Table 1

The main types of impairment seen in neurological orthotic practice are listed in approximate order of severity, noting problems in swing phase, stance phase and commonly used orthotic prescriptions

Impairment	Swing phase problem	Stance phase problem	Primary objective of orthosis	Solutions
Foot slap, for example, tibialis anterior tendinopathy	None	Uncontrolled plantar flexion at initial heel contact, then stable	Stop slapping noise: reduce the force that tibialis anterior needs to apply to control plantarflexion	Modify sole of shoe by moving point of initial contact anterior, towards line of action of tibialis anterior, reducing moment of rotation (figures 1 and 2) or simple AFO (figures 3 and 4)
Minor calf shortening, stable ankle	None	Calf discomfort in flat shoes, ascending slopes; knee hyperextension	Comfort in standing, prevent long term knee injury	Heel wedges inside normal shoes
Isolated low or normal tone foot drop, for example, some upper motor neurone lesions, peroneal neuropathy	Foot drop	Once foot flat on ground, stable	Prevent foot drop in swing	Elastic Lifter, posterior leaf spring (PLS), carbon fibre or silicone AFO (figures 5–7) functional electrical stimulation
Spastic plantar flexion but not inversion, little or no calf shortening	Foot drop	Once foot flat on ground, stable	Prevent foot drop in swing	Stiffer carbon fibre AFO±heel wedges (figure 8) functional electrical stimulation
Spastic plantar flexion and inversion, ±shortening, for example, late cerebral palsy, multiple sclerosis	Spastic plantarflexion and poor hip and knee control	Initial contact with lateral forefoot, may not get heel to ground	Support foot in optimal position, compensate for lost range, facilitate knee flexion in late stance	Moulded AFO (figure 9)
Very weak plantar flexors, low tone, unstable ankle for example, Charcot-Marie-Tooth, Guillain-Barré syndrome, Duchenne muscular dystrophy	Foot drop, difficulty lifting weight of leg	Unstable base of support at ankle	Compensate for weak plantar flexors in stance, as well as foot drop in swing	Strong, stiff carbon fibre (figure 8) or moulded if loss of normal passive range, figure 9)
Weak quadriceps and ankle muscles, for example, poliomyelitis, Guillain-Barré syndrome	Foot drop, difficulty lifting weight of leg	Unstable base of support at ankle and knee	Stabilise knee in stance	AFO is aligned to use ground reaction force to keep shin upright and hence knee straight: strong, stiff carbon fibre (figure 8) or moulded if loss of normal passive range, figure 9
Marked loss of range, for example, fixed plantar flexion but within normal range for ‘standing on toes’ and inversion, for example, late cerebral palsy	Dwarfed by difficulty in stance phase and control of entire limb	Unstable base of support due to small weight bearing area	Permit standing for transfers, therapeutic standing in frame	Stretch by serial casting + botulinum toxin, surgery. Moulded AFO with big heel build up (figure 10).
Fixed in extreme plantar flexion±inversion, for example, late after adult hypoxic brain injury	Only swing phase is when hoisted for transfers	No usable weight bearing area, unable to stand	Permit therapeutic standing in frame and keep feet on wheelchair footplates	Surgery, no AFO
Risk of calf contracture and heel sore while bed bound	Nil	Nil	Maintain ankle range	Pressure relieving or resting AFO (figure 11)
Leg swelling, volume fluctuation	Varies	Rigid AFO does not fit consistently	Usually control ankle in stance phase	External caliper or plastic AFO (figures 12 and 13)
Calf contracture	Varies	Cannot get heel to ground	Regain lost range	Contracture correction device, applying sustained calf stretch (figure 14)
Active patient, for example, running	Foot drop	Good function	Not break during high impact activities	Robust springy external AFO, Turbo Med (figure 13)
Poor ankle control, which responds to compression, perhaps improving proprioception	Variable foot drop	Adequate power but poor control	Optimise active muscle control	If positive response to Tubigrip, bespoke Lycra stocking (figure 15).

The orthotics options are shown in figures 1–15.
AFO, ankle foot orthosis.