Tag Archive: AFO


AFOs for Foot Drop

My last blog entry served as a bit of an introduction into the topic of AFOs. (If you didn’t read it, here is your chance). By way of quick review, AFO is an abbreviation that stands for “Ankle Foot Orthosis”.  Orthosis is the more formal term for a brace.

The number 1 most common reason for someone to wear an AFO is because they have a condition known as “Foot drop (or drop foot)”. Foot drop happens when there is weakness in a muscle group called the “Dorsiflexors”. These muscles run along the front of your lower leg and ankle. They are responsible for the action of lifting your toes up. The muscles in the Dorsiflexor group include the Anterior Tibialis, the Peroneus Tertius and the Extensors of the Toes.

Foot drop muscles

Sometimes when a person has foot drop, the Dorsiflexor muscles themselves are weak, but most frequently it is actually the nerve that runs to these muscles that isn’t functioning properly. Because it is so often a nerve problem, foot drop occurs many times in people who have had a stroke, brain injury or multiple sclerosis. It also common in people who are born with cerebral palsy, muscular dystrophy, CMT, or many other conditions. Foot drop can also be the result of a back or leg injury.

All of these Dorsiflexor muscles are controlled by a nerve called the “Common Peroneal Nerve”. This nerve is actually an extension of the Sciatic nerve which branches off the spinal cord at the lower back and runs all the way down through the leg. If this nerve is damaged at any point, there is a very good chance that the signals will be disrupted and some leg and ankle weakness will occur as a result.

Nerves of Foot Drop

Drop foot can range from mild weakness to complete paralysis of the effected muscle groups. People with mild foot drop sometimes only notice it when they are tired at the end of a long day. Many times mild cases of drop foot go unnoticed until the person begins to realize that they are tripping and falling more frequently than usual, especially on uneven surfaces.

Those with more severe drop foot usually walk with a very distinctive gait called a “steppage gait”. This is where the person picks their knees up especially high in order to allow their foot to swing forward without snagging on the ground. When the foot is placed down on the ground it usually hits with a slapping noise as the toes uncontrollably flap onto the floor.

Here is a little video demonstration:

 

 

The job of an AFO for someone with drop foot is to keep the toes from dragging while the person walks, and also to slow down the slapping motion as the foot is planted on the ground. A whole multitude of devices have been invented to do this task.

Very mild drop foot can be treated with devices like this:

mild foot drop options

More complicated cases of drop foot sometimes require custom molded AFOs with a variety of features. Here is a little photo gallery of typical drop foot AFOs:

Foot drop AFOs

Custom foot drop AFOs like these are made by Orthotists and Pedorthists. They are typically made from a cast of the patient’s leg. The AFO is then designed and fabricated exactly to the specifications of each individual patient. Custom AFOs usually work very well (if the person making it did a good job), but they have several draw-backs: It takes a long time to make them, they are super expensive and because they are made so precisely, they have to be adjusted and fine-tuned frequently to ensure that they fit correctly. If the AFO was made for a child, constant changes have to be made to accommodate growth. Even adults tend to lose and gain weight over the course of the years. These changes can jeopardize the fit of the AFO. A poorly fitting AFO is not as effective as it should be and it can even be dangerous because it could lead to falls or it could cause a sore on the skin.

Because of these complications, new solutions to foot drop are beginning to flood into the market. My personal favorite development is carbon graphite AFOs. These AFOs are lightweight and strong. They are low profile because they don’t have to include bulky joints like the old fashioned plastic AFOs. Many models of this type of AFO can be purchased completely ready to wear. This eliminates the long process of taking molds of the patient’s feet and making the AFOs from scratch. Many patients use a custom foot orthotic in addition to the carbon graphite AFOs in order to ensure total comfort and appropriate support.

The reason carbon graphite AFOs are so cool is that the material is springy which means that it provides energy return. This allows the person wearing the AFO to walk with a very smooth and natural gait. Some people are even able to run marathons, hike, bike, etc with the use of this type of AFO. Can you tell that I am excited about this technology? Here are some cool videos of people using a few of the more common carbon graphite AFOs:

 

 

before:

 

after:

one more:

 

 

These are just some examples of the new solutions to the problem of foot drop. I think that carbon graphite AFOs are the wave of the future. I am very interested in watching the evolution of the AFO as patients become more thoroughly informed about their treatment choices. Patients now have access to huge amounts of information in all sorts of formats (including possibly, dare we say – this blog). They can then use these facts and concepts to educate their caregivers and voice their opinions and preferences. This is great! It means that more and more people get to take advantage of the cutting-edge technology choices. This process then drives improvements and encourages the development of even newer and better AFOs. How exciting!

Walk well.

Creative problem solving

My grandpa fell in love with my grandma because of her creativity. They were in college and they both were attending a dance in a lodge with a fireplace. As soon as the fire was lit, the room began to fill with smoke. Grandpa climbed up on the mantle to investigate the problem and found that the flue wasn’t staying open. He called down into the crowd saying he was sure he could fix the issue if only someone would bring him some string. Soon a girl (Grandma) came over with a small length of white rope. “Will this do?” He saw that it was a string from a mop and he laughed.  It did the trick. He fixed the flue, they danced the night away and the rest is history.

I get really excited about creativity. I guess you could say it’s in my blood. I especially admire innovative problem solving. Albert Einstien famously said: “The definition of insanity is doing the same thing over and over and expecting different results”.

When I think about this quote I remember something that I watched happen while I was on a mission’s trip in the Dominican Republic. Our group was doing some demolition and construction work. Part of this involved using sledge hammers to break up an old cement staircase. We had some big strong guys in our group who were confident that they could handle the job. The biggest guy grabbed the heaviest hammer and swung it as hard as he could. It bounced off the cement without even making a dent. He swung again and again with only blisters on his hands to show for all the effort. Our translator, who was just a skinny little guy, shook his head when he saw what our strong men were doing and picked up a hammer to show how it was supposed to be done. He took one swing and chipped a huge piece off the edge of the top step, he took another and an even bigger chunk cracked away. He explained that cement is resistant to direct blows but if you hit it at an angle it becomes fragile.

I remember this every time I come up against a big obstacle. If at first you don’t succeed…Try the periphery. Walk the borders and look for another way in. Use glancing blows. Harness your creativity. This is what problem solving is all about.

I chose to work in the discipline of Orthotics for several reasons, but one of them was because I saw that it had problems that needed solving. In my undergraduate arrogance I was sure that I could fix the field singlehandedly. I couldn’t wait to get started. Now that I’m actually working in the profession I can still see those flaws, but they seem bigger and more complicated up close. One of the most challenging aspects of the field is its inertia. It’s a lot like an old decrepit concrete staircase that has been sitting around unchanged for the last 50 years.

Here’s an example: Below are 2 pictures of AFOs (Which stands for Ankle Foot Orthosis, “orthosis” means “brace”).  The type of metal brace pictured has been around since the Civil War, and believe it or not, people still wear them today. Can you imagine if all medical technology had not advanced since the Civil War days? We would still be performing operations with rusty old saws and dying from infections without the use of antibiotics. To be fair, that type of AFO is now referred to as the “old style” but “old style” in the same way that bellbottom pants are old style…they are still acceptable, just not considered cutting edge.

old AFO

pic from: http://www.orthomedics.us/Pages/ankle.aspx

The “New style” AFOs are made out of plastic. This type of AFO began to be used in the late 1960’s -1970s, and it really hasn’t changed since. Once again, just for a little perspective – Star Trek was a hit show when this type of brace was developed…to a young person like me this is ancient history. In the last 5 years the Orthotic industry has started to think about possibly accepting the computer fabrication, 3D printing and CAD CAM methods of making braces. But with characteristic glacial slowness, acceptance of this advanced technology hasn’t become very widespread.

Plastic AFO

Pic from: http://www.georgelianmd.com/cms/InformationLinks/Braces/tabid/124/Default.aspx

There are, of course, multiple reasons for how “stuck in a rut” the Orthotic field is. For one thing, only a few orthotic training programs exist in the country, and those are run by the old-school practitioners who continue to teach the “time tested” methods of brace making. For another thing, insurance companies use a series of L-Codes to categorize braces and determine how much money they are willing to pay for each type of brace. These L-codes were set up in the same Star Trek, bellbottom era as the plastic AFOs, and the system is limited largely to what was available back then. Practitioners can’t afford to make newer, more elaborate braces if they are still going to get paid 1970’s prices for their work. And that’s just the beginning of the reasons for the profession’s retarded development.

Realizing all of this has been a little daunting. I don’t think I will be able to wave my magic wand and fix this profession as quickly as I had planned. It’s going to take some work. I’m going to have to continue to swing my sledge hammer at the edges of the problem. Fortunately I am young and patient. The demographics of the Orthotics profession is changing, more young people like me are joining up. I hope they bring their creativity with them.

I have plans to pursue a PhD in the near future. This will allow me to do research in and around the Orthotics field. I can study the old methods and think of new solutions. There is only one problem…I’m going to have to be creative about finding a research institution that will equip me with the knowledge and skills I need to move forward. (In case you hadn’t guessed, I can’t exactly find a university with a graduate program tailor-made for problem solving within the Orthotic industry…try googling that. Nothing.)  It’s just another barrier to negotiate around. (Seriously, if you have suggestions on grad schools let me know.) Collaboration and an interdisciplinary approach is the key.

Some people are already coming up with creative solutions. Check out this website:

http://www.silverringsplint.com/about/

Here’s an example of someone taking an old clunky style brace like this:

Clunky finger splint

And making it into something modern and beautiful and functional like this:

Cool ring splint

That’s creative genius. That’s what I’m talking about.

It’s innovation like this that gets me fired up. We need to take the same imaginative problem solving into the rest of Orthotics. This is important, because if we don’t change our profession we will just continue on in the status quo. Extinct like the dinosaurs. Stuck in a time warp. Doing the same thing over and over again. How insane would that be?

Walk well (and think creatively!).

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