Deliver Cranial Reshaping Helmet

The patient is here today for a followup on his helmet. We checked this device, trimmed it slightly,

added some padding to the posterior distal edge on the occiput to make it more snug. We will see in

back in approximately 2 weeks. At that time, I think that it will be necessary for us to remove some

material.

Static Encephalopathy

This 7-year-old female has no allergies. She is currently taking Depakote and has had no surgeries. She receives physical therapy at school and hipo therapy in town. She is an active ambulator with minimum assistance. She currently has bilateral SAFOs, which she has outgrown. Her toes are over the end and they are too narrow in the forefoot. I heated and relieved these areas today so the she is able to wear these until her new braces are fabricated.

The patient presents with pronated feet bilaterally. Her heels are in valgus, and her forefeet are abducted. She is correctable to neutral bilaterally. Range of motion at her ankles is to 90 degree with knees straight. She has moderate tone with athetosis and no clonus. Her knees and hips are normal. Upon observing her gait, the patient walks externally rotated from the hips bilaterally. Her feet are pronated and she is in a slightly crouched gait. I cast her today for bilateral SAFOs.

Patient Chart Unprocessed - Shoes Undelivered

The patient's wife called today and inquired about the shoes and the status of them, as they had recently been mailed out. Further inquiry into the situation revealed that the chart did not get processed in a timely manor. Therefore, the shoes will not be completed and ready for prefitting until approximately 2 weeks from today's date. I have notified Mrs. _______ of this. She was understanding and I was apologetic. It is my intention that once the shoes are received, the patient come into our office for prefitting. If the shoes fit well, we will rush fabrication of the orthosis for him and see him back rapidly

Definitive Socket Change Delivery - Prosthesis

The patient is in the office today to be fit with her definitive socket change. I also provided to her today her 6 multiply and 6 single ply socks, new ultra-light pyramid and new locking mechanism with 1 locking liner and 1 locking liner without lock. The prosthesis fit very well. We dynamically aligned the patient today utilizing her existing foot and pylon. She walked very well and noted no discomfort. We achieved a 3-ply fit. All bolts and nuts were Lok-Tited and torqued down to manufacturer specifications. I told the patient that she should utilize the prosthesis for 1 month. After that, she should return to the office and we will place a cosmetic cover on her prosthesis. She understands this. She also understands that if there is any difficulty, problems or changes with the new socket, she should return immediately for adjustment.

Unhappy Physical Therapist

The patient received a left AFO with posterior extension in mid-January. The therapist was not happy with this. The brace was not preventing his knee from going into recurvatum. We will remake this brace as a free-ankle AFO with adjustable 90-degree plantarflexion stop. The patient has no change in his medical condition. The parent reports that he has been wearing a solid ankle foot orthosis with posterior extension, but she did not bring it with her today. She reported that he was getting irritation on the heel. I informed her that we could make an adjustment to these if she brought them in while he is waiting for his new brace

The patient presents with a pronated foot on the left. His heel is in valgus and his forefoot is abducted. He has moderate tone and no clonus. Range of motion at his ankle is to 90 degrees with this knee flexed. His knee goes into recurvatum. Upon evaluating his gait, the patient is plantarflexed in swing. He contacts the ground mainly on his toes. He has significant recurvatum and mid to terminal stance. T cast him today, as we could not locate his previous mold.

Fabricate left free-ankle AFO with adjustable 90-degree plantarflexion stop.

Unresolved Brace Bruise - Adjustment

The patient was seen today for an adjustment to his Solid AFOs. The patient has a small red area on the top of the right foot. This area is approximately .5 cm in diameter. It appears to be an irritation from a sock wrinkle. The parent reports that it began as a bruise and has faded to this, but it will not completely resolve. I heated and flared this are. It appeared that the pressure was relieved. The fit was appropriate. The parent will continue to monitor the patient's skin. We will see the patient back as needed for adjustments.

Hip Displasia - Rhino Hip Abduction Brace

Right hip dysplasia. This 7-year-old female has no allergies, is not taking any medications and has had no surgery. I measured her today for a rhino brace. She will fit in a size extra small. I trimmed the foam down to appropriate size. I explained donning, doffing, wear, and care procedures as well as how to assist the patient in sleeping in the brace by propping up her feet and legs with a pillow. We could not release the brace to the patient today due to insurance issues.

Scoop Pads and Supracalcaneal Pads

The patient was seen today for fitting of bilateral AFO-Wraparounds. Proper trimlines and clearances were established. Scoop pads were added posteriorly to decrease the pressure at the back of the calf. Supracalcaneal pads were also added to seat the patient's heel in the brace. The parent was also given inch Aliplast ankle pads to help position the patient's foot. Fit was appropriate. Explained donning, doffing, wear, and care procedures to the parent. They will contact us should they notice any red areas that last longer than 30 to 40 minutes. We will see them back for adjustments as needed.

Crouched Gait - HKAFO's Ineffective- PT Upset

The patient is in the office today for a follow-up on her HKAFO's. At today's visit, the comment from the mother was that the physical therapist is upset that the patient continues to walk with a crouched gait with her knees and hips flexed, and could we do anything with the orthoses to alleviate this. Upon evaluation as previously noted, the patient has tight hip flexors and hamstrings. This is the primary cause of her crouched-type gait. At today's visit I have plantarflexed the ankle angle in hopes of achieving more knee extension. This was ineffective. I have called patients therapist and left a message for her to call me back to discuss the patient's case. The patient will follow-up after she sees her therapist.

Bypass Surgery -Conventional AFO's with Double Action Joints

The patient was seen today for fitting of his bilateral conventional AFOs with double-action ankle joints attached to extra-depth shoes with custom inserts and Velcro closures on the shoes. Fit was appropriate today. On the right brace the medial upright was just touching the patient's ankle. We shifted this 1A inch medially. Fit was appropriate. On the left side, the calf band was touching the fibular head. We lowered this to the correct height. The patient is still recovering from bypass surgery and is still very weak. He was able to stand in the orthosis today. He has not begun therapy. His wife indicated that she will call to receive the therapy schedule once he receives the braces. She reported that he will receive therapy 3 times per week. I instructed the patient and his wife in donning, doffing, wear, and care procedures as well as weaning schedule and proper shoe wear. I emphasized the importance that she monitors the patient's skin for any areas of irritation lasting longer than 30 minutes each time she removes the braces from his feet. I also gave them written instructions to follow today. They should begin weaning into the braces 2 hours today and increase by 2 hours each day. The patient is not ambulating very much at home at this time. I instructed them to call us should they have any problems or questions, and to return for a recheck on the braces 1 week after he begins therapy. They will contact us to set up this appointment once they know when therapy will begin. Otherwise, we will see them back for adjustments as needed.

P W Minor Orthopedic Shoes for Irregular Heel

The patient is in the office today for new shoes. I will order style #1079 from PW Minor for him. I will

increase the size from 1¹A D to 8 D. I will also modify the posterior aspect of the left shoe to

accommodate his irregular heel. This will be done after the prefitting of the shoes. I will order the

shoes 3-day and see the patient in 1 week for prefitting of the shoes.

Tibial Torsion and Genu Varus

Tibial torsion and genu varus.

This 15-month-old female has no known allergies. She is not taking any medication on a daily basis. She is an active independent community ambulator, and she has not had any surgery. She has previously had a Denis-Browne bar and straight last shoes with an 1/8 inch lateral wedge.

The shoes that she is currently wearing measure a 6 D. I measured her at an 8 D or E. She began walking at 9 months old. She did not have abnormalities at birth in regards to being born early. Tracings and measurements were taken of her feet today.

Below Knee Prosthesis

The patient has returned to the office today complaining of pressure on the posterior aspect of her
socket. At today's visit we find that the modification for the popliteal area is causing pressure and
discomfort to her. As I cannot change this in the socket itself, I will remake the socket. At today's visit 1 have replaced her original socket back on to her prosthesis and will remake the socket with appropriate modifications. We will follow up with her in 1 week.

Preparatory Prosthesis

The patient is in the office today for final fit and delivery of his preparatory prosthesis. The device fit very well. We achieved a 3-ply fit. He was able to hold suction quite well. He understands sock ply management. He understands that if there are any irritations to the limb, he should contact us immediately for adjustment. The patient walked quite extensively in the office utilizing his prosthesis. At today's visit, as expected, he is slightly hesitant on weightbearing on his prosthesis. I expect that this will resolve over time. Additionally, he noted after ambulating quite significantly here in the office he was sore in the hamstring area. I felt that this was due to stretching them out. I feel as though in 2 weeks he should be ambulating without crutches. He ambulated in the parallel bars and out utilizing forearm crutches. He also went up and down steps here in the office. I feel very comfortable with the fit and function of the patient's prosthesis. He noted no discomfort. All bolts and nuts were Lok-Tited and torqued to manufacturer's specifications. I provided him with 6 single ply and 6 multi-ply socks with two 3-mm suspension liners and 2 silicone gel liners. We will follow up in 2 weeks for further adjustment.

Clubfoot

The patient has returned to the office today. He was here earlier today for fitting of his clubfoot orthosis. It was too small because he had grown. Because it had never been delivered, I remade it adding material in the appropriate areas. He returned this afternoon for the fitting. It fit very well. Appropriate trimlines and proper clearances were established. Donning, doffing, weaning, and wearing was discussed with his mother. Of note today was that the patient has the presents of chaffing and mild irritation of the skin on the calcaneal area and on the 1^st metatarsal area. I think this is because he sweats a lot within the orthosis. I recommended that his mother change his socks at least 2 times per day. I also drilled a vent hole in the heel of the orthosis to provide him with air circulation in this area. Followup as needed. They will be returning to the physician for a checkup.

SWASH Hip Orthiosis

The patient was seen today for measuring and fit for a SWASH hip orthosis.

Cerebral Palsy - Swash Hip Orthosis

SWASH hip orthosis

Cerebral palsy.

This patient will be 7 years old in a few more weeks. She will be receiving Botox injections in the adductor muscle groups in both legs in the next couple of weeks.

Measurements were taken of the patient today and an appropriate SWASH hip orthosis was fit to the patient. Proper donning and doffing instructions were given to mom. Several adjustments were made to properly fit the patient. Growth adjustments can be made to this orthosis. While she was wearing the orthosis, standing and attempting to take steps, she could adequately clear her feet without scissoring. When she was sitting, she had very good sitting balance. Mom informed me that the therapist also wanted her to sleep in this orthosis. I instructed the mom to begin the patient on a gradual wearing schedule starting with 2 hours today, 4 hours tomorrow, 6 hours the next day and 8 hours the following day. Once she has reached the 8-hour point, she was told to allow the patient to sleep in the orthosis. I encouraged her to allow the patient to wear something snug fitting under the orthosis, possibly tights. The patient appeared to tolerate the device well. I gave mom the Alien wrenches if changes needed to be made in therapy. I marked the initial spots of the settings. I told mom if she has any problems or questions, or if she did not feel comfortable making changes, or if the therapist did not feel comfortable making the changes, to please return. The patient will be seen as needed.

Evaluation, measurement and fitting.

AFO-Free Ankle

The patient was seen today for a recheck of her bilateral AFO-FAs. The patient reports that these are much more comfortable now and she is not having any problems with them except that she and her husband are having difficulty donning the shoes. They report that the back is crumpling even with the use of the shoehorn. I added leather loops to the posterior of both shoes to help pull the heel of the shoe out during donning. I instructed the patient's husband on how to don the shoes again, and he successfully donned the shoes today in the office. The patient is going directly to therapy today, and they will contact us should they have any further problems or questions.

C-5 Tetraplegic - Spinal Cord Injury

Spinal cord injury C-5 tetraplegic.

This 21-year-old male is allergic to AMOXICILLIN. He takes Neurontin and medication to control his bladder muscles. He had a motorcycle accident in July 2000. He had spinal fusion of C-4-5 and a trach. He is nonambulatory and will begin physical and occupational therapy after he receives the braces, and his parents stated they have changed insurance companies and are working out the details with the prescriptions with the insurance. He has bilateral dorsal WHOs.

The patient was left-handed but his right arm now has greater strength. He is able to raise his arms at the shoulders, the right to 90 degrees and the left to 75 degrees. He has bilateral elbow flexion on the right. On the right it is grade 4, and on the left it is grade 3. The patient requests black straps with his orthoses. I have contacted the occupational therapist, and have received a complete description of the type of brace that she wants. She requested a tubular-type static WHO with C-bars bilaterally.

Fabricate tubular-type WHOs with C-bars bilaterally. Casting and measurement. In several weeks for fitting.

WHO with Tool Attachments

The patient was seen today for casting and measurement for a left static WHO and right static WHO with tool attachments, swivel fork, spoon and standard fork.

Shoe Fitting

The patient was seen today for an initial fit of his shoes. A good fit was achieved. The shoes will be used in the fabrication of a brace for the left side. He ambulated in the hall and commented that they felt very comfortable. The shoes appeared appropriate; therefore, we will proceed with the brace.

Soto's Syndrome and Planovalgus

Bilateral UCBs.

Planovalgus and Sotos' syndrome.

This is a 9-year-old female with no known allergies. She is taking Ritalin. She is an active community ambulator, and she does not us any assistive devices. She had bladder reconstruction in 06/2000 and she had 2 hernias prior. Her previous devices were bilateral SAFOs made by Muilenburg Prosthetics.

The patient presents as a pronator. Her heels are in valgus but correctable bilaterally. Her forefeet are abducted and correctable. She presents with no knee recurvatum. Range of motion at the ankles with the knees flexed is to +10 degrees. With the knees straight, the range of motion is to +5 degrees bilaterally. The casting procedure went well. Mom knows what to expect in regards to overall design of the braces.

Fabricate bilateral UCBs.

Cauda Equina Syndrome - Hypotonic No Clonus

Bilateral AFOs. – Orthopedic Surgeon Referral

Cauda equina syndrome with bilateral drop-foot.

This 71-year-old male has no allergies. He is currently taking Xanax and is an insulin-dependent diabetic. He has had many surgeries, spine surgery in December 1999 and June 2000 to relieve pain in his lower limbs. However, his wife reports that this was unsuccessful and they discovered a syrinx at this time. He also had surgery for a broken hip. He has had the 2^nd toe on his left foot amputated. He has had surgery for cataracts and glaucoma. He also has a history of an ulcer on the 2^nd toe of his right foot and on his right heel. He has had no ulcers on his left foot. Today the patient has a small sore on the middle of his right tibia. The patient is a limited household ambulator, uses a walker. Out in the community, however, he does use a wheelchair. He will begin physical therapy after he receives the braces. He has had no previous braces.

The patient's feet present as pronated bilaterally. He is hypotonic with no clonus. Range of motion at his ankles is to 90 degrees with his knees straight. His heels are in valgus and his forefeet are slightly abducted. His right foot is flaccid, and his left foot has a trace of dorsiflexion. His quads are 3+. His skin appears to be somewhat thin. He has some peeling of the skin over his left heels. He has pitting edema in his feet and lower legs. The sensation stops at the top of the left calf and at the middle of the right calf. Traced the patient's legs for conventional AFOs, took impressions for custom inserts, and measured his feet for extra-depth shoes to be attached to the conventional AFOs. I observed the patient's gait with a walker in the office today. He has a very crouched gait and he takes small shuffling steps and drags his toes.

We will order Drew men's doubler shoes for the patient and fabricate custom inserts and bilateral conventional double-upright AFOs with double action ankle joints and an extended stirrup.

KAFO with ShearGuard - Flexion Contracture

The patient is here today to pick up his orthoses that had been adjusted. The left heel counter of the shoe had been cut and the hard aspect of it was removed. We added 3/16 inch Aliplast padding covered with ShearGuard to prevent the patient from rubbing his calcaneus, which would breakdown his scar tissue. He was very satisfied with this. Additionally, the KAFO knee was flexed slightly approximately 3 to 5 degrees to accommodate his flexion contracture. This was also satisfactory. He ambulated in the parallel bars without hands and did very well. He complained of pain in the knee on the lateral aspect of the tibial plateau. When questioned, he described to me that this pain also occurs with physical therapy and range of motion. He is also described some crunching sounds coming from the knee. I suspect that this is meniscus damage from his initial injury and recommended that he discuss this with his physician. Otherwise, he stated that the orthoses are quite comfortable. He will see his physician, and return to see us if any further adjustments are needed.

Loose Rivets - Replace with Copper Rivets

The patient is here today because the rivets have become loose on the graphite reinforcement that we

had placed on the orthoses. To repair it, I will replace these with copper rivets. She will pick this up

tomorrow at approximately 10 am. I will do this at no charge.

Bilateral AFO Wrap-Arounds - Ortho Referral

The patient was in the office today for a routine follow-up on her bilateral AFO-Wrap Arounds. She is doing well and the orthoses are fitting and functioning quite well. I have replaced the straps and pads today at no charge. Of note is a conversation I had with the patient's father today. He stated that they are attempting to stand the patient in a standing frame. She has recently received a new wheelchair, standing frame and varied assistive devices for her home. I briefly discussed with the father the benefits of standing and recommended that he consult with their physician There are different styles of orthoses that may be of benefit to the patient, i.e., a KAFO night splint for extension at the knees, as she has knee and hip flexion contractures. He will consult with physician regarding the orthoses, physical therapy and a game plan to achieve the goal of standing. Otherwise, we will see them in routine follow-up.

Cerebral Palsy - Bilateral Solid Ankle AFO's

Bilateral solid-ankle AFOs. Cerebral palsy. Orthopedic Surgeon Referral

This is a 13-year-old male has no known allergies. He is taking baclofen. He requires maximum assistance when ambulating, and he has not had surgery since his last visit. He receives physical therapy at school, and his previous devices were solid-ankle AFOs with Compcore reinforced at the ankles. The patient brought the braces with him today. He was getting pressure on the right side at the medial malleolus, and on the left at the base of the 5^th metatarsal. These were both heat relieved. He has outgrown the footplate and they are also too short. He can wear them until the new braces are complete. This was explained to the mother.

The casting procedure went well. The patient's heels are in valgus bilaterally and they are not correctable. The right is worse than the left. Range of motion at the ankles is to 90 degrees bilaterally with the knees bent.

Fabricate bilateral solid-ankle AFOs.

Bilateral Equinovarus Contractures

Bilateral free-ankle AFOs with inhibitive footplates. Bilateral equinovarus contractures. Orthopedic Surgeon Referral

This 5-year-old male has no know allergies. He is not taking any medication and is an active community ambulator. He receives physical and occupational therapy. He receives speech therapy at home. He previously had bilateral free-ankle AFOs and did well in them, but has outgrown them.

The patient is a toe walker; however, he is able to come down on his heels when asked to. He slightly pronates bilaterally. Range of motion at the ankles with the knees flexed is +15 degrees, and with the knees straight it is +10 degrees bilaterally. His heels were in a slight amount of valgus but correctable, and his forefeet are slightly abducted but correctable. The casting procedure went well. Mom knows what to expect as far as overall design. NOT footplates will be added. He has mild tone when relaxing or sitting. His tone is more dynamic in nature. When he walks he gets up on his toes.

Bilateral free-ankle AFOs with inhibitive footplates.

Bilateral Equinovarus Contractures

Bilateral free-ankle AFOs with inhibitive footplates. Bilateral equinovarus contractures.

This 5-year-old male has no know allergies. He is not taking any medication and is an active community ambulator. He receives physical and occupational therapy. He receives speech therapy at home. He previously had bilateral free-ankle AFOs and did well in them, but has outgrown them.

The patient is a toe walker; however, he is able to come down on his heels when asked to. He slightly pronates bilaterally. Range of motion at the ankles with the knees flexed is +15 degrees, and with the knees straight it is +10 degrees bilaterally. His heels were in a slight amount of valgus but correctable, and his forefeet are slightly abducted but correctable. The casting procedure went well. Mom knows what to expect as far as overall design. NOT footplates will be added. He has mild tone when relaxing or sitting. His tone is more dynamic in nature. When he walks he gets up on his toes.

Bilateral free-ankle AFOs with inhibitive footplates.

Short AFO-Posterior Entry & UCB

The patient was seen today for fitting of a right SAFO-PE and a left UCB. All trimlines brought back to appropriate length. Grandparents were instructed in proper donning and doffing as well as placement of the orthoses on the limb. They were told proper wean-in time beginning with 2 hours and increase by 2 hours each day until the patient can were the devices all day long. They were told to monitor the skin for any red marks that persist longer then 30 minutes once the orthoses have been doffed, if there are red marks that persist, they were told to stop using the devices and contact our office. They were told to always wear shoes with these devices. The patient was told to return if there are any problems, or in 3 to 6 months for follow-up

AFO-Free Ankle

The patient was seen today at Central Rehabilitation for fitting of a right AFO-FA. All trimlines brought back to appropriate length. All areas checked for pressure. No excess pressure was found. Grandmother and father were instructed on proper placement of the orthosis on the limb. They were told proper wean and wear time beginning with 2 hours and increase by 2 hours each day. They were told if any red marks persist longer than 30 minutes once the orthosis had been doffed, to stop using the device and contact our office. They did not have appropriate shoe wear today. They were told not to use the device until they purchased shoes. They stated they would do that today and start the patient wearing the device. They were told that if they have any questions or concerns, to contact our office, and if there are any problems, to stop using the device. The patient will be seen on an as needed basis.

Calcaneal Valgus Orthotic

Calcaneal valgus. Orthopedic Surgeon Referral

This 5-year-old female has no known allergies. She is not taking any medications, and she is an active community ambulator. She has not had any surgery, and she has previously worn foot orthotics for the past 3 years according to her father. These were made by another company.

The patient presents as a pronator. She has normal tone and no clonus. Her heels are in valgus and correctable. Her forefeet are abducted bilaterally and correctable. Range of motion at the ankles with the knees flexed is +15 degrees, and with the knees straight it is +10 degrees. I think this child will do well in foot orthotics. I think that they will control the calcaneal valgus very adequately. The casting procedure went well. The parents are aware of what to expect as far as design.

Fabricate bilateral foot orthotics upon receipt of a prescription for the physician and upon insurance authorization.

Bilateral KAFO Braces

The patient was seen today for initial fitting of his bilateral KAFOs. The trimlines were adjusted and several pads were added before the patient was able to stand in them. Also, on the right, his hamstrings are tighter and the joints were readjusted to reflect this. Mom commented that she has not allowing him to wear his previous KAFOs very much because she was waiting for the new ones. I instructed her apply the previous braces on the patient while final changes are being made to the new pair to prevent further tightness. He is not having any difficulty with the previous devices. The overall fit of the new devices was very good. The changes will be noted and made. The patient will be seen in 1 week for final fit and delivery.

UCB Foot Orthotics

The patient was seen today at Race Rehabilitation for fitting of her bilateral UCBs. These were fit. All areas checked for pressure. No pressure was found. The patient stood in the braces and everything looked appropriate. Mom did not have appropriate shoes today. She was instructed in the proper donning, doffing as well as placement of the orthoses on the limb. She was told proper wean and wear time beginning with 2 hours and increase by 2 hours each day. She was told if any red marks persist longer than 30 minutes during the wean-in time, to stop using the devices and contact our office. Mother stated that she will purchase a pair of shoes and start the patient wearing the devices. We will see the patient back as needed.

Left Hemiparesis-Traumatic Brain Injury

Left free-ankle AFO Ankle Brace. Orthopedic Surgeon Referral

Traumatic brain injury and lefthemiparesis.

This 58-year-old male has no known allergies. The medications that he is taking are unknown at this time. He requires maximum assistance when ambulating. He has not had any surgery except after the initial accident, which occurred in 04/2000. He was riding his bike and was hit by a car. His wife was present during this, and she is unclear in regards to what was done. He did not have any fractures from the accident. He is receiving physical, occupational and speech therapy. He has not previously worn a device.

The patient has moderate tone on the left. His clonus is not sustained, and his alignment appears neutral. Range of motion at the ankle is to 90 degrees with the knee bent. This patient is very physically fit. Due to his tone and general strength that he continues to have, I was unable to obtain an accurate assessment of range of motion at ankle with the knee straight. I did not have this patient stand, as he requires maximum assistance to do so. The casting procedure went well. I spoke with his wife regarding the design of the device.

Fabricate left free-ankle brace AFO.

Thoracic Myelomeningeal - AFO Braces

RX:Bilateral solid-ankle AFOs. Orthopedic Surgeon Referral

Diagnosis:Thoracic myelomeningeal paraplegia and equinovarus contractures.

History:LATEX PRECAUTIONS were taken on this 4-year-old male today. He is taking Ditropan and a medication for an infection. He does not ambulate and sits by himself. He has not had surgery since his last visit, and he receives physical therapy at school. His previous devices were bilateral wraparound AFOs. I think that he would benefit more from a solid-ankle system with an anterior panel due to swelling. His feet are very chubby. Mom stated she had difficulty with the wraparound AFOs. She stated they pinched the front portion of his foot.

Evaluation:The patient has a scab and a cut on his left great toe. Mom stated this occurred approximately 1 month ago. It is healing. Range of motion on the left is 90 degrees. On the right, he is tighter, and range of motion is -5 degrees. He presents as a supinator on the right and pronator on the left. He has no clonus on either side. He has moderate tone on the right. He has no tone on the left. The orthotic goal today is to cast him and fit him with devices that will hold his foot in neutral alignment to give him support when he begins to stand.

Fabricate: bilateral solid-ankle AFOs.

AFO Pistoning Problem non Toe Walker

The patient was seen today for adjustments to her left SAFO and her right UCB. She was still getting pressure at the back of the heel on the right side. I believe she is pistoning inside the brace. I fared the proximal trimline in the heel section. I encouraged mom to tighten the shoelaces tighter. Mom is concerned because the patient is externally rotating her foot on the left as she walks. I noted that the strap that is on the posterior section of the SAFO was very tight. I loosened this to allow her more plantarflexion. The patient is not a toe walker therefore the strap is loose for her. She was also getting pressure on the navicular. This was heat relieved and I added a pad along the 5^{1 metatarsal to adduct her foot more in the brace. The patient ambulated for approximately 50 feet. Her gait looked improved. I told mom to monitor the areas to ensure that they do not get worse. Because they have turned into calluses, they would take time to dissipate. I advised her to put lotion on the patient's feet at night. This would help soften the calluses. Everything else appears appropriate. The patient will be seen as needed.

Adjust Broken Footplate /AFO Short Articulated

The patient was seen today for repair of a broken brace. The patient had a cracked right AFO-Short Articulated across the bottom of the footplate. It was completely broken off and being held together with duct tape. This was beyond repair, and we will need to fabricate a new one for him. The patient has no change in his medical condition since we last saw him. His left AFO-SA continues to do well. The brace is intact and his skin does not have any areas of irritation. I checked the skin on his right foot, and even though he has been wearing the broken brace, there are no areas of irritation or skin breakdown. We kept the right AFO-SA today and will duplicate this brace, as the patient has not been having any problems with it. We received a prescription for a new AFO.

HKAFO ADJUSTMENT

PROGRESS NOTE: Patient is seen today for fitting of his left lateral upright HKAFO attached to a right wraparound AFO. All trim lines brought back to appropriate height. All areas checked for pressure. No excess pressure was found. Scoop pads were placed in the braces bilaterally. The height of the HKAFO appeared appropriate. The shoe lift on the left side was slightly too tall for the patient. We will take these back and cut ¼ inch off from these so the patient can ambulate with a smoother gait. With the shoe lift on the left side he stands with the knee flexed. When he stands straight. The right leg is off the ground. We will shorten these, diffuse them and mail them to his parents. We will see the patient back in 2 weeks to ensure that the shoe lift is the correct height and everything is functioning well with the brace. He was told to monitor his skin for any red marks and to ensure that they dissipate within 30 minutes. He was instructed if they did not, to stop wearing the braces and to schedule a return visit for adjustment.

Tuberous Sclerosis - Bilateral AFO Wrap Arounds

RX: Tuberous sclerosis.

HISTORY: This 19-month-old male has no allergies, has not had any surgeries and currently takes phenobarbital. He receives physical therapy 2 to 3 times per month at home. The patient reports that he has a rotating therapy schedule with occupation and speech therapy also. The patient is cruising and pulling to stand. He has not had previous devices.

EVALUATION:The patient presents with pronated feet bilaterally. His heels are in valgus and his forefeet are abducted. This is exaggerated upon weightbearing. He has mild tone and no clonus. Range of motion at his ankles is to 90 degrees with his knees straight. His knees and hips are normal. He has no gait to evaluate.

LAB: Fabricate bilateral AFO-Wrap Arounds

Dandy-Walker Syndrome - SAFO's

RX: Bilateral Solid Ankle AFO’s

DIAGNOSIS: Dandy-Walker Syndrome

HISTORY: Patient is an 8 ½ year old male with no allergies. He has had brain surgery along with multiple shunts. He walks with minimal assistance. He receives PT 3x weekly, and he has worn SMO’s in the past.

ASSESSMENT: The patient is a moderate pronator bilaterally with normal tone. His calcaneus is everted and his forefoot is abducted. These abnormalities were corrected as much as possible during the casting procedure. Our orthotic goal is to maintain the ML plane at the ankle as well as stabilize standing.

PLAN: Fabricate bilateral SAFO’s

OA Knee Braces - Load Shifting or Shiftless Loading

Monarch Beach - Lonnie Paulos, MD delivered a speech last week at the St. Regis Resort to a group of orthopedic specialists about the effectiveness of unloading braces.

Dr Paulos said that the #1 indication for prescribing load shifting braces is arthritis of the knee (Esp. Osteoarthritis -OA), and yes, based on all the literature, shoe wedges and knee braces do work to lessen pain.

The following is more from Dr. Paulos's presentation.

What is knee OA? It is the articular cartilage breakdown or loss (smooth lining that covers bone to decrease joint friction. OA can occur in the medial and/or lateral comparment of the knee joint.

The prevalence of knee OA is 12% overall in the USA and begins in the 4th decade, increasing in prevalence with age. OA affects women at a younger age, but is more prevalent in men. The risk factors for knee OA are advancing age, genetic make-up, gender, and hormonal status. Dr. Paulos also includes developmental deformity, muscle weakness that limits flexibility, decreased joint proprioception, obesity, join overuse or injury from repetitive activity, and poor nutrition as potential causes of knee OA.

Sports also can induce knee OA. Dr. Paulos stated that moderate running showed no risk unless the runner had been injured or had a structural abnormality, and that the evidence of OA in older runners was similar to that of non-runners. The highest prevalence of OA, especially at the elite level, was in soccer, and that the risk of hip and knee arthrosis is high with injuries excluded. Weightlifters had a positive risk for patella femoral OA possibly due to body mss and squatting maneuvers.

There is a problem. Arthritis is America's new epidemic. 1 in 5 Americans have arthritis, and OA affects an estimated 20.7 million Americans. OA is the leading cause of disability in the United States.

What are the treatments? A few are to self-medicate, on-line advice, friends, family practice/primary care, rheumatologists, and or surgeon.

Pharmacological Treatments? acetaminophen, NSAID's, analgesics/topicals (Dr. Paulos seemed especially fond of topicals), intra-articular injections (viscosupplementation / HA Supartz, Hyalgan, Synvisc, Orthovisc, Euflexya) cortisone or steroidal, nutriceuticals/supplements.

Non-pharma & nonsurgical interventions? A few would be orthopedic devices (canes, orthotic wedges, and braces).

Surgical intervention? Athroscopy debridement with a osteochondral transplant known as an OAT's procedure. Tissue engineering (Genzyme/Carticel) known as autologous chondrocyte implantation. In this procedure the surgeon removes a small healthy tissue sample and cultures it in the lab for 4-6 weeks. The cells are implanted to cover the defect with membrane. Adhesion occurs with fibrin glue. High tibilal osteotomy and uni/total knee arthroplasty are other surgical procedures.

Patient education: modify risk factors by decreasing frequency and intensty or a complete change in activity, rehabilitation, fitness (lose weight) assistive devices and bracing.

Obesity is a leading cause of OA. The forces across the knee is 3 times the body weight with each step - 10 times with stairs. Weight loss of 11 pounds can decrease OA by 50% with the strongest effect in women and a stonger correlation for weight loss than gain.

Physical Therapy can improve joint ROM and periarticular muscle strength, improve joint proprioception, and develop exercise habit. The exercise habit in increase strength, endurance and flexibility. Exercise will optimize weight, protect joints through improved biomechanics, improve cardio vascular function and a state of well-being.

Orthotics and Braces: heel wedges, heel and sole wedges, brace, sleeve, valgus or varus-producing functional brace, Biona-Care - electromagnet sleeves.

Knee Arthritis - Orthotic Treatment: The literature indicates that patients with mild knee OA did best with an in-shoe heel and sole wedge 1/8 - 1/4". Their pain scores decreased while their functional scores increased

Knee Arthritis -Bracing - Fact and Fiction: Hypothesis - by unloading an arthritic compartment of the knee...patients will experience less pain:increased activity. How does OA bracing reduce symptoms associated with compartmental osteoarthritis? It does so by creating an externally applied three point bending moment tht reduces contact pressure, reducing OA pain. The longer the brace the greater magnitude of the brace., and regardless of brace design ratonale (push or pull) the mechanics of three-point bending are identical.

Do Braces Really Work? - An emphatic - YES! All studies evaluating medial OA using valgus producing knee braces found that biomechanical unloading occurs, and that pain scores decreased and functional scores increased. But not all braces a created equal! Our surrogate studies (Finger and Paulos) have shown that DonJoy's OAadjuster to be 3 times more effective in load shifting, and is why I use the OAadjuster for my moderate unicompartmental OA patients who want to remain active.

The Most Important Use of the OAadjuster? I use the OAadjuster for my varus or valgus osteotomy patients to protect their ligament, meniscal, chondral or osseous procedures over a finite period of time.

Summary - Load shifting braces work to control coupled motions, shift the load where desired, and work best at full extension. DonJoy's line of OA braces allow me to match the product with the patient for best results.

Thank You - Lonnie Paulos, MD

Delivery of Bilateral Shoe Orthotics

Patient here today for delivery of bilateral foot orthotics. A good fit was achieved. Proper donning and doffing instructions were given. A gradual wearing schedule was discussed and agreed upon increasing by 2 hours daily. Explained to patients mother that if child developed any red marks that did not go away within 30 minuts to contact our office for adjustmen. Patient ambulated in the office and the alignment looked good. Patient stated that orthotics felt comfortable. Patient will be seen as needed.

Bilateral Ankle Foot Orthosis - Pressure Left Medial Malleolous

Patient was getting pressure on the left medial malleolous as well as some forefoot abduction occuring in brace. A pad was added along the shaft of the 5th metatarsa, and the area around the medial malleolous was heat relieved. Redonned the orthosis and everything appeared appropriate. Patient was not being pinched by the plastic, and his foot pposition in-brace was much improved.

Solid-Ankle AFO's

DIAGNOSIS: Cerebral palsy and diplegia

RX: Bilateral solid-ankle AFO's

HISTORY: 14-year-old female has no known allergies, and is not taking any medication. She has not had surgery and receives PT at school. She currently has bilateral AFO-SA's with compcore reinforcement at the ankles, and ambulates using a forearm-supported walker.

ASSESSMENT: Presents with fairly neutral feet bilaterally. Her heels rest in neutral and her forfeet are adducted; however, upon weightbearing she pronates mildly with her heels in valgus and her forfeet to neutral. ROM at her ankle mordus is to 90 degrees with her knees flexed. She exhibits mild tone and no clonus, Bilaterally she internally rotates greater on thre right than on the left. Casted her today for bilateral AFO's.

ORTHOTIC GOAL: Maintenance of patient's foot alignment in a neutral position and to prevent him from falling into pronation attempting to relieve left knee and bilateral ankle pain.

PLAN: Fabricate bilateral AFO's SA with compcore reinforce.

Insoles with Custom Shoes - 5th Toe Amputation

DIAGNOSIS: Diabetes and osteomyelitis and 5th toe amputation left foot.

RX: Shoes and insoles

HISTORY: 58-year-old female no known allergies, diabetic 5th toe amputation due to infection. Patient presents with residual Charcot joint with a history of previous ulcerations. Her skin integrity is good. She has neuropathy below the knee bilaterally. Patient can dorsiflex to 90 degrees bilaterally, but the left foot only dorsiflexes to 90 degrees through pronation by pronating. She has pitting edema bilaterally.

ORTHOTIC GOAL: To protect the foot from mechanical stresses and shear forces.

PLAN: Fabricate bilateral total-contact insoles with custom shoes. Custom shoes chosen because of the difference between the left and right feet.

Osteoarthritis Shoe Insert with Wedge for Knee Pain

Have had several patients with medial OA knee pain who were unable or unwilling to wear knee braces, but wanted to put off getting a total knee. I fabricate a 3/16" lateral heel and sole wedge and glue it to the lateral border of super thin and flexible carbon fiber (cf) plate we fabricate. The cf insert is better than a leather insert because it doesn't deform and will spread the vertical and surface load more evenly. The insert fits into a shoe with little problem. The user can usually can tell immediately if the OA wedge helps relieve their knee pain.

Boston Overlap Brace

Have an athlete with a pars fracture I am fitting with a Boston Brace (BOB) this afternoon. I use the B.O.B. because it has respected research papers I can give to the parents.