out successfully.

Step 3/14

Check the walking speed*:
A. If it is about 84m/min (ca. 5km/h), the patient’s walking speed is normal and you can continue checking the alignment dynamically.
B. If it is about 200m/min (ca. 12km/h), it is not possible to check the alignment dynamically. Find cause (maybe the orthosis does not provide sufficient security).
C. If it is about 30m/min (ca. 1.8km/h), it is not possible anymore to identify the gait phases according to Perry reliably.

* Information about walking speed from: Götz-Neumann K (2011): Gehen verstehen – Ganganalyse in der Physiotherapie, 3rd edition. Stuttgart: Thieme, p. 19f.

Note: You can also use the Timed Ten-Meter Walk Test (10MWT) to document the walking speed. (See: Tyler Klenow and Brian Kaluf: Timed Ten-Meter WalkTest (10MWT): Reference Guide. The American Association of Orthotists and Prosthetists, Outcomes Research Committee.)

Step 4/14

The load duration on both legs is:
A. the same → continue at the next step
B. not the same → find cause at the orthosis construction and resolve it  

Step 5/14

 Initial Contact
A. initial contact with heel → correct; continue at step 8
B. initial contact not with heel → continue at step 7 

Step 6/14

Initial Contact → Loading Response – Upper Ankle Joint
An initial heel strike occurs.
No → continue at step 8
Yes and
A. a plantar flexion occurs:

1. without noise when foot strikes the ground → continue at step 9
2. with a loud noise (slapping) when foot strikes the ground → mount a stronger spring unit dorsally to control plantar flexion

B. no plantar flexion occurs (also noticeable by an increased knee flexion) → mount a weaker spring unit dorsally and check again until the situation under A. 1. is reached; continue at step 9

Step 7/14

Initial Contact → Mid Stance
Forefoot contact as initial ground contact and no heel strike even in mid stance.
A. No → continue at step 6
B. Yes. This is an active reaction of the patient to secure themselves → mount a stronger spring unit ventrally

1. successful: continue at step 8
2. not successful: continue at step 6
3. substructure under heel at the orthosis or, if necessary, the shoe until the initial contact occurs with the heel

Step 8/14

Initial Contact → Mid Stance
A. complete foot contact or first contact with the forefoot and heel strike in mid stance
B. foot lifting is not sufficient in swing phase → mount a stronger spring unit dorsally

1. successful: continue at step 9
2. not successful: substructure under heel at the orthosis or, if necessary, the shoe until the initial contact occurs with the heel

Step 9/14

 Loading Response – Knee
A. knee is slightly flexed → correct; continue at step 11
B. knee is strongly flexed and there is (almost) no plantar flexion → patient does not allow sufficient plantar flexion; continue at step 10
C. knee is not flexed (maybe even hyperextended) → mount a stronger spring unit dorsally and check again 

Step 10/14

Loading Response – Knee
Knee is not flexed (maybe even hyperextended). Often, the patient bends forward the upper body in order to carry out a hyperextension despite the measures taken in step 9.
B. dorsal tibial shell:

1. produce new tibial shell with ventral contact area (ventral shell or appropriate cover)
2. successful: continue at step 11
3. not successful: continue at C. 2.

C. ventral tibial shell:

1. check ventral contact area (shell or cover). It must be able to carry the load.
   a. contact area is able to carry the load → correct; continue at C.2.
   b. contact area is not able to carry the load → produce new tibial shell with ventral contact area (ventral shell or appropriate cover)
   c. successful: continue at step 11
   d. not successful: continue at C.2. 2.
2. mount a weaker spring unit dorsally

Step 11/14

 Mid Stance – Knee
A. tibia inclination corresponds to the one when the alignment was checked statically on the patient → correct
B. tibia inclination is higher than the one when the alignment was checked statically on the patient → mount a stronger spring unit ventrally. If the strongest spring force is not sufficient, screw in ventral motion limiting screw. 

Step 12/14

Mid Stance → Late Mid Stance – Ground Contact
A. foot contact is still complete and the contralateral side is in mid swing → continue at step 13
B. situation under A is skipped and the heel lifted immediately → mount a weaker spring unit ventrally; continue at step 13 

Step 13/14

Mid Stance → Late Mid Stance – Upper Ankle Joint
A. tibia inclination increases (a dorsiflexion occurs)

1. without bumping noise → continue at step 14
2. with clearly audible bumping noise → mount a stronger spring unit ventrally. If the strongest spring force is not sufficient, screw in ventral motion limiting screw and check again.

B. No dorsiflexion occurs (noticeable by a hyperextension).

1. ventral spring unit is too weak and the patient secures themselves actively in hyperextension → mount a stronger spring unit ventrally; if necessary, screw in motion limiting screw and check again
2. ventral spring unit is too strong and cannot be compressed so that a dorsiflexion is not possible → mount a weaker spring unit ventrally and check again

Step 14/14

Terminal Stance
A. heel lifts significantly from the ground

1. without bumping noise à correct
2. with clearly audible bumping noise → mount a stronger spring unit ventrally. If the strongest spring force is not sufficient, screw in ventral motion limiting screw.

B. heel does not lift from the ground → mount a stronger spring unit ventrally and, if necessary, screw in ventral motion limiting screw