AFO Prescription - Measurement - Casting - Rectification & Fitting ICRC

International Committee of the Red Cross
AFO
Physical Rehabilitation Programme
Lower Limb Orthotics

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articles from different sources.
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published or sold.
The document is intended
STRICTLY for personal uses as a
training guide and/or reference.
Table of Contents
VII. RIGID AFO ....................................................................................................................... 221

7.1 INTRODUCTION .............................................................................................................. 221
7.2 INDICATIONS ................................................................................................................... 222
7.3 TYPES OF RIGID AFO..................................................................................................... 222
7.4 BIOMECHANICS.............................................................................................................. 222
7.5 MEASUREMENT .............................................................................................................. 229
7.6 CASTING ........................................................................................................................... 229
7.7 RECTIFICATION .............................................................................................................. 231
7.8 MANUFACTURING PROCEDURE ................................................................................. 233
7.9 DESIGN (TRIMLINE) ....................................................................................................... 234
7.10 FITTING............................................................................................................................. 235
VIII. FLEXIBLE AFO ............................................................................................................... 237

8.1 INDICATIONS ................................................................................................................... 237
8.2 TYPES OF FLEXIBLE AFO ............................................................................................. 237
8.3 BIOMECHANICS OF POSTERIOR LEAF SPRING AFOs ............................................ 240
8.4 MEASUREMENT .............................................................................................................. 243
8.5 CASTING ........................................................................................................................... 243
8.6 RECTIFICATION .............................................................................................................. 243
8.8 DESIGN (TRIMLINE) ....................................................................................................... 244
8.9 FITTING............................................................................................................................. 244
IX. JOINTED AFO ................................................................................................................. 245

9.1 INTRODUCTION .............................................................................................................. 245
9.2 INDICATIONS ................................................................................................................... 246
9.3 TYPES OF JOINTED AFOs............................................................................................. 246
9.4 BIOMECHANICS.............................................................................................................. 248
9.5 MEASUREMENT .............................................................................................................. 252
9.6 CASTING ........................................................................................................................... 252
9.7 RECTIFICATION .............................................................................................................. 252
9.9 DESIGN (TRIMLINE) ....................................................................................................... 254
9.10 FITTING............................................................................................................................. 254
X. GROUND REACTION AFO ............................................................................................ 255

10.1 INTRODUCTION .............................................................................................................. 255
Lower Limb Orthotics: Ankle Foot Orthoses Addis Ababa 2012 Version2 ii
10.2 INDICATIONS ................................................................................................................... 256
10.3 BIOMECHANICS.............................................................................................................. 257
10.4 MEASUREMENT .............................................................................................................. 259
10.5 CASTING ........................................................................................................................... 259
10.6 RECTIFICATION .............................................................................................................. 260
10.8 DESIGN (TRIMLINE) ....................................................................................................... 261
10.9 FITTING............................................................................................................................. 261
XI. PTB AFO ........................................................................................................................... 263

11.1 INTRODUCTION .............................................................................................................. 263
11.2 INDICATIONS ................................................................................................................... 263
11.3 TYPES................................................................................................................................ 264
11.4 BIOMECHANICS.............................................................................................................. 265
11.5 MEASUREMENT .............................................................................................................. 268
11.6 CASTING ........................................................................................................................... 268
11.7 RECTIFICATION .............................................................................................................. 270
11.9 DESIGN (TRIMLINE) ....................................................................................................... 272
11.10 FITTING............................................................................................................................. 272
ACKNOWLEDGEMENTS ................................................................................................................. 274
Lower Limb Orthotics: Ankle Foot Orthoses Addis Ababa 2012 Version2 iii
VII. RIGID AFO
7.1 INTRODUCTION
The Rigid ankle foot orthosis is designed to provide maximum

immobilization the ankle foot complex in all three planes of
motion. This AFO usually fabricated from thermoplastic
materials, encompasses as much of the lower leg and foot as
possible, without making it too difficult to don the orthosis.
A Rigid ankle foot orthosis is appropriate for a patient who
required total immobilization of the ankle foot complex to be
stable or functional in standing and during gait.
And also effectively provides Medio-lateral stability at the
ankle, prevent foot drop in swing by resisting plantar flexion,
controls hyper extension of knee (if set in a few degree of
dorsiflexion at ankle), controls hyper flexion of knee (if set in a
few degree of plantar flexion at ankle).
Main Functions of Rigid AFO

• Provides stance phase stability
• Offers Medio-lateral support for ankle instability
• Provides resistance to mild extensor spasticity
• Blocks fully the subtalar joint
• Controls abduction and adduction movements as well
• To relieve pain while supporting the weak extremities.
Lower Limb Orthotics: Ankle Foot Orthoses Addis Ababa 2012 Version2 221
7.2 INDICATIONS
• Instability of ankle and foot

• When decreased ankle motion is necessary
• Post-surgical immobilization
• Moderate to severe spasticity
• Protect an unstable midfoot
• (Child) Ready to stand but not walk
7.3 TYPES OF RIGID AFO
a) Rigid ankle foot orthosis total immobilization of ankle with or without heel raise
b) Rigid ankle foot orthosis total immobilization of ankle with controlling ankle Varus and fore foot
adduction
c) Rigid ankle foot orthosis total immobilization of ankle with controlling ankle Valgus and fore foot
abduction
7.4 BIOMECHANICS
Biomechanical Functions of Rigid AFOs

A molded Rigid AFO is used when maximal tibial restraint is required in order to prevent either
excessive ankle dorsiflexion or plantarflexion from occurring. The Rigid AFO design is also used to
control mediolateral instability at the subtalar joint. This type of AFO benefits the patient by facilitating
toe clearance during swing phase and optimally positioning the foot for heel-first initial contact
at heel strike.
The tibial restraint offered by this AFO presents some disadvantages. Transitional movements that
require ankle flexibility are compromised as a result of the rigid structure of this AFO. For example, a
patient moving from sitting to standing with a rigid AFO set at a neutral ankle position is likely to
experience difficulty initiating and executing this task as the patient will not be able to achieve the
dorsiflexed ankle position. To rise with an AFO set at a neutral angle, a patient needs to adopt a new
movement strategy that compensates for this mobility restraint.
In general, a Rigid AFO has the following functions:
• Provides maximal triplanar control of the ankle-foot complex
• Provides maximal stability during stance phase
• Aids with foot clearance during swing phase
• Controls knee during stance phase
Biomechanical Principles of Rigid AFOs

Ø 3 Point Pressure Control System
Ø GRF Control System
3 Point Pressure Control System

As shown in Figure 146, a rigid AFO design can incorporate four 3-point pressure systems to control
the ankle.
Figure 146: 3PP control systems in a molded rigid AFO.
1. The force system that provides resistance to plantar flexion in swing has a fulcrum at the
anterior ankle, with an upward counterforce on the plantar surface of the foot and anteriorly
directed counterforce at the proximal posterior aspect of the orthosis. For example, in Figure
146(A), plantar flexion is controlled during swing phase by a proximal force (FP) at the
posterior calf band and a distal force at the metatarsal heads (FD) that counter a centrally
located stabilizing force (FC) applied at the anterior ankle by shoe closure.
The foot section is designed to control excessive angular forces at the subtalar joints during
stance.
2. The second force system controls dorsiflexion during stance phase (and consequently
facilitates knee extension in stance): There is a compressive force on the ankle section of the
orthosis, an upward force of the sole of the foot, and a posteriorly directed force on the
anterior proximal tibia. Looking at Figure 146(B), for control of dorsiflexion during stance
phase (i.e., forward progression of tibia over the foot), FP is applied at the proximal tibia by the
anterior closure, FD at the dorsal surface of the metatarsal heads by the toe box of the shoe,
and counterforce FC at the heel, snugly fit in the orthosis.
3. The fulcrum of the valgus/eversion control system is a laterally directed force applied to the
distal tibia and calcaneus just proximal to the medial malleolus, with two medially directed
counterforces applied just below the fibular head proximally and at the lateral foot distally. In
Figure 146(C), the force system for eversion (valgus) locates FD along the fifth metatarsal, FP
at the proximal lateral calf band, and FC on either side of the medial malleolus.
Control in the transverse plane is also determined by the trimlines of the foot section.
Midtarsal joint deformity and the resultant forefoot abduction or adduction can be effectively
countered with trimlines that strategically encompass the shafts of the first and fifth
metatarsals.
4. The fulcrum of the varus/inversion control system is a medially directed force applied to the
distal fibula and calcaneus across the lateral malleolus, with two laterally directed
counterforces applied at the proximal medial tibia and the medial foot. In Figure 146(D), FD is
applied by the distal medial wall of the orthosis against the first metatarsal, FP at the proximal
medial calf band, and FC at the distal lateral tibia and calcaneus/ talus, on either side of the
lateral malleolus. These forces are therefore used to control inversion (varus) of the foot and
ankle.
Because a rigid AFO uses 3PP control systems to hold the ankle joint in a fixed position, this type of
AFO is appropriate for patients who require total immobilization of the ankle-foot complex in
order to be stable or functional in standing and during gait. The rigid AFO:
• Effectively provides mediolateral stability at the ankle
• Prevents foot drop in swing by resisting plantarflexion
• Controls hyperextension of the knee (if set in a few degrees of dorsiflexion at the ankle)
• Controls hyperflexion of the knee (if set in a few degrees of plantar flexion)
• Assists terminal stance by preventing collapse the ankle joint into dorsiflexion at the end of
stance
GRF Control Systems
Since a Rigid AFO blocks the anatomical ankle joint of the patient, the ground reaction force (GRF)
creates a moment about the knee joint during stance phase of the gait cycle.
1. Initial Contact to Foot Flat (First Rocker of the Foot)
The following figure shows how a a GRF control system can be employed in a rigid AFO to
prevent knee hyperextension at weight acceptance: the rigid AFO blocks plantarflexion at the
ankle at initial contact in the stance phase of the gait cycle; the tibia is then forced to rotate
anteriorly to achieve foot flat and the action of the GRF is transferred to the knee joint creating
a flexion moment.
2. Midstance
In normal gait (Figure 147A), knee stability at midstance is assisted by a ground reaction
moment as the body moves over the foot, and the ground reaction force vector passes
anterior to the knee. However, when a patient walks in a "crouch gait" pattern due to
dorsiflexion at the ankle joint or flexion of the knee (Figure 147B), the ground reaction force
vector passes behind the knee at midstance. This creates a flexion moment at the knee,
reducing the stability of the knee. A rigid AFO (Figure 147C) can be used to fix the position of
the ankle and harness the action point of the ground reaction force at a desirable location. The
rigid AFO thereby insures a large enough extension moment is created at the anatomical knee
joint.
Figure 147: GRF control system in a molded rigid AFO.
Rigid AFOs and Gait Deviations
A rigid AFO has a deleterious (destructive) impact on all three rockers of gait since it holds the ankle in
a neutral position throughout all of the stance phase.
1. The fixed ankle position of a rigid AFO prevents the controlled lowering of the foot toward the
floor during loading response as the ankle cannot move into plantarflexion. Instead, the rigid
AFO causes the tibia to accelerate forward quickly resulting in a rapid knee flexion in order to
achieve foot-flat position. This therefore results in the hampering of the first rocker of gait as
shown in the following figure and disruption of the normal shock absorption mechanism and
causes postural instability in early stance.
Note: If the orthosis is set in slight dorsiflexion in an effort to prevent recurvatum in early
stance, the patient must have at least fair eccentric strength of the quadriceps to control the
rapid knee flexion moment in loading response.
2. With the progression from midstance to terminal stance, the fixed angle of the ankle and the
proximal closure of a rigid AFO prevent forward progression of the tibia over the foot.
Disruption of this second rocker of gait hampers forward progression of the COM and
ultimately reduces step length of the opposite swinging limb.
3. If a rigid AFO has a relatively stiff extended toe plate (distal trimline extending to the
metatarsal heads), the extension (dorsiflexion) of the toes that is necessary for continued
forward progression and heel rise may be blocked. This in turn will limit the third/toe rocker of
the foot and the vaulting axis of the tibia as shown in the following picture.
Note: The stance phase tradeoffs/limitations of a rigid AFO can be addressed by footwear: shoes with
a compressible (cushion) heel and rocker sole are effective substitutes when the rockers of gait are
constrained by a rigid AFO.
7.5 MEASUREMENT
The stability of a joint depends on the good and strong active (muscles) and passive (ligaments,
Before taking the measurement, we have to do the proper assessment the clients identify the need.
During measurement, take:
• Circumference of the calf and ankle.
• Length of the foot
• Diameter of lateral and medial malleoli
•
st th
Diameter of 1 and 5 metatarsal
• Unequal leg length (leg length discrepancy)
• Height from the ground to the medial malleoli (specially for jointed Afo)
• Heel height (heel of the shoe)
7.6 CASTING
The aim of doing a plaster of Paris cast is to make a duplicate of the patient's leg to provide correction
of support to a partial or total dysfunctional foot/ankle complex in a biomechanically functional position.
Items needed during casting are indelible pencil, nylon stockinette, scissors, plaster of Paris, plastic
strip, knife, basin of water, assessment form, tape measure, caliper, and foot board with correct heal
height.
To achieve the best outcome during casting , recommends a semi weight bearing casting technique
using a footboard with ½” heel-raise to compensate for the heel height differential in most shoes.
Ensure that your cast is at least 1” taller than the requested height when casting for an AFO.
Procedures of Casting
1) Apply nylon or cotton stockinette
2) Contoured Standing Surface: - Since the AFO must fit the shoe as well as the foot, it is necessary
to use a standing surface, which has a suitable configuration. A prefabricated, plastic standing
surface, with the heel and forefoot portions planar, is satisfactory. The contralateral foot must be
supported on a surface that allows symmetrical stance. A typical standing surface is shown in
(Figure 148), and the actual contour is shown in (Figure 149).
Figure 149
Figure 148
3) Establish neutral foot / leg alignment (Position leg at 90° to thigh and foot at 90° to leg) see Figure
150. If the position of the leg and the thigh are as shown in Figure 151 and 152, the result of
negative cast will be equinus or dorsi flexion respectively. Therefore, the result will not be good.
Figure 150
Figure 151
Figure 152
4) Mark out bony prominences area that are lateral and medial malleoli, navicular, base of fifth
st th
metatarsal, 1 and 5 metatarsal heads, 2c.m.below distal tip of fibular neck and any other bony
prominence or sensitive area.
5) Place protective plastic strip or tube to create a cutting channel on dorsum of foot /leg.
6) Wrap plaster of parts circumferentially onto foot and leg starting at the foot.
7) Realign foot / leg in neutral position (neutral talus/dorsiflex to lock rearfoot/valgus force on 4th +
5th MT heads to lock midtarsal joint, dorsiflexion angle of ankle at selected angle).
8) Hold in position until the plaster is set, then place on footboard (this is used to duplicate the heel
height of the patient's shoe). The angle of the ankle in the saggital plane is chosen by the
Orthotist so that a position as close to neutral as possible is maintained. The changes away from
90 degrees are either with a fixed plantarflexion deformity or when the quadriceps are weak
(polio) requiring the knee to be in extension during the entire stance phase, to maintain stability.
The angle of the tibia in the frontal plane should be vertical.
9) Cut cast open over plastic strip on dorsum of foot / leg. Remove the cast with a minimum of
distortion (change in shape).
10) After removing the negative mold from the patient, check the cast before letting the patient go.
Remember that the aim is for a neutrally aligned foot and ankle.
11) Close cast(s) and check alignment of the negative cast, if cannot correct recast.
12) Give patient fitting date.
7.7 RECTIFICATION
A Rigid AFO minimizes movement at the ankle joint and blocks movement at the sabtalar joint.
Effective in treating flaccid ankles (polio); Osteo Arthritic joint; Spasticity (CP/CVA); Filling the negative
cast by pulling mandrel up 2.5 cm from bottom of cast. It is important to do the modifications in an
orderly manner:
Procedures
• Evaluation of positive model
• Modification of the heel and forefoot
• Addition of metatarsal arch
• Modification of medial ad lateral longitudinal arches
• Smoothing tibia section
• Addition of plaster build-ups
• Smoothing and evaluation of the cast
Step 1: Evaluation of Positive Model

During evaluation of the positive model draw Reference Lines (saggital plane = midline calf/coronal
plane = bisect calf/heel). The ankle should be neutral, tibia vertical in both the sagittal and frontal
planes, unless selected otherwise by nature of pathology or by the choice of the orthotist.
The cast(s) having been stripped of plaster of paris bandage is/are examined on a flat surface, paying
attention to the following landmarks:
1. Heel and forefoot are parallel and the calcaneus
perpendicular to the base of the heel
2. Medial border of the foot is parallel to the line of
progression
3. Look at the bottom of the foot - lateral forefoot in neutral alignment
4. Ankle at 90° or follow desired alignment
5. Tibia vertical (sagittal and coronal planes)
6. If both legs have been casted, both casts should have similar in shape
Step 2: Modification of the Heel and Forefoot

By using a flat surform blade in the holder to flatten the heel and forefoot perpendicular to the long
axis of the leg so that the desired alignment is attained (reference lines in the coronal and sagittal
plane). The metatarsal heads and the heel base are parallel in both coronal and sagittal planes. The
cast sits stable on the flat surface.
Step 3: Addition of Metatarsal Arch

See Step 3 in FO section.
Step 4: Modification of Medial and Lateral Longitudinal Arches

See Step 4 in FO section.
Step 5: Smoothing Tibia Section

The calf region has the fleshy gastrocnemius muscle posteriorly. During casting the plaster wrap may
have put ridges in it. This calf region needs to be blended. You will need to reduce the high areas and
fill in the deep areas. Using a flat surform out of the holder or half-round to blend and reduce if
required. The amount varies from person to person depending on the condition.
If the patient hyper extends at the knee during mid-stance, compression of the posterior calf is
required. The actual amount of reduction depends on the degree of hyperextension as is determined
by the orthotist during patient assessment.
Remember that if the knee extensors are weak it is important to keep the knee in slight extension to
maintain stability during the stance phase.
Step 6: Addition of Plaster Build-Ups

The foot and ankle require build-ups to the bony prominences and borders so that the AFO doesn't put
pressure on sensitive areas. Addition of plaster to the toes ensures that the final orthosis is larger than
the foot on weight bearing and that the orthosis once trimmed to fit does not slide around inside the
shoe.
Again addition of plaster to mold is done with care so that the shape of the mold is not lost. The plaster
should be well mixed so that it is not runny. Water is used in small amounts to smooth the plaster to
mold. If the same step-by-step procedure is used each time you modify the cast the process becomes
routine.
1. Add a small amount of plaster to the base of the fifth metatarsal and the navicular.
2. Add plaster to the medial and lateral borders of the foot, starting at the metatarsal heads and
working from the dorsum (top) side of the foot towards the plantar surface. Add the plaster in small
amounts so that you do not lose the shape of the mold. Work proximally to the level of the malleoli,
no plaster is added to the mold posterior to this point. Blend and smooth.
3. Add plaster to the malleoli keeping the shape. Remember the aim of build-ups is to provide a small
clearance so that pressure is minimized. The anterior portion of the malleoli should have almost the
same amount of plaster in height as the apex so that the ankle can slide into the AFO easily.
A small amount of plaster should also be added to the proximal edge of the malleoli so that if the
patient plantar flexes within the orthosis (i.e. spasticity), there is relief for the malleoli as the patient
rises up. Smooth with water.
4. If a tab is going to be used to act as a counter point to
correct ankle inversion or eversion it should be added just
proximal and anterior to the appropriate malleoli.
Add about 2cm of plaster proximal/anterior to the malleoli.
Blend into superior edge of the malleoli. The purpose is to
give an extra tab of plastic when the AFO has its final
trimlines. A forefoot abduction or adduction stop is also
required. Do a plaster build-up over the appropriate
metatarsal head so that the final plastic trimline is deep
enough. Smooth with water.
5. Using a footboard, add plaster to the toes starting at the
metatarsal heads and working distally so that the toe box
area is similar in shape to the shoe profile.
Approximately 2.5 cm should be added distally to the toes
so that there is enough material to trim to match the shoe
liner (as shown in the figure to the right). Ankle stays at
90. After the plaster has hardened use a flat surform in a
holder to realign the plantar surface of the forefoot.
6. If needed a proximal flare is added to minimize pressure at the proximal edge of the AFO. The
posterior flare should be about 1 cm in depth.
Step 7: Smoothing and Evaluation of the Casts

When cast modification is complete the cast is smoothed using screening and the shape and
alignment is evaluated. As mentioned previously the desired alignment is neutral subtalar, parallel rear
foot/forefoot and ankle at 90 degrees (unless decided differently by the Orthotist during assessment).
If a bilateral AF0s have been done their shapes are compared .The two feet are held so that the
plantar surfaces are together and the shape, position and depth of the medial / lateral metatarsal
arches are compared.
If they are different shapes, changes should be made to produce symmetry (both look the same). The
tibia should be vertical in both the sagittal and coronal planes unless there is a fixed deformity)
We are now ready for fabrication. The cast should be allowed to dry totally.
7.8 MANUFACTURING PROCEDURE
*** Follow the ICRC manufacturing guidelines ***
7.9 DESIGN (TRIMLINE)
The stiffness of a rigid AFO is influence by material choice and thickness. Reinforcements may be
incorporate at the ankle section of a rigid AFO to increase stiffness. Flexing, or ‘buckling’, of the AFO
should not be tolerated as a way of allowing stance phase progression, as this will compromise Medio-
lateral control of the foot. Instead, stance phase progression can be improved by ‘tuning’ the solid
AFO, a process which is essential to optimise the alignment of the ground reaction force (GRF) vector
to the knee and hip joints. The trim line of the rigid AFO depends on the pathology of the clients.
Standard Trimline
Standard plastic AFO would typically have a footplate extending
through the metatarsal heads, but if the toes are also spastic and claw
into a flex position, then a full footplate should also be incorporated into
this type of rigid plastic AFO. Inhibitory footplate designs are commonly
used, which may put the toes into extension to help reduce tone
throughout the entire limb. The foot section designed to control
excessive angular force at subtalar joints during stance.
The proximal plastic trim line 2cm below the head of fibula and pass
the line 1 cm anterior to the tip of the malleoli with no motion allowed at
the tibiotalar or subtalar joint.
At the forefoot, leave the sides of the toes and the head of the
metatarsus completely clear and pass the trim line below them. This
will allow the polypropylene to follow the movement of the metatarso-
phalangeal joints.
Trimline for Correction of Forefoot Adduction

The proximal plastic trim line is 2 cm below the head of fibula. To increase coverage of the lateral
midfoot, the trimline should pass in front of the cuboid in order to enlarge the area of pressure. At the
th
forefoot, the line must be proximal to the 5 metatarsal head. Decrease coverage of the medial mid-
foot at the navicular/malleoli, to facilitate donning. At the forefoot, cover the medial side of the
metatarsal head and toe, to correct forefoot adduction.
Figure 153: Lateral and Medial side trimlines for forefoot adduction correction respectively.
Trimline for Correction of Forefoot Abduction
A. The proximal trim line must be horizontal, 2 cm below the fibula head.
B. Decrease coverage at the level of the lateral malleoli, to ease donning.
th
C. At the forefoot, the line must be distal to the 5 metatarsal head, to avoid metatarsus abductus.
D. Increase coverage of the medial mid-foot at the level of the navicular, to increase mid-foot support.
E. At the forefoot, the line must be proximal to the 1st metatarsal head.
Figure 154: Lateral and Medial side trimlines for forefoot abduction correction respectively.
Varus / Valgus Correction

Varus or Valgus correction straps (T-straps) - A T-strap attached medially and circling the ankle until
buckling on the outside of the lateral upright is used for valgus correction. A T-strap attached laterally
and buckling around the medial upright is used for Varus correction.
***The fabricating processes of correction straps follow the ICRC manufacturing guidelines
manual.
7.10 FITTING
Before fitting of the clients, the appliance should be smooth and removed any sharp edges.
Therefore, during fitting the following points should be considered:
1) Apply a long sock to the leg.
2) Loosen closure straps on the sides of the AFO.
3) Slide the AFO into position, ensuring that the heel is fully and properly seated within the AFO,
and apply the shoe. Alternatively, place the AFO in the shoe and use it like a shoe horn. This
may be easier for patients with limited back, hip, and/or knee range of motion.
4) Tighten and secure the strap(s) for proper suspension.
5) Is not a need of a special shoe to wear over the brace, but a larger shoe size may be needed. If
necessary, the insole of the shoe should remove to accommodate the AFO.
Static
During static fitting, the clients while in sitting and standing positioned.
5.1Check the orthosis on the subject for fit and comfort, and trim it further or modify it as necessary,
paying particular attention to the trim lines, areas of high pressure, and ease of donning.
5.2Check the fitting of the orthosis related to the size of the shoe. The foot portion of the orthosis
should be equal to the size of the shoe.
5.3Check the heal height is correct. If the more heal height have the highest instability of the knee
creates.
5.4With the strap tightened, again check the orthosis on the patient. After a few minutes of wear,
check again for comfort and areas of high pressure. Modify the orthosis if necessary.
5.5Check the joint positioning related to the anatomical position of the limb.(for jointed AFO)
5.6Check medio-lateral and anterior-posterior stability during standing
5.7Check the hip level (if there any leg length discrepancy)
Dynamic
Check dynamic alignment (while patient walking)
1. Coronal View Check the following:-
l Neutral position of ankle (or close to neutral as possible)
l Shoe flat on the floor at mid stance
l Knee Varus/ Valgus
l Consider other gait characteristics
l Movement of COG – lateral trunk bending, forward or backward trunk lean
l Base of support
l Step timing
l Step Length
l Arm Swing
2. In Sagittal View Check the following :-
l Dorsiflexion angle
l Clearance of AFO in swing phase.
l Prevents hyperextension in stance phase.
Checkout Procedures
Like with all orthosis follow up is required to ensure patient comfort and compliance. Make an
appointment before they leave.
VIII. FLEXIBLE AFO
8.1 INDICATIONS
The indications of flexible AFO differ from one type of AFO to another.
8.2 TYPES OF FLEXIBLE AFO
a. Posterior leaf spring ankle foot orthosis

b. Spiral ankle foot orthosis
c. Hemi spiral ankle foot orthosis
Posterior Leaf Spring Ankle Foot Orthosis

The Posterior leaf spring ankle foot orthosis is the most common
type AFO. The degree of trimming and thickness of the plastics
material determine the amount of spring action and thus dorsal
flexion assist and the amount of medial- lateral control.
It is a lightweight straightforward design that prevents the foot
from plantar flexing (dropping) to allow a smooth swing of the
foot without catching the toe on the ground. Variations in the
shape and strapping made based on client needs.
Flexible orthosis is similar to many prefabricated AFOs designs,
and can be made from a range of materials (Figure).
Functions
• Limits plantar flexion
• Allows limited dorsiflexion
• Controls minor Varus/Valgus instability
• Blocks subtalar joint
Advantages
• Lightweight
• Cosmetic
• Durable
• Inexpensive
• Washable
• No special shoes required
Disadvantages
• Ineffective for equinus deformity
• Unable to resist spasticity
• Minimal Medio-lateral control
• Cannot be used with fluctuating oedema
• Requires caution with insensate foot
• Does not stabilise the ankle
Indications
• Drop foot secondary to Cerebral Vascular Accident (CVA)
• Mild drop foot (simple swing phase problems) secondary to other neurological pathologies
Contraindications
• Severe ankle-foot deformities
• Severe spasticity
• Fluctuation edema
• M-L instability of the foot
• Extreme activity
• The need for orthotics influence on the knee and/or the hip
Spiral Ankle Foot Orthosis

The spiral AFO (Figure 155) is believed to provide controlled motions in all planes; that is, adaptation
to transverse rotation, as well as motions in the frontal and sagittal planes. The spiral portion of the
orthosis originates from the medial side of the footplate, passes around the leg posteriorly, and
terminates at the level of the medial tibial condyle. A horizontal band is attached to the spiral at the
level of the calf. The plastic used in the construction of the orthosis.
A plastic orthosis winding in spiral curve from just below the knee around the leg to the heel and fitting
inside the shoe and under the arch. Used most often to counteract footdrop. Developed in 1968 at the
Institute for Rehabilitation Medicine, New York University, New York.
Spiral AFO allows for rotation in the transverse plane while controlling ankle dorsiflexion and plantar
flexion, as well as eversion and inversion.
Indications
• Motor weakness affecting all compartments of the ankle-foot complex may be flaccid or mild to
moderately spastic
• Medial-lateral instability of ankle during stance or swing phase
• Slightly diminished motor power at the knee in addition to motor weakness at the ankle
• Loss of proprioception at the ankle
Contraindications
• Well-defined imbalance of forces acting on ankle-foot complex
• Greater than moderate spasticity
• Fluctuating oedema
• Fixed deformities of the ankle
Hemi Spiral Ankle Foot Orthosis
This AFO consists of a shoe insert with a spiral starting on the lateral side of the shoe insert, passing
up the posterior leg, and terminating at the medial tibial flare where the calf band is attached. This
design is used for achieving better control of equinovarus than the spiral AFO can.
In contrast to the full Spiral AFO describes a complete turn of 360 deg. around the leg the hemi spiral
AFO covering only half a turn of 180 deg. (Figure 156). Thus, the reduction of the helical turn in the
hemi spiral results in greater stiffness with improved resistance against the equinus tendency. At heel
strike, external torque of the foot induced by the unwinding of the spiral, which, as mentioned above, is
in the direction opposite from that of the full spiral AFO.
Indications
• Motor weakness of the evertors and dorsiflexion of the foot with resultant imbalance of forces
in the direction of equinovarus
• Moderate spasticity when present with condition described in "1" above
• Medio-lateral instability during stance or swing
Contraindications
• Severe spasticity with sustained clonus
• Fluctuating oedema
• Fixed deformities
Figure 156
Figure 155
TIP= Drop foot is a term that describes a disorder where a patient has a limited ability or inability to
raise the foot at the ankle joint. This makes walking difficult as the toes tend to drag on the ground,
which leads to tripping and instability. Patients adapt to this by using their hip muscles to exaggerate
lifting the foot above the ground (known as a “step page gait”) or by swinging their leg outward so that
the foot can clear the ground (known as “circumduction”).
8.3 BIOMECHANICS OF POSTERIOR LEAF SPRING AFOs
Biomechanical Functions of Posterior Leaf Spring AFOs

Posterior Leaf Spring AFO design is the most flexible plastic AFO with a thin plastic band behind the
ankle allowing the patient to overpower the brace during the plantar flexion phase and yet assisting
dorsiflexion of the foot during swing phase. This design is typically used for flaccid foot drop.
A Posterior Leaf Spring AFO:

• Provides sagittal plane control that varies depending on design of the AFO
• Resists Plantarflexion, Assists Dorsiflexion
o Allows plantarflexion during loading response
o Controls anterior progression of the tibia over the foot during midstance
o Provides foot clearance during swing phase
PLS AFOs with trim lines just behind the malleoli will allow for increase of support and provide both
dorsiflexion positioning of the foot and mediolateral stability of the ankle. Much less motion is allowed
with this brace design and the patient cannot easily propel during push-off.
Biomechanical Principles of Posterior Leaf Spring AFOs
A posterior leaf spring (PLS) AFO is an AFO with medial and lateral trimlines placed well posterior to
the midline of the malleoli (Figure 157). This design feature results in flexibility (Figure 158) of the
orthosis at the anatomic ankle joint. The degree of flexibility is determined by the thickness of the
material used to make the orthosis and the arc of the radius at the distal third of the AFO.
Figure 157 Figure 158
Because of its posterior trimlines and flexibility at the ankle, the PLS cannot "contain" the calcaneus as
well as a solid-ankle design. As a result, the PLS may not be as effective in controlling mediolateral
foot position and may not be appropriate for patients with flexible deformity of the rear, mid-, or
forefoot.
If a patient requires some external mediolateral stability at the ankle, but not the rigid control of a solid-
ankle AFO, the trimlines can be placed somewhere between those of a solid-ankle AFO and a PLS
design. This design, known as a semisolid AFO or a modified PLS orthosis, has some of the functional
characteristics of the solid ankle and PLS AFOs. Although somewhat less flexible at the ankle than a
PLS in loading response, this modified PLS design is able to provide some control of knee position
during stance.
The conventional double upright counterpart to the PLS uses a spring mechanism incorporated into
the mechanical ankle joint to assist dorsiflexion in swing, as well as to provide a smooth transition from
heel strike/initial contact to foot flat at the end of loading response. The most commonly used
conventional dorsiflexion assist joint, the Klenzak, is shown in Figure 159. The uprights are connected
to the distal stirrup at the mechanical ankle joint. The stirrup is fixed between the heel and sole of the
shoe. A coil spring and small ball bearing are placed in a channel in the distal uprights that runs
toward the posterior edge of the stirrup. When the spring is compressed at initial contact and early
loading response, it resists plantar flexion, allowing a controlled lowering of the foot to the floor. Recoil
of the spring when the foot is unloaded in preswing and initial swing assists dorsiflexion for swing
phase toe clearance. The amount of dorsiflexion assist provided is determined by adjustment of a
screw placed in the top of the channel to compress or decompress the spring further.
Figure 159
The PLS or dorsiflexion assist conventional AFO is chosen when the primary problem is weakness of
dorsiflexion. The PLS and dorsiflexion assist conventional AFO are also effective substitutes for
anterior compartment muscles.
Posterior Leaf Spring AFOs and Gait Deviations

During loading response, in the first rocker of early stance, a Posterior Leaf Spring AFO substitutes for
eccentric contraction of the muscles of the anterior compartment (primarily the tibialis anterior),
providing a controlled lowering of the foot toward the ground, thus allowing a controlled plantarflexion
at heel strike.
In the second rocker, the flexibility of the PLS allows the dorsiflexion necessary for tibial advancement
over the foot during midstance. A Posterior Leaf Spring AFO also provides a “spring” effect at push off.
Once the limb is not bearing weight and the swing phase begins, a PLS AFO holds the ankle at 90
degrees, assisting clearance and appropriately positioning the foot for the subsequent initial contact.
8.4 MEASUREMENT
Similar measurement procedures as Rigid AFOs are followed.
8.5 CASTING
The casting procedures of flexible AFO are also similar to those described for the Rigid AFO with the
following exceptions:
•
O
The position of the foot and the leg during casting should be 85 related to the ground (5
degree of dorsiflexion). This can help Pre loading of the AFO so there is some spring action.
This is needed so that there is a force to lift the foot past 90 degrees during swing phase and
work to control plantar flexion of the ankle from heel strike to foot flat.
8.6 RECTIFICATION
The cast modification techniques for a flexible AFO are similar to a rigid AFO with the exception of the
malleoli. The changes for flexible are discussed below.
For the remainder of the step-by-step procedure refer to the cast modification procedure for Rigid
AFO's.
1. Position the AFO cast in the holder so that the foot is aligned with the toe out for that patient.
Usually this is 8-12 degrees.
2. Draw a posterior reference line (midline) down the center of the calf (coronally), so that the heel
achilles tendon is divided in half. Draw two more reference lines on either side of the central one
aligned 2.5cm from the midline.
3. Add plaster to either side of the achilles tendon by pulling the plaster knife in toward the midline
posteriorly from the medial and lateral borders. Starting at the achilles tendon and working
proximally to the predetermined length. Flare and blend the plaster into the calf proximally. The
purpose of this modification is to create symmetry in the concavity ofthe flexible strut on the medial
and lateral borders. This is so the plastic will flex evenly on dorsiflexion of the ankle and not dig
into the patient's calf. No plaster should be added to the central portion of the calf as this will affect
the fit.
4. Add plaster posteriorly to the malleoli so that the trimlines for the plastic will flow from the foot into
the calf portion.
5. Using a round and 1/2 round surform blend the plaster build up so that symmetry of the cast is
reached.
6. Smooth the cast and cheek alignment.
The Flexible AFO is usually made from polypropylene plastic with hook and loop (Velcro) closures for
the strap and the medial and lateral trimline placed well posterior to the midline of the malleoli.
The degree of flexibility determined by the thickness of the thermoplastic material used to construct
the orthosis and the arc of the radius at the distal third of the AFO.
8.9 FITTING
Similar procedures as in Rigid AFOs are followed.
IX. JOINTED AFO
9.1 INTRODUCTION
Jointed ankle foot orthosis are effective devices that are used to control plantar and/or dorsiflexion
(up or down movement of the foot) and side to side movement. Several designs are used with a large
variety of joints (hinges) available. The type of joint selection is based on the client needs and
consideration is made for weight and shape of device. The hinged AFO is most often used for people
who have had a stroke (CVA) or Cerebral Palsy. The hinged ankle foot orthosis can be plastic (see the
following Figure) custom hinged ankle foot orthosis, or Klenzak orthosis (conventional style).
There are a number of mechanical ankle joints, which may be incorporated into Jointed AFOs to allow
or assist motion in one direction while preventing or limiting motion in another. Typically, hinged AFOs
block plantar flexion at 90º. A JAFO that allows dorsiflexion should only be considered when an
adequate range of dorsiflexion is already present. Specifically, there should be adequate length in the
gastrocnemius to allow approximately 10º dorsiflexion with the knee fully extended. It is important that
this range of dorsiflexion should be achievable without any spastic catch in the plantar flexors and
without undue resistance due to tone. Even if adequate dorsiflexion range is present, JAFOs may be
inappropriate in the presence of moderate to severe Medio-lateral instability of the foot.
Additional clinical finding that indicate use of an JAFO are
• Some or all voluntary control of dorsiflexion, but no plantarflexion control
• limited voluntary control of both dorsiflexion and plantarflexion
• A need to use ankle motion in skill development
Posterior Shell Jointed AFO are needed:
• If control in Coronal Plane required
• Useful Movement at ankle Joint
• Maximum gait efficiency
Because of the space needed for mechanical ankle joint the width of the JAFOs at the ankle is usually
marginally wider than a solid ankle designs.
9.2 INDICATIONS
• Mild posterior tibial tendon dysfunction

• Mild degenerative arthritis
• Lateral and medial instability of subtalar joint
• Sinus tarsi syndrome
• Drop foot
• Severe pronation
• Chronic ankle instability
• All ankle injuries including high ankle sprains
• Trauma
9.3 TYPES OF JOINTED AFOs
Ankle Joints - The mechanical ankle joints can control or assist ankle dorsiflexion or plantar flexion by
means of stops (pins) or assists (springs). The mechanical ankle joint also controls medio-lateral
stability. Knee extension moment is promoted by ankle plantar flexion, and knee flexion moment is
promoted by ankle dorsiflexion. The common types are:-
1. Jointed AFO –Free Motion
2. Jointed AFO –Plantar Flexion Stop (Control)
3. Jointed AFO –Dorsiflexion Stop (Control)
Free Motion Ankle Joint

The stirrup has a completely circular top, which allows free ankle
motion and provides only Medio-lateral stability.
Indication
¡ Medial – Lateral instability
Controls:
Ø Maximum frontal control
Ø No sagittal motion control
Plantar Flexion Stop Ankle Joint
This ankle joint stop is produced by a pin inserted in the posterior channel of the ankle joint or by
flattening the posterior lip of the stirrup's circular stop. The plantar flexion stop has a posterior
angulation at the top of the stirrup that restricts plantar flexion but allows unlimited dorsiflexion and
promotes knee flexion moment. This design is used in patients with weakness of dorsiflexion during
swing phase and flexible pes equinus.
Indication
¡ Foot drop
¡ Knee hyperextension in stance
¡ Mild to severe STJ spastic instability
¡ Toe walkers (flexible pes equinus)
Controls:
Ø Maximum plantar control
Ø No dorsiflexion limit
Ø Moderate genurecurvatum control
Dorsiflexion Stop Ankle Joint

The stirrup has a pin inserted in the anterior channel of the ankle joint or by flattening the anterior lip of
the stirrup's circular stop. The dorsiflexion stop has an anterior angulation at the top of the stirrup that
restricts dorsiflexion but allows unlimited plantar flexion and promotes a knee extension moment in the
meantime. This design is used in patients with weakness of plantar flexion during late stance.
Indication
§ Forward angulation of the tibia during stance
§ Knee flexion gait pattern
§ Weak plantarflexors
§ Unstable midfoot during stance phase
Controls:
Ø No plantar control
Ø Maximum dorsiflexion limit
9.4 BIOMECHANICS
Biomechanical Functions of Jointed AFOs

Jointed AFO is the most versatile AFO that is designed. It can be made to apply maximum control over
the ankle joint, it can be made to provide limited articulation, or it can be made to provide variable
range of motion in the ankle joint. In general, jointed AFOs:
• Control medio-lateral stability at the ankle
• Prevent and correct deformities
• Reduce the energy cost of ambulation
• Control the end points of dorsiflexion/plantar flexion range:
Paralysis of Dorsiflexion, Plantarflexion, Inversion, Eversion
Most mechanical ankle joints prevent mediolateral instability and either control or assist dorsiflexion
and plantar flexion by means of stops or assists (springs)
a. Plantar flexion control:
o May use plantar flexion stop-angulation of the top of the stirrup posteriorly that
restricts plantarflexion but allows unlimited dorsiflexion. Substitutes for paralyzed foot
dorsiflexors during swing phase. Maintains the ground reaction force posterior to the
knee joint and causes rapid foot flat after heel strike.
b. Dorsiflexion control
o May use dorsiflexion stop-anterior angulation that allows full plantar flexion while
limiting dorsiflexion. Substitutes for paralyzed gastroc-soleus muscles during push-off.
Allows center of gravity and the ground reaction force to move forward to the
metatarsal head area, and creates a moment arm infront of (anterior to) the knee,
which promotes knee extension and stability.
c. Dorsiflexion—assist spring joint (Klenzak Joint)
o Uses coils located posteriorly that are compressed following heel (or foot) strike (in
stance phase). At heel strike, the springs also yield slightly into plantar flexion and
help prevent inadvertent knee flexion. During swing phase, the spring rebounds to aid
dorsiflexion.
o Alternative: Double action ankle joint (Klenzak Joint shown in the following figure). It
allows adjustable range of plantarflexion and dorsiflexion
d. Dorsiflexion/plantar flexion assist joint
o Has an anterior spring that is compressed at midstance and as it recoils, it helps to
plantarflex the ankle into push-off.
e. Bi-channel adjustable ankle lock (BICAAL) joint
o Has anterior and posterior receptacles with springs that can be compressed to assist
motion. The springs can be replaced by pins to alter the alignment of the joint and thus
convert it into adjustable stops.
Biomechanical Principles of Jointed AFOs

A Jointed AFO is a plastic orthotic design that
incorporates a mechanical ankle joint
placed between foot and calf sections of
the orthosis. A variety of mechanical ankle
joints are commercially available (different
types of ankle joints are discussed in the
‘General AFO Science’ section of the first
capter in this document). Some jointed AFOs
require an overlap of the foot and calf,
whereas others do not. Those with true
articulations, such as the Oklahoma joint,
have a single axis of motion that should be
aligned as closely as possible to the anatomic
ankle joint. Other orthotic joints, such as the
Gillette joint, are flexible, nonarticulating, and
axis-less. The configurations of the foot and
calf sections of an articulating AFO are
essentially the same as those of the solid-ankle AFO. The width of the orthosis at the ankle is usually
marginally wider than a rigid AFO because of the mechanical ankle joint. Because of the need for
normal subtalar and midfoot arthrokinematics in the second rocker of gait, an articulating AFO is not
usually appropriate in the presence of severe spasticity that limits ankle motion or if severe instability
or if malalignment of the midfoot is present.
A 90-degree plantar flexion stop mechanism can be incorporated into
the articulating AFO if prevention of plantar flexion is desired (for
example, if spastic equinovarus is a concern). This is usually
accomplished by an overlapping lip or pin stop mechanism (Figure on
the left).
Another version of the articulating AFO uses an adjustable posterior check strap to limit the excursion
into dorsiflexion (Figure 160). If the check strap is maximally tightened, the orthosis functions much
like a rigid AFO. The check strap can be loosened, lengthened, allowing only as much forward
progression of the tibia in the second rocker as is safe and functional for the patient. This adaptation
makes the articulating AFO the most versatile of all thermoplastic designs.
Figure 160
Articulated Ankle Foot Orthoses
Free Motion Joints:
Ø No sagittal motion control
Plantar Control:
Ø Maximum plantar control
Ø No dorsiflexion limit
Ø Moderate genu recurvatum control
Dorsiflexion Control:
Ø No plantar control
Ø Maximum dorsiflexion limit
Jointed AFOs and Gait Deviations
The following figures illustrate the gait (stance phase) of a person with an AFO that has a free motion
joint. (Gait deviation of AFOs with plantarflexion control, AFOs with dorsiflexion control, and AFOs with
plantarflexion and dorsiflexion assist are to be analyzed by students as assignment and discussed in class with
the teacher.)
9.5 MEASUREMENT
Similar measurement procedures as Rigid AFOs are followed.
9.6 CASTING
Similar cast taking procedure follows as Rigid AFO. Except if we use Free motion ankle joint made out
of aluminium before filling the negative cast it should be transfer the anatomical joint.
9.7 RECTIFICATION
The stiffness of a rigid AFO is influence by material choice and thickness. Reinforcements may be
1. Draw reference Line in the coronal plane so that both medial and lateral lines are at the same
level. The correct position for height of the ankle joint is the distal tip of the medial malleoli,
which corresponds to the apex of the lateral malleoli.
2. Draw a reference line for each malleoli in the saggital plane. For conventional alignment
(Line of Progression Alignment), this is midline laterally and slightly posterior to the apex
medially. For anatomical alignment, this is the apex of each malleoli. The type of alignment
chosen is up to the Orthotist. This depends in part on the amount of tibial torsion (twisting).
3. Apply the ankle alignment jig to the cast making sure that the plastic joint spacers are parallel.
Adjust clearances so that there are 6mm medially and 5mm laterally. These are general
figures and will change depending on the ankle alignment achieved in casting whether the
patient gets edema (swelling) and the force required to correct the ankle (amount of muscle
tone).
4. Once the alignment and clearances of the joint spacers is done the jig is stabilized against the
cast by using electrical tape. Plaster is mixed runny so that it can flow into the space between
the cast and the spacer. Once set the jig is removed.
5. The malleolar build up is blended to the cast using a round surform. The joint face should be
slightly larger (2mm) than the joint used in fabrication to permit rotation. The build up should
be the same shape as the joint used (flat or concave).
6. The other build ups are done in the same way as Rigid AFO. The completed cast is then
smoothed with screening and water and the alignment checked.
7. The actual joints are the formed (bent or molded) to the cast and nailed into position. Silicone
is applied to the edges and the cast is set aside to dry.
Function Design and Joint Placement

To understand biomechanical principles of AFOs, one must understand the functional anatomy of the
ankle-foot complex itself. The medial malleolus is the down word extension of the tibia. The
corresponding lateral malleolus of the fibula is slightly longer and more posteriorly located.
If a lower extremity orthotics includes mechanical ankle joints, it is essential that the axis of the
mechanical ankle joints be aligned, as closely as possible, to the obliquely oriented anatomical axis of
motion. The Orthotist can choose to use line of progression or anatomical joint alignment for
placement of the mechanical joint. This depends in part on the amount of tibial torsion (twisting).
For conventional alignment (Line of progression Alignment):-Typically, a pair of mechanical joints
is incorporated in to the medial and the lateral aspect of the orthosis. The distal border (tip) of the
medial malollous is used as a reference point for placement of the mechanical joint in the frontal plane.
A horizontal line that bisects the medial and lateral malleolus at the same height from the ground is
used the position the lateral joint.
In the transversal plane, the mechanical joint axis should be parallel to each other, to follow the line of
progression and the degree of the external rotation dictated by the patient's tibial torsion.
For anatomical alignment:-should take the apex of each malleoli.
Trimlines depend on the motion we need to control.

For AFO with plantar flexion control, draw a horizontal line posterior to the marks joining the two sides
(Figure below).
For AFO with free plantar flexion, draw a “V” posterior to the midline of each cavity. Ensure that the “V”
does not extend forward past the centre of the cavity (as shown in the following figures).
9.10 FITTING
Similar procedures as Rigid AFOs are followed.
X. GROUND REACTION AFO
10.1 INTRODUCTION
The design of a GRAFO included a full toe plate, rigid ankle, and an anterior tibial shell section. The
combination of these three components allow the plantarflexion-knee extension couple (PF/KE) to
occur, causing a knee-extension moment. This knee-extension couple helps to support weak
quadriceps and plantarflexor muscles.
A GRAFO (shown in the piture on the right) is a form of solid AFO which is
designed to maximise the indirect orthotic control of knee flexion during
stance phase. To have this effect on the knee, a GRAFO must be very stiff
and must be optimally aligned so as to ensure that the ground reaction
force is in front of the knee in mid to late stance, generating an external
knee extension moment. A specific design feature of the GRAFO is a
plastic pretibial shell close to the knee, which helps prevent excessive tibial
progression. The addition of a padded anterior shell more comfortably
captures the resultant extension moment, stabilizing the knee. Note also
the corrugation incorporated in the medial and lateral walls of the ankle-foot
orthosis to provide additional rigidity to the orthosis.
The Ground Reaction Ankle Foot Orthosis is thought to be effective by
limiting ankle dorsiflexion and reducing knee flexion in stance by controlling
the amount of tibial advancement over the foot during the second rocker
(Figure 161). This improved ankle and knee position is thought to reduce
the elevated internal knee extensor moment in stance commonly
associated with crouch gait, thereby reducing the activation of the
quadriceps muscle required to stabilize the knee during stance.
Figure 161
As a result of the biomechanical advantages of the GRO design, a patient with little quadriceps
function is able to be stable in stance, full weight bearing, without knee instability.
Fixed deformity in any of the three anatomical planes or the presence of dynamic contracture of the
knee and/or hip will compromise the effectiveness of a GRAFO.
Advantages:-
• The major advantage of the FRO is that, besides stabilizing the ankle and subtalar joints, it assists
the knee extension capabilities of the patient with fair minus strength in their quadriceps femoris
muscles, and therefore helps prevent the knee joint from buckling.
• This device is molded to provide total contact, thus preventing pressure sores over bony
prominences compare to conventional KAFO.
• As the principle goes, the more plantar flexion in the orthosis, the more extension force applied at
the knee joint.
10.2 INDICATIONS
• Knee instability in sagittal plane

• Foot drop with knee instability (combination of ankle weakness instability such as drop foot and
weak quadriceps causing knee instability)
• Flexor pattern “crouch” gait
• Spina Bifida patients (tendency to collapse into flexion), due to polio, spinal injury, CVA,
Neurological conditions
Contraindications:
• Genu-recurvatum
• Patient is concerned with bulk and cosmetics
10.3 BIOMECHANICS
Biomechanical Functions of Ground Reaction AFOs

The design of a GRAFO includes a full toe plate, rigid ankle, and an anterior tibial shell section. A
Ground Reaction AFO is specifically designed to use the moment created by the ground reaction force
as a primary source of sagittal plane stability for the knee joint during stance. Ground Reaction AFOs
achieve their desired function by virtue of the forces generated between the moulded structure of the
device, the shoe, and the enclosed limb segments.
A ground reaction AFO functions to:

• maintain affected joints in proper alignment
• accentuate knee extension at midstance; limit a crouched gait pattern
• prevent tibial collapse by compensating for weak or absent gastroc-soleus (calf) or quadricep
muscles
• correct deformities in the subtalar and midtarsal joints
A ground reaction AFO uses a rigid anterior shell with padding (shown in the following figure) to apply
force on the anterior surface of the tibia. This type of AFO is effective when there’s sufficient knee
range of motion possible and patients don’t have fixed knee flexion contracture. If the deformity in the
knee is fixed, the GRAFO resists dorsiflexion and knee flexion but does not create a true extension
moment.
Biomechanical Principles of Ground Reaction AFOs

Ground Reaction AFOs prevent plantarflexion of the foot in swing phase and improve ground
clearance, reducing the risk of tripping by applying a system of three forces to the posterior calf, the
plantar surface of the foot near the metatarsal heads, and the dorsum of the foot near the ankle joint.
When a person bears weight on a ground reaction AFO that he or she wears
inside the shoe, the AFO's rigid walls transfer the ground reaction force
posteriorly on the tibia. Thus, the AFO directs a force posteriorly against
the anterior tibia during midstance and terminal stance, and prevents or
controls tibial advancement. In this way, the AFO's force produces a
plantarflexion moment that counters the ground reaction force's (GRF)
tendency to dorsiflex the ankle.
If a GRAFO is aligned in plantarflexion, the alignment inclines the
tibia posteriorly during stance. This ankle aligment causes the knee joint's
lateral axis to lie more posteriorly. In this location, the knee joint axis lies
posterior to the ground reaction force's line of application throughout a longer
period of time during walking cycle. Therefore this planarflexed alignment
increases the time during which the ground reaction force lies anterior to the knee joint axis, and
produces knee extension.
Therefore, the GRAFO relies on the plantarflexion-knee extension couple where a fixed, slightly
plantar flexed ankle creates an extension moment at the knee. (Note: The force systems that control
foot and ankle position are similar to those described previously for Rigid AFO.)
Ground Reaction AFOs and Gait Deviations

1. As stated in the previous sections, a GRAFO assists plantarflexion by preventing ankle
dorsiflexion. Restricting ankle dorsiflexion with GRAFOs induce premature loss of heel
contact causing a sudden forward progression of the center of mass.
2. The magnitude of the knee extension moment created by a GRAFO depends on:
A. plantarflexion angle of the AFO
• when an GRAFO is set in neutral or a few degrees of plantarflexion, the tibia is
restrained from advancing over the foot in the second rocker of gait, and the
ground reaction force passes anterior to the knee earlier in stance phase
B. length and rigidity of the toe plate
3. As the length and stiffness of the toe plate increase, the third rocker of the foot becomes
limited, and additional extension forces are brought to bear on the knee in the latter half of
stance phase
10.4 MEASUREMENT
Take the following measurements in addition to Rigid AFO measurements and record on the patient's
chart.
• Diameter (diagonal measurement) from the heel to dorsum of the ankle.
• Height from the ground to the tibial tubercule.
10.5 CASTING
• The patient is comfortably seated in a casting chair, the knee kept in 10 degree flexion and
ankle 5 to 15 degrees plantar flexion, while the foot is kept in neutral position and all bony
prominences are identified with an indelible pencil. A latex rubber tube is run anteriorly over
the dorsum of the foot along the tibial crest to the level of the fibular neck.
• The tube then winds medially to the mid anterior-posterior dimension of the knee. This allows
the negative impression to be sectioned for removal, yet it can be properly "keyed in" for exact
placement and orientation.
• A length of tube guaze stockinette is placed over the limb to act as a cast separator, and the
shank is then wrapped with elastic plastic bandage to the level of the fibular neck.
• The foot is then placed on a footboard in neutral subtalar position with slight plantar flexion to
accommodate the heel height of the patient's shoe. Care must be taken to position the foot in
the correct amount of toe out, and to maintain the shank in proper orientation to mid-saggital
alignment.
• When the ankle-foot section has hardened, the knee is extended to approximately 15 degrees
of flexion and wrapped with plaster bandage to the level of the proximal border of the patella.
The patellar tendon is then outlined as a reaction point from the floor for knee extension by
compressing with thumb and forefinger pressure in the same manner as with a below knee
patellar tendon bearing (PTB) orthosis casting. Since weight bearing is not a consideration,
the popliteal area and contour of the posterior calf need not be disturbed. The negative
impression is removed and filled in preparation for modification.
10.6 RECTIFICATION
• Modification follows standard procedures with plaster buildups over all bony prominences for
pressure relief.
• The footplate is fully modified for support of the medial and lateral longitudinal arches. In
addition, a slightly more aggressive modification is made under the sustentaculum tali and
transverse metatarsal arch to provide a stable base for the calcaneus in a slight plantar flexion
position and comfortable distal reaction point under the metatarsal heads.
• The patellar tendon is now isolated. Although not an area covered by the orthosis, the patella
was included in the negative impression so that the tendon modification could be properly
oriented with respect to natural toe out. If this is not done, the orthosis will tend to rotate
medially or laterally and begin to impinge on the femoral condyles.
• The positive model is then smoothed, coated with a parting lacquer and covered with nylon
hose in preparation for vacuum forming.
5mm thick sheet of polyethylene or polypropylene is drape vacuum-formed over the positive model
from posterior to anterior, creating an anterior seam. In the area of the patellar tendon, the seam is
pinched together tightly with Teflon sheeting to ensure good bonding at this point. When this technique
is performed with the plastic material at the proper temperature, there is no need for plastic welding
equipment or other bonding agents to maintain the structural integrity. The positive model is broken
out, and the orthosis is trimmed and smoothed for fitting.
The Ground Reaction AFO has trim lines that incorporate the malleoli and extend up and anterior to
the proximal third of the shank segment to provide control of the foot and ankle and constrain ankle
dorsiflexion during the second rocker component of gait (shown in the following Figures).
10.9 FITTING
The Application of Ground Reaction Ankle Foot Orthosis is different from rigid AFO because of the
anterior panel which might cause difficulties during donning and doffing. Therefore, it is better to follow
the following steps.
1. Apply long cotton sock or stockinette to leg
2. If the floor reaction AFO has a detachable anterior panel, loosen the straps on the side of the
panel
3. To slide the foot and leg into the FRAFO, plantar flex the ankle (point the toes down) through
the top of the orthosis (see Figure 162).
4. Make sure the heel is fully seated. The heel needs to be all the way back and in contact with
the bottom of the footplate (see Figure 163).
5. Check to ensure the heel is all the way back by looking along the sides and back where the
plastic is separated above the heel (see Figure 164).
6. If applicable, apply the anterior panel and tighten straps snuggly. The Orthotist may mark the
straps to assist you in keeping consistent pressure between applications.
Figure 162 Figure 163 Figure 164
7. Secure the velcro of the wrap around strap just above the ankle.
8. The shoelaces need to be opened wide, then slide the foot with the GRAFO into the shoe.
9. Special shoes are not needed to wear over the orthosis, but a larger shoe size may be
indicated. If necessary, remove the insole of the shoe to accommodate the GRAFO. Shoes
with wide toe boxed and Velcro are generally easier to put on over the orthosis. Tighten
shoelaces/Velcro securely.
Checkout Procedure
Like with all orthosis follow up is required to ensure patient comfort and compliance. Make an
appointment before they leave.
XI. PTB AFO
11.1 INTRODUCTION
The patellar tendon bearing orthosis is custom made of thermoplastic and can be made with or without
ankle joints. The orthosis transfers some weight from the foot and ankle to the lower leg and patellar
tendon. It provides compression to the lower leg and will reduce
some of the weight to the foot and ankle.
The PTB AFO is a modification of the solid ankle design, with
additional anterior shell that incorporates the weight bearing
principle of a PTB socket of transtibial prosthesis. The anterior
shell PTB AFO modified to include a shelf to support the medial
tibial flare and patella tendon bar. The medial tibial flare and calf
muscle complex is used to take some of the body weight so that
the full weight does not pass through the lower leg and ankle.
This is done so that with non-union fractures the unloading gives
the bone a chance to heal.
The primary goal of the PTB AFO design is to reduce the axial
loading of distal limb during gait.
The orthosis oriented approximately 10 degrees of knee flexion
(with respect the vertical) so that the portion of body weight is
loaded on the anterior shell of the AFO at the medial tibial flare of
and patella tendon bar during stance. A portion of the axial
loading forces is then transmitted down the metal upright (plastic
shell) incorporated into the medial and lateral walls of the
orthosis, reduced loading of the tibia, fibula and bone of the foot.
11.2 INDICATIONS
• Neuropathic ulcers on the plantar surface of the foot

• Charcot ankle/foot
• Distal tibial/talar/calcaneal fractures
• Post reconstructive surgery
• Instability and pain associated with arthritis
• Other conditions that require reduce weight bearing through the foot–ankle complex
Contraindications
• Proximal Fracture
• Open Fracture
11.3 TYPES
There are two possible methods for fabricating Moulded PTB AFO:
1) Anterior Closing Shell
Indication: Weak at ankle level, especially for heavy patients or patients walking with ankle
dorsiflexion.
Advantage: Easy to fit into normal shoes.
2) Posterior Closing Shell
Indication: Strong at ankle level, thus suitable for overweight patients or patients walking with
ankle dorsiflexion.
Disadvantage: Sometime difficult to fit into normal shoes because of the volume of the orthosis at
mid-foot.
11.4 BIOMECHANICS
Biomechanical Functions of PTB AFOs

The structural integrity of the ankle joint may be impaired due to trauma or as a result of an
arthritic condition. Axial loading of the ankle complex can contribute to pain and disability when the
articular cartilage is damaged, or the underlying bony structures become deformed. Sometimes,
immobilization of the joint alone will provide some relief and in these cases a Rigid AFO may be
employed to achieve that objective.
However, when the damage in the ankle joint is more severe, it may be necessary to consider
relieving the joint of the normal weight bearing forces and moments. The biomechanical
requirements for this situation entail the identification of an alternative skeletal load bearing area
proximal to the ankle onto which these loads may be transferred. The Patellar Tendon Bearing AFO,
which is a custom ankle foot orthosis with external bracing designed to un-weight the ankle or heel, is
widely employed as a solution for this situation. It utilizes a below-the-knee socket design that is rigidly
linked to the patient’s shoe.
In general, PTB AFOs have the following functions:

• Transfer weight bearing from foot and ankle to patella tendon and medial tibial flare by
using prosthetic principles
o Relieve pain in Ankle complex due to weight bearing
• For simple fracture
o Provide immobilization
o Contain surrounding tissue
o Hold bones in correct alignment
o Allow patient to wald and can promote healing
• For Osteoarthritis of Ankle joint
o Reduce weight passed to ankle joint
o Minimize movement so that bone on bone forces are reduced
o Unload the heel in order to relieve it from pain (due to ulcers)
Biomechanical Principles of PTB AFOs
The PTB AFO is a modification of the Rigid AFO design, with an additional anterior shell that
incorporates the weight-bearing principles of a PTB socket for a transtibial prosthesis (Figure
165). This moulded plastic design consists of a rigid posterior ankle-foot shell extending proximally to
the level of the knee crease to which is hinged an anterior shell extending from mid patella towards the
ankle. The required proximal support is achieved by the manner in which the two sections are
moulded onto the flares of the tibial condyles and into the patellar tendon anteriorly and into
the popliteal region posteriorly. The anterior shell of the PTB AFO includes a "shelf" to support
the medial tibial flare and a patellar tendon bar.
Figure 165: Trimlines for a PTB socket (transtibial prosthesis).
The primary goal of the PTB AFO design is to reduce axial loading of the distal limb, the foot-
ankle complex. The effective transfer of the loads associated with weight bearing is achieved through
the rigidity of the posterior shell of the PTB AFO. For a PTB AFO design to be effective:
1. the anatomic knee must have structural and skin integrity to tolerate the extra loading
forces applied by the PTB design
2. the patient must have adequate quadriceps strength for knee stability in early stance
Patellar Tendon Bearing Socket (Transtibial Prosthesis)
The patellar tendon-bearing (PTB) socket consists of a

laminated or thermoplastic socket that provides an intimate,
total contact fit over the entire surface of the residual limb.
The anterior wall of the socket extends proximally to

encapsulate the distal third of the patella.
Just below the patella, located at the middle of the patellar
ligament, is an inward contour or bar that converts the
patellar tendon (ligament) of the residual limb into a
weight-bearing surface.
The patellar tendon is not the only weightbearing surface
used by the PTB socket. The medial and lateral walls extend
proximally to about the level of the adductor tubercle of the
femur. Together, they serve to control mediolateral/rotary
forces applied to the residual limb. The medial wall is
modified with an undercut in the area of the medial flare
of the tibia, a pressure-tolerant surface and primary
weight-bearing area.
The lateral wall provides relief for the head of the fibula and
the cut end of the fibula. This wall applies pressure along the
fibular shaft to enhance medial-lateral stability. In addition,
the lateral wall acts as a counter pressure to the medial wall.
The posterior wall is slightly higher than the patellar
bar and is designed to apply an anteriorly directed force
to maintain the patellar tendon on the bar. The posterior
wall is flared proximally to allow comfortable knee flexion and
is contoured to prevent pressure on the hamstring tendons.
The PTB prosthesis is designed to maintain the residual limb in slight initial flexion
(from 5 degrees to 10 degrees) to convert the patellar bar to a more horizontal
supporting force. However, because the patellar bar is not completely horizontal, the
residual limb still has a tendency to slide down posteriorly. This tendency must be
counteracted by the posterior wall that is contoured to maintain the patellar tendon’s position
on the patellar bar.
Figure 166: Top view of a (A) Patella Tendon Bearing Socket, and (B) Total Surface Bearaing Socket.
The total contact fit provides relief over nonpressure-tolerant areas and supports the body’s
weight over the pressure-tolerant areas of the limb. Total contact is necessary to prevent limb
edema, but does not imply equal pressures throughout the socket. PTB socket design is
appropriate for nearly all transtibial amputations, but is seen less often with introduction of
the total surface-bearing socket.
11.5 MEASUREMENT
Take the following measurements in addition to Rigid AFO measurements and record on the patient's
chart.
• M/L diameter = tiblal flare to head of fibula

= knee center - widest part with knee extended
• A/P diameter = patella tendon (with quadriceps relaxed) to popliteal area
• Circumference = at PTB with knee slightly flexed to check volume
= mid gastrocemius to check volume of leg at this point
11.6 CASTING
It is very important to take a good cast in correct alignment as this Orthosis supports and stabilises the
leg. Incorrect positioning during casting will make the brace painful to walk in and possibly injure the
knee.
1. Apply a tight fitting stockinette to the leg. Secure proximally with an elastic and Yates clamp or clip.
2. Slide a cutting strip under the stockinette down the front of the leg from above the knee to the top
of the foot.
3. Use a block of wood or a footboard to simulate the height of the shoe's heel so that the tibia is
vertical.
4. Mark the following landmarks with an indelible pencil.
• Malleoli ( medial and lateral)
• Navicular
• Base of the fifth metatarsal
• Metatarsal heads
• Medial tibial flare
• Medial border of the tibia
• Lateral border of the tibia
• Crest of the tibia
• Tibial tubercle
• Fibular head
• Patella
• Lateral tibial eplcondyle
• PTB bar
• Adductor tubercle
• Any abnormal bony prominence or scar tissue
You may find if your proximal marks move during casting that. They need to be marked out after the
foot and ankle has been casted.
5. The method of casting of PTB AFO are similar to TT prosthesis. Keep the leg slightly flexed. Insist
on the medial flare and antero-posterior pressure. (Figure 167)
6. Begin casting at the toes and work proximally to mid calf. Place on the footboard. Make sure the
subtalar and ankle joints are in the correct alignment. The tibia should be vertical in the coronal
plane and either neutral or angled slightly forward (to make rollover easier) in the sagittal plane.
Allow the plaster to harden. Make sure to mould the malleoli and foot well.
7. When the plaster is hard, extend the knee to about 15 degrees of flexion. Support the leg in this
position by putting a soft pad under the heel. If the marks on the proximal section are not done,
mark out with indelible. Wrap with plaster proximally to the level of the adductor tubercle and mold
in the medial tibial flare and tibial borders. Smooth the plaster making sure the cast is well molded
around the knee. Using the palms of both hands, compress the MIL dimension between the medial
tibial flare and the lateral aspect of the leg along the proximal fibular shaft. Pressure in the A/P
dimension is applied with the thumbs pressing on each side of the patellar tendon and the fingers
compressing posteriorly between the hamstring tendons (this creates a natural relief area for the
tendons). Do not let the thumbs extend around to the sides of the cast but keep them central.
Figure 168
Figure 167
8. When the plaster has hardened remove with a cast saw or knife making sure not to deform the
cast, close and check the alignment. The foot should be in neutral with the tibia vertical, neutral
subtalar joint.
11.7 RECTIFICATION
1. Check the alignment of the negative mold. Realign if necessary and fill with plaster
2. Strip plaster off the positive mold and remark all landmarks with an indelible pencil
3. Check alignment
4. Using a half round surform reduce the M/L dimension at the medial tibial flare to within 3mm of the
measurement.
5. Using a round surform reduce the cast at the level of the patella tendon to the depth of the thumb
imprints. Make sure to blend it rather than making a sharp cut.
6. Reduce the cast in the popliteal area to within 3mm of the A/P measurement. Blend this reduction
into the shape of the cast. (Figure 169)
Figure 169 Figure 170
7. Decrease the calf circumference uniformly by 1cm

8. Plaster build-ups:
a) Add a small amount of plaster to the base of the fifth metatarsal and the navicular. Blend to
cast with fingers wet with water.
b) Add plaster to the medial and lateral borders of the foot, starting at the metatarsal heads and
working from the dorsum side of the foot towards the plantar surface. Add the plaster in small
amounts so that you do not lose the shape of the mold. Work proximally to the level of the
malleoli making sure to keep the shape of the cast, no plaster is added to the mold posterior to
this point. Remember that the PTB Orthosis is total contact and bivalved to the foot. Blend and
smooth.
c) Add plaster to the malleoli keeping the shape. Remember the aim of build-up is to provide a
small clearance so that pressure is minimized. The anterior portion of the malleoli should be
curved slightly so the anterior portion of the PTB contains the malleoli securely. It should have
almost the same amount of plaster in height as the apex so that the ankle can slide into the
AFO easily. A small amount of plaster should also be added to the proximal edge of the
malleoli so that if the patient plantarflexes within the orthosis there is no pressure. Smooth
with water.
d) Using a footboard add plaster to the toes starting at the metatarsal heads and working distally
so that the toes box area is similar in shape to the shoe profile. Approximately 1.5cm should
be added distally to the toes so that there is enough material to trim to match the shoe liner.
Ankle stays at 90°. After the plaster has hardened use a flat surform in a holder to realign the
plantar surface of the forefoot.
e) Now plaster must be added to the tibial section. Bony prominences are the fibular head, crest
of the tibia, lateral epicondyle. Place some plaster at the apex of the fibular head and flare out
to the cast. The total build-up should be 5mm at the apex. The proximal section of the tibial
crest should have a 5mm build-up that flows into the borders and distal portion. Remember
that there will be a foam liner on the tibia. The lateral tibial epicondyle should also have a 5mm
build-up if prominent.
f) The posterior shelf in the popliteal area should be at the same height as the apex of the tibial
tubercle. Its purpose is to provide a flare while sitting and relief for the hamstrings. The relief
for the medial hamstrings should be 5mm lower than the lateral. Blend the shelf into the cast.
g) Smooth the whole cast and check alignment.
Mark the orthosis trimline as follows:

A The top must be horizontal, 6 cm above the patella tendon
groove.
B The patella and the hamstring tendons are left free.
C The shell overlaps the antero-posterior mid-line by 1.5 cm.
D At the ankle, keep the line 1 cm anterior to the top of the
malleoli.
E The usual distal limit of the anterior shell is horizontal, at 1/3 of
the length of the leg, but may be longer to provide greater
protection.
F At the forefoot, clear the sides of the toes and the head of the
metatarsus completely, passing beneath them. This will allow
the polypropylene to follow the movement of the metatarso-
phalangeal joints.
11.10 FITTING
In general, the fitting procedure is the same as with the other types of AFOs. Use a nylon or sock to
protect the patient's leg during initial fitting. Make sure the plastic has no sharp edges. Check the
patient's leg for any skin breakdown or red marks. Test for muscle tone in aligning the ankle in neutral.
Have the patient slip the leg into the posterior portion of the PTB orthosis.
Check the fit and trimlines for the following:
• Malleoli (minimal amount plastic to apex of malleoli) no pressure on the bones
• M/L borders (2/3 towards dorsum of foot)
• Distal trimlines to select motion control (malleolar fracture, it is kept the foot long. Mid tibia
fracture, it can be cut behind MT heads)
• Posterior popliteal fossa able to flex knee past 90° without pinching
• Contact by the plastic in the medial tibial flare
• No pressure at or around the fibular head
• Trimlines in the foot enable the putting on of a shoe easily
The anterior shell is now clipped over the posterior one and secured with straps. Check the following:
• Compression of the calf musculature to provide stabilizing hydrostatic pressure. If not sufficient
pressure, trim from the posterior shell M/L to achieve more compression. May need to cut lateral
tab deeper.
• Position of the patellar bar on the tendon
• No pain on the bony prominences
• Trimlines proximal anterior mid-patella, M/L to adductor tubercle if control needed. Distal
anterior shell is usually trimmed in a semicircular pattern at the level of the mid-tarsal joint.
Once the fit and trimlines are established it takes about an hour to finish the orthosis. The patient can
leave for choose to weight. All edges are beveled and smoothed. Holes 5mm or 6mm are drilled in the
anterior shell (through the foam) and posterior shell (proximal calf). The straps are riveted into place.
Final fit is achieved by the orthotist marking the straps for sufficient tightness and the patient practicing
putting it themselves. The orthotist should watch the walking pattern from both the sagittal and coronal
planes. If rollover is difficult then a rocker sole can be added to the shoe (with sufficient lift put on the
opposite shoe).
Follow up. Like with all orthosis, follow up is required to ensure patient comfort and compliance. Make
an appointment before they leave.
ACKNOWLEDGEMENTS
Franck Joumier Prosthetist Orthotist
Girma Bireda Prosthetist Orthotist
Hiywot Zerihun Biomedical Engineer
Sara Taye Physiotherapist
Brigitte Hoben Physiotherapist
Bernard Matagne Prosthetist Orthotist
Jean Pierre Schepens Prosthetist Orthotist
Roberto Ciconne Physiotherapist
Vincent Lejeune Physiotherapist

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International Committee of the Red Cross

Physical Rehabilitation Programme

Lower Limb Orthotics

VII. RIGID AFO ....................................................................................................................... 221

VIII. FLEXIBLE AFO ............................................................................................................... 237

IX. JOINTED AFO ................................................................................................................. 245

X. GROUND REACTION AFO ............................................................................................ 255

XI. PTB AFO ........................................................................................................................... 263

ACKNOWLEDGEMENTS ................................................................................................................. 274

The Rigid ankle foot orthosis is designed to provide maximum

Main Functions of Rigid AFO

• Instability of ankle and foot

7.3 TYPES OF RIGID AFO

Biomechanical Functions of Rigid AFOs

Biomechanical Principles of Rigid AFOs

3 Point Pressure Control System

Figure 146: 3PP control systems in a molded rigid AFO.

Figure 147: GRF control system in a molded rigid AFO.

Step 1: Evaluation of Positive Model

Step 2: Modification of the Heel and Forefoot

Step 3: Addition of Metatarsal Arch

Step 4: Modification of Medial and Lateral Longitudinal Arches

Step 5: Smoothing Tibia Section

Step 6: Addition of Plaster Build-Ups

Step 7: Smoothing and Evaluation of the Casts

7.8 MANUFACTURING PROCEDURE

*** Follow the ICRC manufacturing guidelines ***

Trimline for Correction of Forefoot Adduction

Varus / Valgus Correction

8.2 TYPES OF FLEXIBLE AFO

a. Posterior leaf spring ankle foot orthosis

Posterior Leaf Spring Ankle Foot Orthosis

Spiral Ankle Foot Orthosis

Biomechanical Functions of Posterior Leaf Spring AFOs

A Posterior Leaf Spring AFO:

Figure 157 Figure 158

Posterior Leaf Spring AFOs and Gait Deviations

Similar measurement procedures as Rigid AFOs are followed.

*** Follow the ICRC manufacturing guidelines ***

8.8 DESIGN (TRIMLINE)

Similar procedures as in Rigid AFOs are followed.

• Mild posterior tibial tendon dysfunction

9.3 TYPES OF JOINTED AFOs

Free Motion Ankle Joint

Dorsiflexion Stop Ankle Joint

Biomechanical Functions of Jointed AFOs

Biomechanical Principles of Jointed AFOs

Articulated Ankle Foot Orthoses

Free Motion Joints:

Ø Maximum frontal control

Ø No sagittal motion control

Ø Maximum frontal control

Ø Maximum plantar control

Ø Moderate genu recurvatum control

Ø Maximum frontal control

Ø Maximum dorsiflexion limit

Similar measurement procedures as Rigid AFOs are followed.

Function Design and Joint Placement

AFO Prescription - Measurement - Casting - Rectification & Fitting ICRC

AFO Prescription - Measurement - Casting - Rectification & Fitting ICRC

AFO Prescription - Measurement - Casting - Rectification & Fitting ICRC

* Follow the ICRC manufacturing guidelines *

* Follow the ICRC manufacturing guidelines *

* Follow the ICRC manufacturing guidelines *

* Follow the ICRC manufacturing guidelines *