Key Pearls For Prescribing AFOs

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Some DPMs have found AFOs helpful in treating dropfoot.
Clinical Editor: Howard Dananberg, DPM

Q: Are there any specific problems you see with AFOs that could be considered areas to avoid during the fabrication process?
Dr. Dananberg says he often finds the foot bed of the device is excessively long and ends in front of rather than behind the metatarsal heads. Although some who fabricate these AFOs may feel the increased length will better maintain the toes’ rectus position, Dr. Dananberg believes this increased length blocks metatarsophalangeal joint dorsiflexion and makes walking most difficult.
By creating a device that ends behind the metatarsal heads and even incorporating a first ray cutout, you can achieve sufficient control of a dropfoot condition, according to Dr. Dananberg. The difference is patients can step efficiently and far more comfortably, notes Dr. Dananberg. He adds that designing a device this way “can often prevent the arch irritation so common with AFO use.”
Dr. Richie says you must inform the lab about the specific limitations of the patient in terms of fixed structural deformity as well as muscle weakness or spasticity.
“Patients with lateral ankle instability and high tibial varum should have their AFOs modified to fit the varus deformity of the leg. Otherwise, their lateral instability will get worse,” he contends.
Dr. Richie says you cannot position a patient with dropfoot and severe equinus in a fixed solid AFO set at 90 degrees at the ankle. He also notes that one should not prescribe an articulated, full-motion AFO for a patient with spasticity. In summary, Dr. Richie says it is essential to give the lab as much biomechanical information about your patient as possible.
“Certainly, this is much more important than the required information for the fabrication of standard custom foot orthoses,” he concludes.

Dr. Dananberg (pictured) practices in Bedford, N.H.
Dr. Richie is a Director of the American Academy of Podiatric Sports Medicine. Dr. Banks is the Director of Podiatric Medical Education and Residency Training at the Emory-Northlake Regional Medical Center in Tucker, Ga. He is a Fellow of the American College of Foot and Ankle Surgeons and is on the faculty of the Podiatry Institute.

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