Foot orthosis and shoe modifications

Foot orthoses (FOs) normalize the foot’s architecture and function. The primary goal is to redistribute the forces experienced by the foot during the stance phase of weight bearing. If correction of the foot is not feasible, the FO may be prescribed to accommodate for foot abnormalities. Common causes of foot abnormalities include neuropathy, architectural bone changes, and muscle dysfunction.

Prescribing a FO requires an understanding of the diagnosis, its impact on the function and form of the foot, the desired biomechanical correction or accommodation, and patient characteristics, such as the patient’s weight, activity level, and other comorbidities.

A foot orthosis is composed of three basic layers ( Fig. 1 ). A firm base functions to support or control the foot structure and achieve or maintain normal alignment. If normal alignment is not achievable, the FO should effectively accommodate the abnormality. A moderately dense middle layer functions as a shock absorber. A soft layer or covering is applied to prevent shearing of the plantar aspect of the foot and aids in pressure identification.

Accomodative foot orthotic.

FOs and shoe modifications are indicated in many clinical scenarios. Leg length discrepancy is a common clinical problem. Treatment goals include equalizing limb length, creating a more symmetric posture, and improving gait. If the leg length discrepancy is greater than 1 inch, the correction should be placed on the outside heel and sole of the shoe. However, if a discrepancy of 0.5 to 1 inch is present, modification of the external heel is appropriate. If the discrepancy is less than 0.5 inch, no correction is typically needed unless the patient is symptomatic.

In the case of subtalar joint arthritis, fusion, or instability, the goals are pain relief through limiting joint motion, joint support, and accommodation of deformities. Treatment options include a high-quarter shoe with reinforced counters, long steel shank, rocker sole, and a shock-absorbing cushioned heel. The steel shank decreases joint motion and reduces pain. A rocker sole modification facilitates forward progression during stance and reduces the duration of weight bearing. FOs with a soft layer for comfort and a semirigid layer for support are also helpful.

Pes planovalgus deformity requires reduction in eversion coupled with support of the longitudinal arch. Children are effectively treated with a high-quarter shoe with broad heel, long medial counter, and medial heel wedge. Adults do well with a Thomas heel and medial heel wedge. The FO should be designed to provide medial longitudinal arch support.

The treatment goals for pes cavus deformity include redistributing the weight-bearing over the entire foot to reduce pressure at the metatarsals. In addition to high-quarter shoes with a high toe box, lateral heel, and sole wedging, the FO should include metatarsal relief and medial and lateral longitudinal arch support.

The treatment goals for a fixed pes equinus deformity include the provision of heel strike, containment of the foot in the shoe, and reduction of pressure at the metatarsal heads. If the condition is unilateral, another goal is leg-length equalization. In addition to prescribing a FO with medial longitudinal arch support, a high-quarter shoe with heel elevation, modified lace stay for wide opening, and possible addition of a rocker bar on the sole of the shoe may also be used.

In the case of pes varus, the treatment goal depends on whether the foot is flexible or fixed. With a flexible deformity, the goal is achieving normal alignment. However, if the deformity is fixed, a prescription for a FO and a shoe that accommodates the foot abnormalities is indicated.

Metatarsalgia, painful metatarsal heads, is managed through reducing pressure over the metatarsal heads and supporting the transverse arch. The FO can be fabricated with a metatarsal pad or sesamoid pad to alleviate pressure over the painful metatarsals. Effective shoe modifications include a metatarsal bar or rocker sole.

Hallux valgus is a common deformity. Treatment focuses on reducing pressure on the first metatarsophalangeal joint and great toe by preventing forward foot slide. Pain is also reduced by immobilizing the first metatarsophalangeal and shifting weight to the lateral foot. Shoes that accommodate the deformity are critical and include a shoe with a soft vamp and broad ball and toe box. In more difficult cases, a relief in vamp with cutout or balloon patch is needed coupled with a low-heeled, stiff-soled shoe with rocker bottom. FO prescription should indicate a metatarsal or sesamoid pad to increase the transverse arch, and a medial longitudinal arch support.

Hallux rigidus, restricted motion at the metatarsophalangeal joint of the great toe, results from degenerative arthritis, faulty biomechanics, or structural abnormalities of the foot. Treatment goals include reducing motion or pressure at the first metatarsophalangeal joint and facilitating push-off. A shoe with a stiff sole or modification to increase the stiffness of the foot’s sole reduces pain. The FO should include a sesamoid pad and medial longitudinal arch support.

Foot fractures require immobilization. Depending on the location of the fracture, devices such as a walking cast or off-the-shelf walking boots may be required. Post-fracture healing shoes with a long steel shank to provide rigidity, longitudinal arch support, and metatarsal relief may be necessary.

Diabetes is a common disease, with diabetic peripheral neuropathy a common complication that can lead to insensate foot and even amputation. The treatment goal is to protect the foot and its structure, provide appropriate support, and accommodate any fixed deformities. Custom FOs are prescribed to protect the foot through equalizing weight-bearing pressure over the entire foot, minimizing shear, and accommodating any structural abnormalities. Extra-depth shoes allow extra room in the toe box for hammering or clawing of toes common in peripheral neuropathy.

Charcot foot refers to architectural changes caused by neuropathic disorders, such as diabetes mellitus, alcoholic neuropathy, or syphilis. During the inflammatory phase, a custom bivalved ambulatory AFO is indicated until the chronic phase is reached ( Fig. 2 ).

Bivalved ambulatory walking boot.

Chronic architectural changes typically result. Treatment requires accommodation of the resulting fixed deformities. Custom deer skin shoes may be required ( Fig. 3 ).

Extra-depth, extra-wide deerskin oxford shoe with rockered sole.

Custom FO should be designed to appropriately distribute weight-bearing forces.

Ankle foot orthosis

AFOs are most commonly prescribed for lower-extremity weakness, such as dorsiflexion or plantar flexion weakness. AFOs are also used to control medial lateral instability or reduce axial loading of the leg. Because ankle plantar flexion facilitates an extension moment at the knee, an AFO can be used to control knee extension. One must remember that although an AFO does not control the knee, it can strongly influence knee function.

AFOs with sagittal control systems influence plantar and dorsiflexion ( Fig. 4 and Table 1 ). The floor-reaction AFO uses ground reaction forces to stabilize ankle mortise and creates an extension moment at the knee, resulting in stability ( Fig. 5 ).

Articulated polypropylene AFO.

Floor reaction AFO.

Less commonly seen is the patellar tendon–bearing AFO that provides axial unloading through incorporating a patellar tendon bar to accept the forces at the ankle ( Fig. 6 ).

Patellar tendon–bearing-type AFO.

A prescription for an AFO may or may not order an ankle joint. An AFO may include a joint to allow dorsiflexion or plantar flexion of varying degrees. A solid ankle in an orthosis prevents ankle motion in all directions. A stop, which is a static mechanical unit, can be added to an orthosis to inhibit an undesired motion ( Table 2 ).

The common option when an ankle joint is not needed is the leaf spring design, commonly used for flaccid foot drop ( Fig. 7 A). A solid ankle AFO is indicated if medial lateral ankle instability, ankle fusion, or ankle pain with gait is present, or in cases of diffuse lower-extremity weakness ( Fig. 7 B). These AFOs do not include an external ankle joint.

( A ) Flexible or posterior leaf spring design polypropylene AFO. ( B ) Solid ankle polypropylene AFO.

An AFO can be designed to provide control in the coronal plane. Medial and lateral control is achieved in metal and leather AFOs through incorporating a T-strap at the ankle to direct the ankle in a varus or valgus direction. AFOs made of plastic use a valgus correction (sustentaculum tali modification) or a plastic extension medially/laterally above the ankle to control varus and valgus motion. Additionally, a high medial or lateral trim line on the foot plate can also be used. If an AFO is laminated, the rigid characteristics of lamination provide coronal control.

Knee ankle foot orthoses

During gait, the primary functions of the knee are shock absorption, stable support during stance, and limb shortening during the swing phase of ambulation. When an external device is needed to augment the function of the knee and ankle, a KAFO is prescribed. If the problem is limited to the knee alone, a KO is typically prescribed.

Multiple types of KOs are available commercially, which are used to provide medial or lateral stability at the knee ( Fig. 8 ).

Knee orthosis, Swedish knee.

KAFOs are typically hybrid orthoses made of metal and plastic with a metal knee joint incorporated. Whenever possible, plastic components are preferred over metal or leather to reduce the weight of the orthosis. Plastics can be used to produce a more intimate fit. Carbon fiber is increasingly being used because it is a strong rigid material but is lightweight. Unlike some plastics, carbon fiber cannot be reheated to allow for remolding, and therefore fit must be precise.

Indications for a KAFO are myriad. KAFOs are most typically prescribed for lower-extremity paralysis or weakness, knee instability, and extension spasticity caused by an upper motor neuron lesion. Components include proximal and distal thigh cuff, calf band, double or single upright metal supports, and metal knee and ankle joints. The orthosis can be made with an unrestricted ankle allowing full dorsiflexion and plantar flexion. Single upright KAFOs are often used for knee instability. The single upright can be placed medially or laterally. For genu valgum, the upright is placed laterally, and medially for genu varus.

Variations exist on the basic design, and various knee locking mechanisms can be chosen. Although double metal uprights provide more stability compared with a single upright, one must consider whether the additional stability outweighs the disadvantage of added weight and bulk.

An orthosis with a free knee does not inhibit knee flexion or extension; however, stops, or mechanical devices that block motion, can be incorporated to limit ROM if required, such as after knee surgery. Variable units that allow for adjusting the orthotic knee ROM are also available.

In addition to evaluating the lower-extremity dysfunction and function the KAFO can provide, one must also consider the other functional problems and comorbidities that may be present. For instance, patients who require a high level of stability for standing and ambulating but have poor, impaired upper-extremity fine motor function would benefit from a KAFO with a bail lock for locking and unlocking the knee ( Fig. 9 ).

Locking knee ankle orthosis with bail lock release.

Stance-control knees are available. These devices lock once heel strike is achieved and release with toe-off. Typically these devices require hip extension strength of a least fair plus to extend the leg to activate the stance control.

Although total unloading of the lower extremity with a KAFO is not possible, a quadrilateral brim (ie, a plastic thigh portion that extends to the ischial tuberosity) can accept the load of weight-bearing. This device is similar to the quadrilateral socket used in a transfemoral amputation prosthesis.

Lastly, a KAFO can serve as an adjunct to exercise and other therapeutic modalities. A KAFO with a dial lock can maintain a prolonged stretch to treat a knee contracture ( Table 3 ).

Hip orthosis

Hip orthoses are used for hip flexion, extension, abduction, and adduction. They are not effective for controlling hip external and internal rotation, but are frequently used after hip arthroplasty and surgical correction of the hip to control hip adduction. If control rotation at the hip is indicated, the orthosis must be converted to a hip knee ankle foot orthosis (HKAFO) to allow further control.

Hip knee ankle foot orthoses

HKAFOs controls flexion, extension, abduction, and adduction, and also hip rotation through the below-the-knee components and the foot plate. These orthoses provide maximal support of the lower extremities. They are used in cases of paraplegia from spinal cord injury, poliomyelitis, or other causes. These also allow upright standing and ambulation with a walker and swing-to or swing-through gait pattern.

Essentially an HKAFO is a KAFO with a pelvic band and hip joint added. They are heavy and cumbersome, although the advent of lighter weight materials has helped. These orthoses cause high energy consumption during gait .

A reciprocating gait orthoses is also known as a lumbosacral HKAFO with cables. The cable system couples the flexion and extension of the bilateral hips. This coupling results in extension of the contralateral hip when the other hip is flexed. A release mechanism to allow simultaneous hip flexion is incorporated. This design has been shown to decrease energy expenditure and increase ambulation speed and distance in the community .

Foot orthosis and shoe modifications

Foot orthoses (FOs) normalize the foot’s architecture and function. The primary goal is to redistribute the forces experienced by the foot during the stance phase of weight bearing. If correction of the foot is not feasible, the FO may be prescribed to accommodate for foot abnormalities. Common causes of foot abnormalities include neuropathy, architectural bone changes, and muscle dysfunction.

Prescribing a FO requires an understanding of the diagnosis, its impact on the function and form of the foot, the desired biomechanical correction or accommodation, and patient characteristics, such as the patient’s weight, activity level, and other comorbidities.

A foot orthosis is composed of three basic layers ( Fig. 1 ). A firm base functions to support or control the foot structure and achieve or maintain normal alignment. If normal alignment is not achievable, the FO should effectively accommodate the abnormality. A moderately dense middle layer functions as a shock absorber. A soft layer or covering is applied to prevent shearing of the plantar aspect of the foot and aids in pressure identification.

Accomodative foot orthotic.

FOs and shoe modifications are indicated in many clinical scenarios. Leg length discrepancy is a common clinical problem. Treatment goals include equalizing limb length, creating a more symmetric posture, and improving gait. If the leg length discrepancy is greater than 1 inch, the correction should be placed on the outside heel and sole of the shoe. However, if a discrepancy of 0.5 to 1 inch is present, modification of the external heel is appropriate. If the discrepancy is less than 0.5 inch, no correction is typically needed unless the patient is symptomatic.

In the case of subtalar joint arthritis, fusion, or instability, the goals are pain relief through limiting joint motion, joint support, and accommodation of deformities. Treatment options include a high-quarter shoe with reinforced counters, long steel shank, rocker sole, and a shock-absorbing cushioned heel. The steel shank decreases joint motion and reduces pain. A rocker sole modification facilitates forward progression during stance and reduces the duration of weight bearing. FOs with a soft layer for comfort and a semirigid layer for support are also helpful.

Pes planovalgus deformity requires reduction in eversion coupled with support of the longitudinal arch. Children are effectively treated with a high-quarter shoe with broad heel, long medial counter, and medial heel wedge. Adults do well with a Thomas heel and medial heel wedge. The FO should be designed to provide medial longitudinal arch support.

The treatment goals for pes cavus deformity include redistributing the weight-bearing over the entire foot to reduce pressure at the metatarsals. In addition to high-quarter shoes with a high toe box, lateral heel, and sole wedging, the FO should include metatarsal relief and medial and lateral longitudinal arch support.

The treatment goals for a fixed pes equinus deformity include the provision of heel strike, containment of the foot in the shoe, and reduction of pressure at the metatarsal heads. If the condition is unilateral, another goal is leg-length equalization. In addition to prescribing a FO with medial longitudinal arch support, a high-quarter shoe with heel elevation, modified lace stay for wide opening, and possible addition of a rocker bar on the sole of the shoe may also be used.

In the case of pes varus, the treatment goal depends on whether the foot is flexible or fixed. With a flexible deformity, the goal is achieving normal alignment. However, if the deformity is fixed, a prescription for a FO and a shoe that accommodates the foot abnormalities is indicated.

Metatarsalgia, painful metatarsal heads, is managed through reducing pressure over the metatarsal heads and supporting the transverse arch. The FO can be fabricated with a metatarsal pad or sesamoid pad to alleviate pressure over the painful metatarsals. Effective shoe modifications include a metatarsal bar or rocker sole.

Hallux valgus is a common deformity. Treatment focuses on reducing pressure on the first metatarsophalangeal joint and great toe by preventing forward foot slide. Pain is also reduced by immobilizing the first metatarsophalangeal and shifting weight to the lateral foot. Shoes that accommodate the deformity are critical and include a shoe with a soft vamp and broad ball and toe box. In more difficult cases, a relief in vamp with cutout or balloon patch is needed coupled with a low-heeled, stiff-soled shoe with rocker bottom. FO prescription should indicate a metatarsal or sesamoid pad to increase the transverse arch, and a medial longitudinal arch support.

Hallux rigidus, restricted motion at the metatarsophalangeal joint of the great toe, results from degenerative arthritis, faulty biomechanics, or structural abnormalities of the foot. Treatment goals include reducing motion or pressure at the first metatarsophalangeal joint and facilitating push-off. A shoe with a stiff sole or modification to increase the stiffness of the foot’s sole reduces pain. The FO should include a sesamoid pad and medial longitudinal arch support.

Foot fractures require immobilization. Depending on the location of the fracture, devices such as a walking cast or off-the-shelf walking boots may be required. Post-fracture healing shoes with a long steel shank to provide rigidity, longitudinal arch support, and metatarsal relief may be necessary.

Diabetes is a common disease, with diabetic peripheral neuropathy a common complication that can lead to insensate foot and even amputation. The treatment goal is to protect the foot and its structure, provide appropriate support, and accommodate any fixed deformities. Custom FOs are prescribed to protect the foot through equalizing weight-bearing pressure over the entire foot, minimizing shear, and accommodating any structural abnormalities. Extra-depth shoes allow extra room in the toe box for hammering or clawing of toes common in peripheral neuropathy.

Charcot foot refers to architectural changes caused by neuropathic disorders, such as diabetes mellitus, alcoholic neuropathy, or syphilis. During the inflammatory phase, a custom bivalved ambulatory AFO is indicated until the chronic phase is reached ( Fig. 2 ).

Bivalved ambulatory walking boot.

Chronic architectural changes typically result. Treatment requires accommodation of the resulting fixed deformities. Custom deer skin shoes may be required ( Fig. 3 ).

Extra-depth, extra-wide deerskin oxford shoe with rockered sole.

Custom FO should be designed to appropriately distribute weight-bearing forces.

Ankle foot orthosis

AFOs are most commonly prescribed for lower-extremity weakness, such as dorsiflexion or plantar flexion weakness. AFOs are also used to control medial lateral instability or reduce axial loading of the leg. Because ankle plantar flexion facilitates an extension moment at the knee, an AFO can be used to control knee extension. One must remember that although an AFO does not control the knee, it can strongly influence knee function.

AFOs with sagittal control systems influence plantar and dorsiflexion ( Fig. 4 and Table 1 ). The floor-reaction AFO uses ground reaction forces to stabilize ankle mortise and creates an extension moment at the knee, resulting in stability ( Fig. 5 ).

Articulated polypropylene AFO.

Floor reaction AFO.

Less commonly seen is the patellar tendon–bearing AFO that provides axial unloading through incorporating a patellar tendon bar to accept the forces at the ankle ( Fig. 6 ).

Patellar tendon–bearing-type AFO.

A prescription for an AFO may or may not order an ankle joint. An AFO may include a joint to allow dorsiflexion or plantar flexion of varying degrees. A solid ankle in an orthosis prevents ankle motion in all directions. A stop, which is a static mechanical unit, can be added to an orthosis to inhibit an undesired motion ( Table 2 ).

The common option when an ankle joint is not needed is the leaf spring design, commonly used for flaccid foot drop ( Fig. 7 A). A solid ankle AFO is indicated if medial lateral ankle instability, ankle fusion, or ankle pain with gait is present, or in cases of diffuse lower-extremity weakness ( Fig. 7 B). These AFOs do not include an external ankle joint.

( A ) Flexible or posterior leaf spring design polypropylene AFO. ( B ) Solid ankle polypropylene AFO.

An AFO can be designed to provide control in the coronal plane. Medial and lateral control is achieved in metal and leather AFOs through incorporating a T-strap at the ankle to direct the ankle in a varus or valgus direction. AFOs made of plastic use a valgus correction (sustentaculum tali modification) or a plastic extension medially/laterally above the ankle to control varus and valgus motion. Additionally, a high medial or lateral trim line on the foot plate can also be used. If an AFO is laminated, the rigid characteristics of lamination provide coronal control.

Knee ankle foot orthoses

During gait, the primary functions of the knee are shock absorption, stable support during stance, and limb shortening during the swing phase of ambulation. When an external device is needed to augment the function of the knee and ankle, a KAFO is prescribed. If the problem is limited to the knee alone, a KO is typically prescribed.

Multiple types of KOs are available commercially, which are used to provide medial or lateral stability at the knee ( Fig. 8 ).

Knee orthosis, Swedish knee.

KAFOs are typically hybrid orthoses made of metal and plastic with a metal knee joint incorporated. Whenever possible, plastic components are preferred over metal or leather to reduce the weight of the orthosis. Plastics can be used to produce a more intimate fit. Carbon fiber is increasingly being used because it is a strong rigid material but is lightweight. Unlike some plastics, carbon fiber cannot be reheated to allow for remolding, and therefore fit must be precise.

Indications for a KAFO are myriad. KAFOs are most typically prescribed for lower-extremity paralysis or weakness, knee instability, and extension spasticity caused by an upper motor neuron lesion. Components include proximal and distal thigh cuff, calf band, double or single upright metal supports, and metal knee and ankle joints. The orthosis can be made with an unrestricted ankle allowing full dorsiflexion and plantar flexion. Single upright KAFOs are often used for knee instability. The single upright can be placed medially or laterally. For genu valgum, the upright is placed laterally, and medially for genu varus.

Variations exist on the basic design, and various knee locking mechanisms can be chosen. Although double metal uprights provide more stability compared with a single upright, one must consider whether the additional stability outweighs the disadvantage of added weight and bulk.

An orthosis with a free knee does not inhibit knee flexion or extension; however, stops, or mechanical devices that block motion, can be incorporated to limit ROM if required, such as after knee surgery. Variable units that allow for adjusting the orthotic knee ROM are also available.

In addition to evaluating the lower-extremity dysfunction and function the KAFO can provide, one must also consider the other functional problems and comorbidities that may be present. For instance, patients who require a high level of stability for standing and ambulating but have poor, impaired upper-extremity fine motor function would benefit from a KAFO with a bail lock for locking and unlocking the knee ( Fig. 9 ).

Locking knee ankle orthosis with bail lock release.

Stance-control knees are available. These devices lock once heel strike is achieved and release with toe-off. Typically these devices require hip extension strength of a least fair plus to extend the leg to activate the stance control.

Although total unloading of the lower extremity with a KAFO is not possible, a quadrilateral brim (ie, a plastic thigh portion that extends to the ischial tuberosity) can accept the load of weight-bearing. This device is similar to the quadrilateral socket used in a transfemoral amputation prosthesis.

Lastly, a KAFO can serve as an adjunct to exercise and other therapeutic modalities. A KAFO with a dial lock can maintain a prolonged stretch to treat a knee contracture ( Table 3 ).

Hip orthosis

Hip orthoses are used for hip flexion, extension, abduction, and adduction. They are not effective for controlling hip external and internal rotation, but are frequently used after hip arthroplasty and surgical correction of the hip to control hip adduction. If control rotation at the hip is indicated, the orthosis must be converted to a hip knee ankle foot orthosis (HKAFO) to allow further control.

Hip knee ankle foot orthoses

HKAFOs controls flexion, extension, abduction, and adduction, and also hip rotation through the below-the-knee components and the foot plate. These orthoses provide maximal support of the lower extremities. They are used in cases of paraplegia from spinal cord injury, poliomyelitis, or other causes. These also allow upright standing and ambulation with a walker and swing-to or swing-through gait pattern.

Essentially an HKAFO is a KAFO with a pelvic band and hip joint added. They are heavy and cumbersome, although the advent of lighter weight materials has helped. These orthoses cause high energy consumption during gait .

A reciprocating gait orthoses is also known as a lumbosacral HKAFO with cables. The cable system couples the flexion and extension of the bilateral hips. This coupling results in extension of the contralateral hip when the other hip is flexed. A release mechanism to allow simultaneous hip flexion is incorporated. This design has been shown to decrease energy expenditure and increase ambulation speed and distance in the community .

Cervical orthoses

The cervical spine is the most mobile part of the spinal column. C5-C6 is the site of greatest cervical flexion extension, whereas the atlantoaxial joint (C1-C2) is the location of greatest cervical rotation. In addition, the neck functions in multiple planes of flexion, extension, rotation, and lateral bending. It is a small surface area on which to purchase an external device and deliver the indicated forces for effective treatment.

Like other orthoses, spinal orthoses increase stability or function though application of external forces. The three-point force system, the practice of directing two forces in opposition to the third, is the foundation of achieving spinal control and position.

Most COs are made of metal or plastic and function primarily to immobilize the cervical spine. They also relieve pain, reduce deformity, restrict undesired motion, substitute for weak muscles, and support soft tissues and fracture healing. Spinal instability is a contraindication for a spinal orthosis, except the halo cervical thoracic orthosis, which is used selectively for cervical injury.

Prefabricated COs are available in soft or rigid designs. A soft cervical orthosis provides sensory feedback to the patient, but provide virtually no control of cervical motion.

Multiple rigid or hard cervical orthoses are commercially available. They provide some sagittal plane motion but little coronal plane control. The Philadelphia collar is an example of a reinforced rigid collar, as are the Miami J and Aspen collars ( Fig. 10 ).

Rigid Aspen cervical collar.

To achieve better cervical control, two- or four-poster braces, which have rigid uprights, are available. In addition to the control that the uprights provide, pads are provided at the occiput, mandible, sternum, and thorax. Extensions can be added to increase control of the lower cervical spine.

Cervicothoracic orthoses

The sternal occipital mandibular orthosis (SOMI) is probably the most common prefabricated CTO. Components of this device include a shoulder unit with a sternal yoke, and mandibular and occipital pads and bars. This construction achieves adequate control in all planes, except extension. The SOMI can be used for adults and children.

To achieve triplanar control, a Halo CTO is often prescribed. The chest jacket provides the base of the orthosis, with the halo ring secured to the bone of the skull with pins. The halo, or ring, is affixed to the chest jacket with external supports or superstructure. This CTO does not cover the neck, and therefore postsurgical incisions and other wounds can be visually monitored.

Although the Halo allows some spinal snaking, this is intersegmental motion, and therefore rotational control is maintained. The Halo is commonly used for high cervical (C1, C2) spinal fractures.

A Halo orthosis provides immobilization using the long leverage of the three-point control. The skull is used as the end point of fixation. An advantage of newer Halo materials is that a Halo can be constructed of MRI-compatible materials.

Cervical orthoses are challenging to fit fabricate. These challenges include accurate fit, adequate purchase on the body, and providing the correct direction and magnitude of therapeutic forces while also considering the forces the body exerts in response. Body habitus and patient compliance can further complicate the process.

Lastly, no cervical orthosis completely eliminates cervical motion. For optimal fit and outcome, a well-trained orthotist or practitioner must fabricate and fit the orthosis. Poor fitting will not only prevent achievement of treatment goals but also may lead to further problems ( Table 4 ).