Drop foot AFO help

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I have a patient who has had MS for 20 years and is now experiencing some falls due to a right drop foot. She wants me to help her and I have advised an Ankle foot orthotic to help with dorsiflexion. She wants me to provide this for her even though I have said I have not issued patients with these before. She has a fairly mobile foot and generally walks by utilising her quads to lift her lower leg, but when she is tired etc she finds she trips and is prone to falling. I would be grateful of any advice anyone has on this subject, i.e which AFO is good to use, do I go for a standard swedish AFO or should I beware of anything in particular.

Thank you

 

Walsh:

Here is a good review article describing the different drop-foot AFO braces:

http://lowerextremityreview.com/article/controlling-drop-foot-beyond-standard-afos

The gait compensation you describe, where the patient flexes the hip and knee more during the swing phase of gait to prevent tripping on their "drop-foot" during swing is called a "steppage gait pattern".



I would suggest you contact your local prosthetist/orthotist and arrange a time when you can visit them with your patient so you can become more educated on which braces are best for your patient. Your patient will respect your desire to seek someone with more knowledge than yourself in order to make their life healthier and happier.

Good luck.:drinks

 

Hi Walsh,

As you are dealing with MS, there are neurological elements that will greatly affect your prescription. This is obviously very relevant at the foot ankle complex but is almost more importnt more proximally, at the hip in particular.

Extended rectus femoris contraction is common in patients with upper motor neurome deficiency. The recus switches on at intial swing phase but instead of switching on just long enough to "accelerate" the hip into flexion, it stays switched on causing the knee to be extended at mid swing, thus effectively lengthening the leg. This makes ground clearance incredibly difficult regardless of the amount of dorsiflexion in which the foot and ankle is held.

A good test for this is a Duncan Ely test http://www.ncbi.nlm.nih.gov/pubmed/14580132. Essentially you can predict the likelihood of extended rectus contraction using this test and if it shows as being strongly positive, you are going to have to deal with that in some way in addition to something at the foot and ankle.

As far as foot and ankle control goes there are plenty of things available on the market, some of which I have covered before in this thread http://www.podiatry-arena.com/podiatry-forum/showthread.php?p=217551 (my musings are toward the end)

If you let me know where in the country you are, I could probably recommend and orthotist who might know what they are talking about. We are a small community so we tend to know everyone else

Hope this helps

Robin

 

I second (third) the call to have an Orthotist become involved.

Also a great opportunity to network with a fellow health professional.

 

If you have never even taken an impression for an AFO....definitely ask for help. Its trickier than it looks and it can be difficult to maintain a 90 ankle/foot with a neurologically impaired patient.

The general recommendations I would make to the orthotist is for a hinged ankle, Tamarak type AFO with the foot plate ending BEHIND the met heads. These are spring loaded to assist with dorsiflexion at toeoff. Adding a 1st ray c/o helps as well, and allows for a far smoother propulsive maneuver. Over my years of practice, I cut off many distal ends of AFO foot plates and outcomes were outstanding and patients able to walk far faster. Improved speed also improves balance, to the effect is multifactorial.

The orthotist will likely resist as this is not how they are trained, however, with the patient's support and your observations and recommendations, this can be done correctly.

Good luck,
Howard

 

HI Dandanberg
all my AFO's used to finish behind the met heads. Only stopped cause I don't practice any more! An AFO thermoformed from Teufel Ortholen, a high density PE makes a very lightweight, highly cosmetic and very functional device with great smooth gait. NOt everywhere can do this though as the material is a bastard to work with. There is a picture here:
http://www.rehab.research.va.gov/jour/73/10/1/20.pdf

But as mentioned earlier. MS can be complicated and needs careful assessment. If you are in Aus let me know and I can recommend an orthotists who can help

Cheers

 

Try an Ossur foot up first, its cheap and usually does the job and no casting or fitting issues. You can stitch the plastic tongue into the shoe to alter the direction of moments about the AJC as required.

Cheers Dave Smith

 

I would agree with Howard in that, habitually, orthotists like to make footplate lengths for neuro patients full length for fear of increasing tone with something behind the met heads. It is a fairly common misconception in my experience.

I would say that you need to be careful about the recommendation for an articulated AFO with a dorsi assist hinge as a starting point. The length of the footplate and the rigidity of the ankle is critical for controlling the direction and magnitude of the ground reaction vector in the sagittal plane. As I mentioned previously, for many neuro patients the hip is more critical than anything else. Having the ground reaction vector "tuned" to best assist with hip extension in terminal stance will allow easier hip extension for the patient which has significant positive effects on gait.

If you are trying to harness the ground reaction vector to assist with knee and hip extension, a rigid AFO with reinforced footplate and point load rocker on the shoe will be critical. However, if the problem is for a flaccid foot drop with coronal plane instability, then the prescription mentioned by Howard is preferable.

It is more likely to be the latter of the two situations but my point is that AFO prescription variables are no different foot orthotic prescription variables. One needs to identify the functional deficit and use the most appropriate prescription variables based on what is required

Regards,

Robin

 

Hello all

Its good to see some discussion on AFO's on Podiatry Arena. I am an Orthotist myself and agree that there is a misconception regarding full length footplates and increased muscle tone. I have started making them alot thinner or removing them completely with good results.

Its pretty difficult to give Walsh an exact prescription for the patient in question. There are, as with insoles, a significant amount of options. You can see this from all the suggestions above. It is dependant on the presentation of the patient i.e. is there a combination of PF and DF weakness, is there some contributory weakness proximal of the ankle etc. Liasing with an Orthotist and your patient would allow you to get a grasp of all the different varieties of AFOs (OTS and custom) and hopefully achieve the best result for your patient.

Thanks

Doug