22 
Lower Limb Orthoses
KEY POINTS
• Lower limb orthoses are the most commonly prescribed type of
orthoses, with ankle–foot orthoses making up 26% of all orthoses
provided in the United States,4 and are either prefabricated or
custom made.
• Lower limb orthoses create biomechanical effects on joints
adjacent to the orthosis.
FOOT ORTHOSES
Foot orthoses (FO) are like the tires on an automobile: They provide
a critical, biomechanical contact point for the human body, and they
can be helpful to correct problems in the foot, knee, hip, and spine.
Prescription foot orthoses are divided into two categories as defined
by the American Podiatric Medical Association.2
1. Functional orthotics are designed to control abnormal motion. They
may be used to treat foot pain caused by abnormal motion; they
can also be used to treat injuries such as shin splints or tendinitis.
Functional orthotics are usually crafted of a semirigid material such
as plastic or graphite.
2. Accommodative orthotics are softer and meant to provide additional
cushioning and support. They can be used to treat diabetic foot
ulcers, painful calluses on the bottom of the foot, and other uncom-
fortable conditions.
Among the two types are custom and noncustom orthoses.5 Custom
foot orthoses start with a thorough examination of the foot–ankle
complex by a health professional to determine limitations in range of
motion in both the forefoot and the rear foot, including calcaneal talus
alignment. Once this is done, a gait assessment is performed without
shoes and socks on, and if there are areas on the foot that need to be
unloaded, this is noted. An impression is taken using step-in foam, cast,
or a scan (with an optical digitizer) with the foot held in subtalar
neutral. The foot orthotic is made from the positive model of this
impression, and the choice of materials depends on the pathology that
is being corrected. Any other type of foot orthosis is noncustom. This
includes the type patients may receive from various outlets claiming
custom fit and the type from the big box stores with optical scanners.
There are many minor foot problems for which noncustom foot orthoses
provide appropriate treatment.3
Successful foot orthotic treatment is dependent on the shoes that
are used in conjunction with the orthosis. If a person brings in a shoe
that barely accommodates his or her feet (too tight or too worn), then
placing a foot orthotic into it will lead to failure. Special considerations
John R. Fox, William Lovegreen
• Advances in both material science and orthotic design have
resulted in improved functional outcomes for individuals who
require lower limb orthoses.
are also required with high-heel shoes, flip flops, and cowboy boots.
After fitting the patient using the proper shoes, the orthotist reassesses
the patient’s gait to determine whether goals for alignment, posture,
pain, and corrections to the foot–ankle complex are being met. Education
and follow up is key to a successful outcome.11 If the foot–ankle alignment
is off biomechanically, it will create a problem with the knee, hip, and
spine. Returning to the automobile analogy, a bad alignment means
worn tires, ball joints, and suspension (and a lot of money spent on
replacement parts).17
ANKLE–FOOT ORTHOSES
As the name implies, ankle–foot orthoses (AFOs) are used for problems
dealing with foot and ankle issues that are either biomechanical or
neurophysiologic in nature. These orthoses include any device that
passes across the ankle joint but stays distal to the knee joint. Such
orthoses are used for diagnoses that range from ankle sprains to stroke
management. This type of brace could potentially be used for any
neuromuscular condition requiring support or assistance at the level
of the foot and ankle.
AFOs consist of myriad materials, no longer just metal and leather
(conventional) or plastic. Many current AFO designs comprise a hybrid
of different materials. This includes carbon graphite, various plastics,
metal, and various materials for padding. Like FOs, AFOs come in two
varieties: custom made for the individual patient or prefabricated (off
the shelf).
The custom AFO builds up from the foot orthosis and is attached
to either a shoe or a foot plate (foot orthotic) that is placed into the
shoe. It may or may not have an ankle joint that will control ankle
motions in several planes. These motions include plantarflexion,
dorsiflexion, inversion (pronation), and eversion (supination) of the
foot and varus and valgus of the ankle. Control of the foot–ankle complex
provides control of the tibia’s progression over the ankle and of the
knee’s flexion and extension moments during the stance phase parts
of the gait cycle. The AFO can also control toe-off (push off) and swing
239