LOWER LIMB ORTHOSIS

D r. S u m i t R a g h a v, P T
As s i s t an t P ro f e s s o r
Jyotirao Subharti College of Physiotherapy
 ANKLE-FOOT ORTHOSIS (AFO)

AFO is prescribed for-

1. Muscle weakness affecting the ankle and sub-talar
joint
2. Prevention or correction of deformities of the foot
and ankle
3. Reduction of inappropriate weight bearing forces
 TYPES

1. Polypropylene solid AFO

2. Hinged AFO (HAFO)
3. Metal and leather AFO
4. Floor reaction AFO (FRAFO) or Ground reaction AFO
(GRAFO)
5. Posterior leaf spring AFO (PLS-AFO)
6. Supra-malleolar orthosis
7. Dynamic AFO
Polypropylene Solid AFO
 Polypropylene Solid AFO

 The solid or rigid AFO allows no ankle motion, it covers the back
of the leg completely and extends from just below the fibular
head to metatarsal heads.

 The solid AFO enables heel strike in the stance phase and toe
clearance in the swing phase. It can improve knee stability in
ambulatory children.

 It also provides control of varus/ valgus deformity. Solid AFOs

provides ankle stability in the standing frame in non-ambulatory
children.
Cont….

 A solid ankle foot orthosis aims to prevent all movement of the

foot and ankle at the talo-crural, subtalar and midfoot joints.
 It is commonly prescribed in case of moderate to high spasticity
in children with cerebral palsy.
Hinged AFO
 Hinged AFO

 Hinged AFOs have a mechanical ankle joint usually preventing

plantar flexion, but allowing relatively full dorsiflexion during
the stance phase of gait.

 They provide a more normal gait because they permit

dorsiflexion in stance phase of the gait, thus making it easier to
walk on uneven surfaces and stairs.

 This is the best AFO for most ambulatory patients. Adjust the
plantar flexion stop in (3- 7 degrees) dorsiflexion to control knee
hyperextension in stance in children with genu recurvatum.
Cont….

 The hinged AFO is contraindicated in children who do not have

passive dorsiflexion of the ankle because it may force the midfoot
joints into dorsiflexion and cause midfoot break deformity.

 Knee flexion contractures and triceps weakness are other

contraindications where a hinged AFO may increase crouch gait. 

 The AFO may be fitted with a hinge that allows 10 degrees passive
dorsiflexion while preventing plantar flexion. This creates a
more natural gait.
Metal and Leather AFO or Conventional AFO
Metal and Leather AFO or conventional AFO

This type of AFO is to prescribed with adjustable ankle

joint for plantar flexion and dorsiflexion and corrective
straps for valgus and varus deformities.
This AFO provides some medio-lateral stability.
This is the oldest type of AFO.
FRAFO or GRAFO
 Floor Reaction AFO or GRAFO

This type of AFO is made with a solid ankle, the upper portion wraps around
the anterior part of the tibia proximally with a solid front over the tibia.

The rigid front provide strong ground reaction support for patients with weak
triceps surae. The foot plate extends to the toes. The ankle may be set in slight
plantar flexion of (2-3 degrees) if more corrective force at the knee is
necessary.

Use the GRAFO in patients with quadriceps weakness or crouch gait. It is an

excellent brace for patients with weak triceps surae following hamstring
lengthening.

Children with static or dynamic knee flexion contractures (more than 15

degrees) do not get benefit out of it and do not tolerate the GRAFO.
PLS_AFO
 Post. Leaf Spring AFO

 A Posterior Leaf Spring AFO is a rigid AFO trimmed behind the

malleoli’s to provide flexibility at the ankle and allows passive
ankle dorsiflexion during the stance phase.

 A PLSO provides smoother knee-ankle motion during walking

while preventing excessive ankle dorsiflexion Varus-valgus
control is also poor because it is repeatedly deformed during
weight bearing.

 A PLSO is an ideal choice in mild spastic equinus. Do not use it

with patients who have crouch gait and pes valgus.
Cont..

 The Posterior Leaf Spring (PLS) AFO is deemed a swing phase

orthosis in that it is effective during swing phase only.

 It permits controlled plantarflexion in early stance phase during

loading of the limb and then maintains the foot at plantargrade
during swing phase to ensure the foot clears the ground.

 The orthotic treatment goal of the PLS-AFO is to maintain the

foot and ankle in a plantargrade position during swing to permit
foot clearance, but permit ankle plantarflexion and dorsiflexion
during stance phase.
Supramalleolar Orthosis (SMO)
 Supra-malleolar Orthosis (SMO)

A SMO (Supra-malleolar Orthosis) supports the foot just

above the ankle bone or malleolus. 

SMOs are prescribed for patients who have soft, flexible,

flat feet (pes- plano valgus).  They are mostly worn by
children. 

The SMO is designed to maintain a vertical, or neutral, heel

while also supporting the arches of the foot. A SMO can
help improve standing balance and walking.
Dynamic AFO
 Dynamic AFO

The Dynamic Ankle Foot Orthosis generally refers to a custom

made Supra-malleolar orthosis fabricated from thin
thermoplastic material.

It fits the foot intimately and the use of the flexible and thin
thermoplastic means that the DAFO can provide circumferential
control of the rear and fore foot to maintain a neutral alignment.

In the original designs of DAFOs, a ‘neurological’ foot plate

was often incorporated that consisted of a pad at the peroneal
notch, a metatarsal dome and dorsiflexing the lateral four toes
Cont..

 It was theorized that applying these pressures to the foot would

decrease the level of spasticity in the gastrocnemius and therefore
reduce the level of equinus often observed in spastic CP gait.

 To effectively control sagittal plane deformities such as a plantar

flexed ankle, a long lever arm is required that involves extending
the trim lines up to the proximal calf.

 Therefore, DAFOs should only be used where there is coronal or

transverse plane deformities of the foot and ankle that can be
passively corrected with minimal force.
 Parts of conventional AFO
Proximal calf band with
leather straps

Medial and lateral bars

articulating with medial
and lateral ankle joint
help in control of plantar
and dorsiflexion

Stirrup anchor the

uprights to the shoe
 Orthotic Ankle Joint

1. Free ankle (normal)

2. Limited ankle joint (if ankle is in flail position)
3. 90 degree foot drop stop ankle joint(in dorsiflexors
weakness)
4. Reverse 90 degree ankle joint( in case of calcaneus
deformity)
5. Fixed ankle joint (weight relieving from foot)
 Indications

Paralysis of dorsiflexors
Paralysis of plantarflexors
Paralysis of muscles of both foot and ankle
Spasticity
Calcaneal Fracture ( A window is provided to avoid
direct contact of heel to innersole)
 Knee Ankle Foot Orthosis (KAFO)

It is prescribed for the mobility and stability to knee,

ankle and foot.

Parts of KAFO- similar as conventional AFO,

uprights are extended to the lower thigh band
Conventional KAFO
 Orthotic Knee Joint

Knee joints are provided in calipers, so that the

wearer can sit down.
There are three basic types of orthotic knee joints:

1. Straight set knee joint

It provides rotation about a single axis. It allows free
flexion and prevents hyperextension. It is used in
combination with a drop lock to give further stability.
This is the joint usually prescribed in India. It is cheap
and easy to repair
Cont….

2. Polycentric knee joint

It uses the double axis system to simulate the
flexion/extension movements of femur and tibia at the
knee joint

3. Posterior offset knee joint

It is prescribed for patients with weak knee extensors
and good hip extensor strength.
 Knee Locks used in KAFO

These are locks incorporated into the knee joint, to

stabilize the knee joint in extension.
 Drop Lock

It is placed on the lateral upright bar and drops over

the joint when fully extended. This is commonly used
in India.
 Spring Loaded Lock

It may be added to the drop ring lock when the

patient is unable to reach the knee joint. It provides
automatic locking rather than gravity dependence.
This lock is easier for locking and unlocking the
knee.
 Cam Lock

Cam lock with spring loaded cam fits into groove in

full extension. It is also easier to release and gives
good stability.

In double upright bar, it provides simultaneous

locking and unlocking thereby provides maximum
rigidity.

It is indicated in weight bearing braces when

semiautomatic unlocking is desired.
Cam Lock
 Ball Lock/Swiss Lock

It provides an easy method of unlocking medial and

lateral knee joints.

The patient can catch the ball on the edge of the

chair to release the lock mechanism to permit sitting.

This is useful for adolescent young men and women

who are conscious about their appearance and can
wear the caliper beneath their clothes.
Ball Lock/Swiss Lock
 Dial Lock

It may be adjusted every 6 degree for precise control

of knee flexion.
 Plunger Type Lock

It is cosmetically more acceptable since it is

concealed in the knee mechanism. It is indicated in
persons having hand weakness.
 Indications

Muscle weakness (mainly quadriceps and hip

extensors)
Upper motor lesion (improve impaired
locomotion due to loss of normal control of muscles
of lower limb)
Loss of structural integrity ( due to ligaments
injury and joint disease)
Deformity of joint
Load bearing problem
 Hip-Knee-Ankle-Foot Orthosis (HKAFO)

It can be prescribed with a pelvic band, which is used

to control rotational movement at hip joint.

The pelvic band is a padded rigid steel band

extending posteriorly and laterally, which fits
between iliac crest and greater trochanter.

A soft front closure with Velcro or buckle strap

fastener is used.
HKAFO
Conventional HKAFO
Cont….

It is connected by lateral upright to KAFO with

uniaxial hip joint usually with a drop lock, which
allows hip flexion and extension only.

It could also be used in an ischial weight relieving

caliper in which patients bears weight on the ischial
seat and weight is transmitted from ischial seat
through metal uprights and shoe sole to the ground.
Cont….

HKAFO provides improved standing balance and a

better controlled forward leg swing in patients with
weak hip muscles.

Disadvantages of HKAFO: difficulty in donning

and doffing, decrease step length and significant
increase in lumbar spine movements to compensate
for limited hip motion.
 Components of HKAFO
Same components as
for KAFO, except that
in addition there is an
attached hip joint, with
a drop lock and a pelvic
band, which
encompasses the pelvis
between the iliac crest
and greater trochanter
 Uses

It is prescribed whenever the muscles controlling the

hip and its stability are weak.

Control hip rotation

To limit internal rotation, the client wears a waist

belt, secured to the posterior midline of the belt are
two straps, each having its distal attachment on each
of the uprights of the HKAFO.
Cont….

To limit external rotation, a strap doubled on itself

passes anteriorly between the left and right lateral
uprights

Hip Control

Bilateral hip joints control frontal and transverse

plane motion
 Functional Electrical Stimulation(FES)

Technique that used electric currents to activate

nerves innervating extremities affected by paralysis
and neurological disabilities to restore normal
functions

The concept of FES was introduced by Liberson and

co-workers to control foot drop during the swing
phase in hemiplegic patients. This theory is based on
the survival of motor neuron in UMN lesion such as
hemiplegia.
Cont….

Such stimulation is done to obtain a functional

movement, such as picking up objects or walking.
Multichannel stimulators are being used for
paraplegics in research laboratories, to stimulate
walking.

A FES consists of:

• Stimulator
• Leads/Cables
• Electrodes which may be superficial and implanted
 Miniaturization and Portability

A miniature electrical stimulator producing currents

between 90 and 200 mA, of pulse duration between
20 and 300 microseconds, and voltage between 50 to
120 V is fitted to the patient.

It must be lightweight and portable.

 Placement

A power pack which powers the stimulator is worn on a

waist belt and in the typical peroneal stimulator, one skin
electrode is applied to the common peroneal nerve below
fibular head on the affected side, while the inactive
electrode is applied to the leg at motor point tibialis
anterior muscle
 Method of Application

A heel switch is incorporated in the shoe that turns

on the stimulator when the heel leaves the ground
and turns it Off on heel strike.

Thus at heel off the tibialis anterior and other

dorsiflexors are stimulated, affording clearance, and
at heel strike the stimulation is switched off, allowing
the ankle to become plantigrade.
 Implanted Electrodes

Some times electrodes are surgically implanted

instead of being placed directly on the skin. This
eliminates the need for wires passing all over the
affected area.
When an implanted electrodes is used, it must be
placed directly on the nerve with a flexible wire
lead/cable connected to a subcutaneously implanted
receiver located over the antero-medial aspect of
thigh.
Cont….

There is an antenna located over the implanted

receiver, responding to signals from a transmitter
incorporated into the shoe. Phasing of the
stimulation during the gait cycle is controlled by the
heel switch. The power pack for the stimulator and
transmitter in worn at waist
 Criteria

The selection of patients who can use the FES has to be

done carefully:
1. Such patients should be able to walk independently
at a speed more than 25m/min without an orthosis,
and have good balance and saving reactions.

2. The major gait problem should be foot drop, without

equinus contracture.
3. Proprioception should also be intact
Cont….

4. The regular use of FES system could result in an

increase in the strength of foot dorsiflexors in the long
term, and may improve the gait pattern through re-
education and over a period the patient may reach a
stage where he/she may no longer need it.

This principle is also used to major hip and thigh

muscle groups in patients with spinal cord injuries for
muscle strengthening, maintaining standing posture
and ambulation