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This information sheet answers your questions about ankle and foot orthoses: what they are, what they do and what the differences are between them. In addition we talk through the type of questions you might want to consider when meeting with your specialist. This was written with children in mind, but it is equally relevant to adults, and includes some quotes from adult users on their orthoses.
Ankle and foot orthoses (AFOs), or splints, are external devices fitted to the body which are used to:
They have been used for many years to help manage the gait (walking pattern) of children with hemiplegia. They are used to reduce unwanted and uncontrolled movements associated with muscle imbalances, weakness or increased tone (tightness) in the lower leg and the foot and ankle.
Abnormal movement in children with hemiplegia often means a tip-toe walking pattern (equinus or plantarflexed gait) with the added complication of the ankle becoming twisted outwards (varus ankle) or collapsing inwards (valgus ankle).
The adoption of a toe-walking gait also leads to secondary problems:
I am aware that when I walk, my arm comes up. It is almost a balance thing, and it has got worse as my walking got worse, if that makes any sense...It’s not as bad when I have a splint on my leg doing its job properly
Toe-walking gait not only affects a child’s posture, but also increases the potential risk of the development of contractures (shortening) of tendons and muscles, leading to permanent stiffening of the ankle and knee in later life.
One way to help prevent this type of walking is to fit a below-knee ankle/foot orthosis (AFO) which can help control any abnormal movement of the foot and ankle during walking, play or rest.
Not all children need an AFO. But those who do not have the problems of a toe walking gait may still have general weakness or some instability of the ankle joint complex. This can lead to problems of balance, such as walking with legs wide apart and a general loss of confidence.
In cases like this, the fitting of foot orthoses can be helpful in reducing unwanted foot and ankle positions and consequently improve balance and posture.
Ankle dorsiflexion is the movement of the foot at the ankle joint in an upward direction. Hemiplegia can affect a child’s ability to achieve ankle dorsiflexion (resulting in an equinus foot posture), and this impedes walking.
While the use of AFOs can be helpful in certain circumstances, some AFOs (particularly solid AFOs) don’t allow dorsiflexion to occur – and for some children this won’t be suitable. See next section for more information.
AFOs can be made with a solid ankle complex which holds the foot and ankle at a set angle usually around 90 degrees if the child can get this position easily (neutral plantargrade position). This prevents the foot and ankle from being pushed down (plantarflexion) and prevents the development of a toe-walking gait as well as sideways movements of the ankle (valgus and varus movements). While the use of a solid ankle AFO can be helpful in certain circumstances, it is not just incorrect movement that is restricted, the ability to dorsiflex (see previous section) is lost too – and for some children this won’t be suitable.
The hinged AFO is in many ways very similar to the fixed ankle type. During the manufacture of the hinged AFO a simple mechanical joint is fitted at the level of the ankle joint and incorporated into the moulding. A backstop is also fitted behind the ankle to prevent plantarflexion (toe walking).
The measures that can help reduce ankle and foot instability range from simple supportive footwear, to footwear with adaptations, to complex multi-material biomechanical and functional foot orthoses.
I was upset when H was given her first pair of Piedros, she was so dainty and was going to have to wear great big clumpy boots. But she loved them, and we made them pretty with frilly ankle socks. She only took them off for bed, they were her ‘special boots'
I am currently using a specially made insole which has had fantastic results. Before getting it I was told I would have to have an operation as that was the only option left. But since getting it my foot has dramatically improved - my ankle used to roll outwards and my foot would turn in, and now the ankle is completely central…
Unlike more traditional rigid orthoses, Supramalleolar Orthoses (SMOs - orthoses which finish just above the ankle) or Dynamic Ankle Foot Orthoses (DAFOs – a brand name) are thin and flexible. They come in a variety of designs and can be very useful in improving medial and lateral stability around the ankle.
There are a number of alternative treatments available to the families of children with hemiplegia, which can often be provided via the NHS, or via private health professionals. These include compression garments (elasticated material orthoses or splints). Although some people use these orthoses for their foot/leg, they are more often used for arm/hand. At the moment there is no conclusive medical evidence of the benefits of these garments in children with hemiplegia, but there are families who have told HemiHelp that they have worked for their children. They may be useful for children who have a type of muscle stiffness called dystonia, where the muscles pull in more than one direction, which can make rigid splints very painful. However, they are not the answer for all children with hemiplegia, and care has to be taken, with advice from professionals closely involved in your child’s care as to the efficacy of this treatment.
Whatever type of orthosis is recommended or fitted, they share many common design points and try to provide some or all of the elements below:
Orthoses are not a stand-alone solution to balance, posture and gait difficulties caused by hemiplegia, and are commonly used with other interventions as part of a child’s overall management programme. It is also true that no two children are the same and what works for one might not work for another.
The goal of splints is to provide the least amount of restriction as possible while still encouraging and promoting a child’s own abilities and long-term development.
It is important that a full assessment is carried out in a relaxed environment to ensure that the correct orthotic prescription is made. A quick 10-15 minute consultation in a busy clinic to take a decision on orthotic provision and design will most probably not lead to the best outcome. Once fitted with an orthosis, the child needs to have regular reviews to ensure the continued effectiveness of the orthosis as her or he develops and grows.
When choosing the best splint to supply a child’s orthotist and therapist should consider what developmental level the child is at and what they do all day. How the splint will be worn and how easy it is to get on and off. For older children a splint may not be acceptable because of its appearance and this should be considered carefully and discussed with them to get their agreement before it is supplied.
It is important that a full assessment is carried out in a relaxed environment to ensure that the correct orthotic prescription is made. A quick 10–15 minute consultation in a busy clinic will most probably not lead to the best outcome.
Information should be given about when to wear the splint, how to look after it and what to do if there are problems. A time frame to review the splint should be agreed as this will ensure it remains a good fit and continues to be useful when the child develops and grows.
When a child grows out of their orthosis always ask yourself the question: is my child still getting some benefit from this type of orthosis? A full assessment must be carried out again to review the type of orthotic management the child needs.
We can provide references on the source material we used to write this information product. Please contact us at firstname.lastname@example.org
HemiHelp makes every effort to ensure the accuracy of information in its publications but cannot be held liable for any actions taken based on this information.
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