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

ImpairmentSwing phase problemStance phase problemPrimary objective of orthosisSolutions
Foot slap, for example, tibialis anterior tendinopathyNoneUncontrolled plantar flexion at initial heel contact, then stableStop slapping noise: reduce the force that tibialis anterior needs to apply to control plantarflexionModify 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 ankleNoneCalf discomfort in flat shoes, ascending slopes; knee hyperextensionComfort in standing, prevent long term knee injuryHeel wedges inside normal shoes
Isolated low or normal tone foot drop, for example, some upper motor neurone lesions, peroneal neuropathyFoot dropOnce foot flat on ground, stablePrevent foot drop in swingElastic 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 shorteningFoot dropOnce foot flat on ground, stablePrevent foot drop in swingStiffer carbon fibre AFO±heel wedges (figure 8) functional electrical stimulation
Spastic plantar flexion and inversion, ±shortening, for example, late cerebral palsy, multiple sclerosisSpastic plantarflexion and poor hip and knee controlInitial contact with lateral forefoot, may not get heel to groundSupport foot in optimal position, compensate for lost range, facilitate knee flexion in late stanceMoulded AFO (figure 9)
Very weak plantar flexors, low tone, unstable ankle for example, Charcot-Marie-Tooth, Guillain-Barré syndrome, Duchenne muscular dystrophyFoot drop, difficulty lifting weight of legUnstable base of support at ankleCompensate for weak plantar flexors in stance, as well as foot drop in swingStrong, 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 syndromeFoot drop, difficulty lifting weight of legUnstable base of support at ankle and kneeStabilise knee in stanceAFO 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 palsyDwarfed by difficulty in stance phase and control of entire limbUnstable base of support due to small weight bearing areaPermit standing for transfers, therapeutic standing in frameStretch 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 injuryOnly swing phase is when hoisted for transfersNo usable weight bearing area, unable to standPermit therapeutic standing in frame and keep feet on wheelchair footplatesSurgery, no AFO
Risk of calf contracture and heel sore while bed boundNilNilMaintain ankle rangePressure relieving or resting AFO (figure 11)
Leg swelling, volume fluctuationVariesRigid AFO does not fit consistentlyUsually control ankle in stance phaseExternal caliper or plastic AFO (figures 12 and 13)
Calf contractureVariesCannot get heel to groundRegain lost rangeContracture correction device, applying sustained calf stretch (figure 14)
Active patient, for example, runningFoot dropGood functionNot break during high impact activitiesRobust springy external AFO, Turbo Med (figure 13)
Poor ankle control, which responds to compression, perhaps improving proprioceptionVariable foot dropAdequate power but poor controlOptimise active muscle controlIf positive response to Tubigrip, bespoke Lycra stocking (figure 15).
  • The orthotics options are shown in figures 1–15.

  • AFO, ankle foot orthosis.