Selecting Appropriate AFOs: Key Considerations And Modifications

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The Arizona AFO is popular among podiatrists for treating Charcot deformities and adult-acquired flatfoot.
Selecting Appropriate AFOs: Key Considerations And Modifications
Clinical Editor: Nicholas Sol, DPM

Q: What are the three or four most frequent diagnoses for which you prescribe a hinged AFO?
Drs. Richie and Huppin each use hinged AFOs for adult acquired flatfoot secondary to posterior tibial tendon dysfunction (PTTD) and lateral ankle instability. Dr. Sol uses them for PTTD, spastic ankle equinus and neuromuscular disease.
Although adult-acquired flatfoot is “by far the most prevalent” condition for which Dr. Huppin uses a hinged AFO, he also utilizes these devices for subtalar joint DJD. Dr. Richie uses the hinged AFO for peroneal tendinopathy and employs them with dynamic assist hinges for dropfoot if there is no specificity of the calf.

Q: Which types of hinged AFOs do you most frequently prescribe and why?
Dr. Richie touts his own Richie Brace®. “This short, articulated AFO with a balanced podiatric orthotic footplate can address almost all of the conditions previously treated with long leg hinged AFOs,” he says. “The advantages are comfort, fit, cosmetic appearance, shoe fit and improved frontal and transverse control of the ankle-rearfoot complex.”
Likewise, Dr. Sol uses the Richie Brace or another freely articulated AFO for PTTD. To brace for spastic ankle equinus, he utilizes a tension reducing ankle foot orthotic (TRAFO), which he describes as “an articulated semi-solid AFO with medial and lateral adjustable limited motion joints.”
Dr. Sol will usually prescribe either a single or double upright for patients who require spring assisted dorsiflexion or plantarflexion. He says he does this because he has been “disappointed by plastic AFOs with integrated joints that neither provide enough torque nor endurance.”

Q: What shoe modifications do you most frequently prescribe for use with an AFO?
All three panelists advocate using rocker soles in some instances. Dr. Huppin uses various heel-to-toe rocker soles for those with ankle DJD.
“Prior to getting the AFO, it is imperative patients understand that they are likely going to need new shoes to fit the device and that modifications to those shoes may be necessary,” maintains Dr. Huppin.
To that end, he gives his patients a list of stable shoes that work well with the AFOs. For example, when Dr. Huppin treats those who have PTTD, he’ll add a medial buttress and medial flare to shoes for additional control.
Dr. Sol’s most common modification is a 3/8-inch double rocker sole for those with non-articulated ankle foot orthoses.
“The rearfoot rocker helps smooth loading response and relieves the knee from excessive shock,” he notes. “The forefoot rocker assists during the propulsive phase of gait and enhances hip extension, thereby reducing the load on the hip flexors.”
The rocker sole is the only shoe modification that Dr. Richie uses. He says he mainly prescribes this with a solid AFO because the abrupt flexion and extension moments transmitted to the knee during contact and heel rise can be “a great concern” with these AFOs. According to Dr. Richie, research has shown that if you use a solid AFO with shoes that have a rocker sole, you can reduce damaging knee moments.
Since post-polio patients commonly have a leg length discrepancy, he recommends using an external shoe lift instead of applying a heel lift to the solid AFO.

Dr. Sol (shown at the right) founded the Walking Clinic, PC and practices in Colorado Springs, Colo. He is a consultant to Tekscan.

Dr. Huppin is an Adjunct Associate Professor and Assistant Chairman of the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is also the Director of Education at ProLab Orthotics.

Dr. Richie is a Director of the American Academy of Podiatric Sports Medicine. He is also an Adjunct Clinical Professor of Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College.

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Anonymoussays: October 21, 2009 at 11:50 pm

My patient has dorsiflexion weakness with a muscle grade of 2 and exhibit a mild footdrop during swing phase should a posterior leaf spring ideal in this situation? The patient has normal muscle tone

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