• Ankle-Foot Orthoses 


The AFO is composed of a founda8on, ankle control, foot control, and a

superstructure. Founda8on The founda8on of the orthosis consists of the
shoe and a plas8c or metal component. Insert A plas8c or metal insert or
foot plate founda8on (Fig. 30.9) has several advantages. Because internal
modifica8ons can be incorporated in it, the insert provides good control
of the foot. It must be worn with a shoe that closes high on the dorsum of
the foot to retain the orthosis. The insert facilitates donning the orthosis
because the shoe can be separated from the rest of the brace. The insert
also permits interchanging shoes, assuming that all shoes have been
made on the same last. Less expensive shoes, such as sneakers, can be
worn, because the founda8on does not need to be riveted to the shoe.
Because the insert is usually made of a thermoplas8c material, such as
polyethylene or polypropylene, the orthosis with an insert is rela8vely
lightweight. The ortho8st creates a plaster model of the pa8ent’s leg,
then modifies the model, removing plaster in areas where the orthosis is
to apply substan8al pressure, and adding plaster where pressure relief is
required. Thermoplas8c is then heated and molded over the modified
plaster model. An insert founda8on, however, is inappropriate if the
pa8ent cannot be relied on to wear the orthosis with a shoe of proper
heel height. If the orthosis is placed in a shoe with too low a heel, the
uprights would incline posteriorly, increasing the tendency of the wearer’s
knee to extend. Conversely, if the orthosis is worn with a higher heeled
shoe, the pa8ent might experience knee instability. The insert reduces
interior shoe volume, and thus must be used with suitably spacious shoes.
Custommolded foot plates may be more expensive than other types of
founda8ons. If the orthosis is to be used by a very obese or excep8onally
ac8ve individual, a plas8c foot plate may not provide adequate support.
S8rrup An older founda8on for the AFO is the steel s8rrup, a U-shaped
fixture, the center por8on of which is riveted to the shoe through the
shank. The arms of the s8rrup join the brace uprights at the level of the
anatomical ankle, providing congruency between ortho8c and anatomical
joints. The solid s8rrup (Fig. 30.10) is a one-piece aQachment that
provides maximum stability of the orthosis on the shoe. The split s8rrup
(Fig. 30.11) has three segments. The central por8on has a transverse
rectangular opening. Medial and lateral angled side pieces fit into the
opening. The split s8rrup simplifies donning the orthosis because the
wearer can detach the uprights from the shoe. If a central piece is riveted
to another shoe, the shoes can be interchanged. The



Ankle Control Most AFOs are prescribed to control ankle mo8on by
limi8ng plantarflexion and/or dorsiflexion, or by assis8ng mo8on. The
pa8ent with dorsiflexor weakness or paralysis risks dragging the toe
during swing phase. Dorsiflexion assistance can be provided by a posterior
leaf spring that arises from a plas8c insert (Fig. 30.12). During early
stance, as the pa8ent applies force to the braced foot, the upright bends
backward slightly. When the pa8ent progresses into swing phase, the
plas8c recoils forward to liX the foot. Thinner, narrower plas8c permits
rela8vely greater mo8on. Mo8on assistance can also be achieved with a
steel dorsiflexion spring assist (Klenzak joint) (Fig. 30.13) incorporated into
each s8rrup. The coiled spring compresses in stance and rebounds during
swing. The 8ghtness of the coil can be adjusted. An orthosis with a
dorsiflexion spring assist is no8ceably bulkier than the posterior leaf
spring model. Both types of spring assists yield slightly into plantarflexion
at heel contact, affording the wearer protec8on against inadvertent knee
flexion. Other AFO designs which control toe drag are presented in Figures
30.14 and 30.15. Healthy subjects wearing a posterior leaf spring AFO
exhibited less hip extension and ankle plantarflexion during the transi8on
from stance to swing phase.39 AFOs with flexible ankle control altered the
stance phase transi8on between rear- and forefoot among nondisabled
adults.40 The alternate approach to prevent toe drag is plantarflexion
resistance, which stops the ankle from plantarflexing so that the pa8ent
with weak dorsiflexors will not catch the toes and stumble during swing
phase. A

joint placed in a plas8c hinged AFO (Fig. 30.16) or a steel posterior stop
(Fig. 30.17) can be incorporated in the s8rrup. The posterior stop also
imposes a flexion force at the knee during early stance, preven8ng the
knee from hyperextending. Healthy adults walking with the ankle fixed in
plantarflexion consumed more oxygen than when walking with AFOs
which kept the foot in neutral posi8on.41 An anterior ankle stop limits
dorsiflexion, aiding the individual with paralysis of the triceps surae to
achieve propulsion during late stance. Limi8ng all foot and ankle mo8on
can be done with a plas8c solid ankle-foot orthosis (Fig. 30.18); its
trimlines are anterior to the malleoli. Able-bodied adults fiQed with solid
ankle AFOs descended stairs more slowly than when walking without
orthoses.42 The solid ankle orthosis may be divided transversely at the
ankle, with the two sec8ons hinged, crea8ng the hinged ankle-foot
orthosis (see Fig. 30.16). It permits slight sagiQal mo8on, facilita8ng
progression to the foot-flat posi8on in early stance. The joint at the hinge
may be a plas8c overlap or a flexible plas8c rod. A versa8le op8on is a pair
of metal hinges that can be adjusted to alter the excursion of ankle
mo8on. An alterna8ve to the plas8c solid ankle AFO is a metal joint that
resists both plantarflexion and dorsiflexion, known as a limited mo8on
joint. One type of limited mo8on joint is a pair of bi-channel adjustable
ankle locks (BiCAALs) (Fig. 30.19) that consist of a pair of joints, each of
which has an anterior and a posterior

spring. The springs may be replaced by metal pegs (or pins), the lengths of
which determine the amount of mo8on provided by the orthosis. To
compensate for lack of plantarflexion in early stance, the shoe worn with
the solid AFO or the orthosis with a limited mo8on stop should have a
resilient heel. Similarly, to facilitate rollover in late stance, the shoe sole
should have a rocker bar. Hinged AFOs reduced frontal plane mo8on
during ramp descent exhibited by subjects who have subtalar
osteoarthri8s.43 Adults with hemiplegia who wore AFOs demonstrated
increased cadence, walking speed, step length, and ankle dorsiflexion,44
and the AFO enabled some pa8ents to walk with increased stride length
and cadence.45-50 Other subjects with stroke improved their scores on
the Berg Balance Scale when wearing AFOs51 and improved weight
transfer during stance phase.52 Balance improvement was also achieved
by those wearing an anterior AFO,53,54 while other subjects
demonstrated beQer func8on with a posterior leaf spring AFO.55
Orthoses may either contribute to improved compensatory func8ons of
the nonpare8c limb,56 or may be less important during swing phase of
the pare8c limb as compared with pelvic obliquity.57 A hinged AFO with
full-length insert and posterior stop improves early stance stability for
subjects with hemiplegia.58 The alignment of a solid AFO should be
individualized to achieve op8mal func8on.59 Limited inves8ga8on of
energy expenditure of adults with hemiplegia wearing AFOs suggests that
wearing orthoses results in more efficient gait.60-62 Adults with
hemiplegia complicated by plantarflexor contracture walk with less
plantarflexion and greater knee flexion when wearing either an AFO with
posterior stop or a solid AFO.63 Func8onal electric s8mula8on is an
alterna8ve to an AFO for some adults with stroke and other central
neuropathies. Various commercially available systems all incorporate a
cuff on the proximal leg; the interior of the cuff contains a skin electrode
over the peroneal nerve. The electrode is s8mulated by a self-contained
electrical unit. As compared to walking with an AFO, subjects report more
posi8ve results, par8cularly during swing phase.64-68 Children with
hemiplegic cerebral palsy improved weight-bearing on the pare8c limb
while wearing either a posterior leaf spring AFO or a hinged AFO with
plantarflexion stop.69 Other children with similar disability showed slight
gait improvement.70-72 Energy expenditure lessened when children wore
a hinged AFO.73-76 Other inves8gators found that hinged AFOs were
preferable to other designs for level walking77,78 and stair climbing.79
Some young pa8ents with excessive knee flexion achieved beQer gait
when wearing AFOs with anterior band (floor reac8on orthosis).80-82 The
desirable effect occurred only if the child did not have knee flexion
contracture. Foot Control Medial–lateral mo8on can be controlled with a
solid ankle AFO. The rigidity of the orthosis can be increased by using
thicker or s8ffer plas8c, corruga8ng the plas8c, forming the edges with a
rolled contour, or embedding carbon fiber reinforcements. A solid ankle
AFO (see Fig. 30.18) or a hinged solid ankle AFO (see Fig. 30.16) also
controls frontal and transverse plane foot mo8on of children with cerebral
palsy to a limited extent.83 Less effec8ve is a metal and leather orthosis
to which a leather valgus (or varus) correc8on strap is aQached. The
valgus correc8on strap (Fig. 30.20) is sewn to the medial por8on of the
shoe upper near the sole, and buckles around the lateral upright, exer8ng
a laterally directed force to restrain prona8on. The varus correc8on strap
has opposite aQachments and force applica8on. Either strap, although
adjustable, complicates donning. Superstructure The proximal por8on of
the orthosis, the superstructure, consists of one or two uprights, and a
shell, band, or brim. Plas8c AFOs usually have a single upright or shell.
Both the solid ankle and the hinged solid ankle AFOs have a posterior
shell extending from the medial to the lateral midline of the leg, thus
providing excellent medial-lateral control and a broad surface to minimize
pressure. The posterior leaf spring AFO (see Fig. 30.12) has a single
posterior upright that does not contribute to frontal or transverse plane
control. The spiral AFO (Fig. 30.21) is a design in which a single upright
spirals from the foot plate around the leg,

termina8ng in a proximal band. It may be made of polypropylene, nylon
acrylic, or carbon fiber. The spiral orthosis controls, but does not
eliminate, mo8on in all planes. Orthoses with plas8c shells or uprights are
molded over a cast of the pa8ent’s leg and are designed to fit snugly for
maximal control and minimal conspicuousness. Such AFOs are
contraindicated for the individual whose leg volume fluctuates markedly,
because the orthoses cannot be adjusted readily. Metal and leather
orthoses usually have medial and lateral uprights to maximize structural
stability. Occasionally, a single side upright will suffice when the pa8ent
insists on a less conspicuous orthosis and the person is not expected to
exert undue force. Some AFOs have an anterior upright, thereby avoiding
pressure and shear stress on the calf and Achilles tendon. Aluminum
uprights are typically used because they are lighter in weight than steel.
Carbon graphite and 8tanium uprights weigh appreciably less than
aluminum and rival the strength of steel; however, orthoses made of
these materials are more expensive. Most orthoses have a posterior calf
band made of rigid plas8c or leather-upholstered metal. The band has an
anterior buckled or pressure closure strap (Fig. 30.22). The farther the
band is from the ankle joint, the more effec8ve the leverage of the
orthosis; however, the band must not impinge on the peroneal nerve. An
anterior band that is part of a solid ankle AFO imposes posteriorly
directed force near the knee, enabling the AFO to resist knee flexion. Such
an orthosis is known as a floor reac8on orthosis (Fig. 30.23). In fact, all LE
orthoses are influenced by the floor reac8on when the wearer stands or is
in the stance phase of gait. If the AFO is to reduce the amount of weight
transmiQed through the foot, it may have a patellar-tendon-bearing brim
(Fig. 30.24), resembling a trans8bial (below-knee) prosthe8c socket. The
plas8c brim has a slight indenta8on over the patellar tendon, and is
hinged to facilitate donning. The brim must be used with a plas8c solid
ankle or a steel limited-mo8on ankle joint.