In this blog post we are going to be answering some very important questions.
Those questions are :
1.) How do you put an afo and shoe on at the same time?
2.) How can you put on an afo with compromised hand strength?
3.) How do you angle your foot to put on an afo and shoe all at once?
4.) Are AFOs only for foot drop?
5.) Do AFOs help to control balance?
6.) Can an AFO take someone off of a cane?
7.) Do AFOs help with postural sway?
8.) Do prefab AFOs help with balance?
9.) Do prefabricated AFOs support the knee?
10.) How do you make more room in a shoe for an AFO?
#1 Safety Rule
The number one safety rule for Thermoplastic AFOs is that this ankle and foot orthoses do not tread on the bottom of them. Thermoplastic AFOs are the most commonly used type and always need to be placed inside of a shoe whenever the foot is on the ground. This is a rule, that if reinforced by many medical health professionals, will help a patient be safer with their orthosis during activities in daily living (ADLs).
The image to the right is not a safe scenario for this patient, because their foot is on the ground without any sort of tread underneath their foot. A plastic AFO should go inside of a shoe whenever the foot is on the ground.
Most people have seen the one on the left, it is a very traditional style of shoe horn. We want to show you this one on the right because it is the clipped shoe horn that can be attached to the back of somebody’s shoes. It is great for patients who struggle with hand control. They really do not have to control it at all, because it is always there. Or they could take it out after the AFOs plug, this is great for patients who struggle with hand control. Plastic AFOs will not allow this to push into the back of the leg in the Achilles Tendon area.
AFO General Instructions/Application Basics
Three options for Tight Fitting Shoes, With Respect To An AFO
If you are working with a patient and you notice that the shoe seems to be tight when the AFO is used, you can help them by making the patient aware of 3 options:
- Remove Their Current Shoe’s Insole
- Stretch Their Shoes
- They Can Get New Shoes
Learn How To Help Your Patients Approach This Options more effectively and we will talk about that in more detail in the video.
Remove the Insole from the Shoe
Many health professionals and patients will remove ⅛ ” insole that comes with the shoes when using AFO. This can make a big difference in how the AFO and shoe fit together. This is true because many AFOs are 3/16 “ thick and by removing the ⅛” insole(which is 2/16 “), you will have more room in the shoe. What is left over is 1/16 “ and although this does have size, the difference becomes less significant.
The next option you can present to your patient is the orthotist can stretch their current shoe(s). This process can take time but if the shoe is tight in one specific area or multiple areas, this can really help a patient gain functionality. The device you see here to the right is actually a shoe stretcher. At the bottom left-hand corner you can see how the force can be applied to the shoe and over the time it can be tightened via the mechanism at the top right-hand corner. We will again show this in more detail as the video progresses.
People always love a good reason to go shopping. The last option you can help to inform your patient about is to simply consider getting new shoes. Moreover, reminding the patient to bring the AFO with them to the shoe store will help them avoid any guesswork when it comes to size.
Many times a patient will guess and think that a half shoe size longer and wider will suffice. This is not necessarily the case. As a medical professional you can pass along the ideas above and the person can save some time and frustration by knowing to bring their AFOto the shoe store with them when they do indeed go to buy something new.
Let’s review this information in more detail/ Check our this video clip…
AFOs & Shoes- Creating Space
Let’s say this is your patient’s shoe and the AFO is not quite fitting so perfectly into the shoe. You have options:
One of your options is to make more room by taking the insole out of the shoe if we measured that to be about ⅛ “ or 2/16 “. The reason I am saying 2/16 “ to you is that an AFO is usually 3/16 “, so we are making more room inside of a shoe if you remove that. You do not always have to that, but it is just an option for any medical professional, any patient that is watching this video.
The other option you can do is we will say at the bone right here or the brace is pressing out or something is not working right, it is too tight right here in the shoe. One of the things an orthotist can do for the patient is actually use something called a shoe stretcher. The point of it that I am trying to make to you is that we can make more room inside of the shoe for the patient, it does change the shape of the shoe slightly, especially in the beginning. But you have an option; you can go to the orthotist (as you are the medical professional or the patient that is watching this video) and have them stretch out that area or multiple areas in the shoe. That might make all the difference for you as a patient or someone who just does not want to go and buy new shoes. So I am going to show you this really quickly, it is a method by an orthotist in many instances, maybe not all, maybe there is another tool out there, but they can stretch your shoe which can increase the comfort and compliance and activities of daily living as a result. This is a shoe stretcher that we use and you can already kind of imagine the process. Here, we are pushing out on the leather, on the material whatever it is via this action and then you can tighten it up more by tightening the bottom. So if you give an orthotist a day, they can definitely knock out a few spots where if you want a whole area stretched. This thing just needs time, it just does not happen that quickly, but it can stretch out a shoe for you. So this is what an orthotist would do to help you with your AFO and your shoe tightness issue. So, they would come in like this and you can see it start to press out the material right there. And we can lock this in right there and begin to really crank down in a safe way on the material. So you can see that bone now, the first metatarsal at this point and it will have more room inside that shoe. An orthotist would now leave this shoe. There is no exact time frame, but you will see results after 20-30 minutes for sure. So this is the shoe stretching tool and it can be used to help a patient with their AFO compliance activities of daily living and help them ultimately walk better if they have comfortable shoes to wear.
The number 1 safety rule also for AFOs is that they do not have any tread, so the fact that a shoe has tread is a very important concept that is probably the number one safety rule. Because of the plastic on the AFO on any surface, there is very little traction there. So in most cases, you want it to be inside of a shoe for thermoplastic AFOs which are the most common types, so just remember the tread inside of a shoe. Your last option, as you can even see it right now how it kind of pushed that area of the shoe just over a couple of minutes and has now created more room. So the function of it might be better for the patient that way.
(The previous video captured the process, but these pictures can show you in a little better detail what the effects are of the show stretching process. Let’s take a look… Shoe after
being stretched for a short while(1-2 minutes). Different shoe materials may vary in terms of results seen.)
So we have discussed taking out the insert that comes with the shoe, ⅛ “ you take that out and it makes some more room in there. If that is not chosen as an option, you can try to stretch the shoe to help the patient get more comfort. Now, if that option does not work, another thing you can do is go shopping. Now, it is easy for me to just say “Hey, go, get new shoes”, but the point is if you bring the brace with you to get the new shoes, then there is very little guessing involved. You are not thinking “Oh, a half-size bigger and maybe just a little bit wider shoe, that will take care of it”. If you bring the AFO with you to the shoe store and trying X amount of shoes, then that is probably your best-case scenario if you go shopping. So it is my recommendation if you can hold off on your shoes until you are able to go to the shoe store with the brace.
AFOs and Balance Improvement
AFOs are than just foot drop. The following information shows how an AFO can assist with balance improvement for a patient by helping them to control their weight line. If there was a device that could help to take someone off of a cane, an AFO could be the way to address their foot drop and balance issues without holding anything.
Let’s look at balance in more detail:
So it’s one thing to claim AFOs can potentially take someone off of a cane, but its another to feel like we understand why they help someone with their balance to get them to that point.
Let’s take a look at the following illustration. It talks about the patient’s weight line and how when a custom AFO is used, the orthotist can cast someone with the intention of holding their balance steady. In this way, we are positively influencing postural sway.
How Balance Increases With An AFO
As we can see in the left image, it shows that the weight line is centered for the patient. A custom AFO can be cast and fabricated with the intention of holding the weight line centered and the ankle at 90 degrees. This left image shows someone who is obviously not falling. Many orthotists will simulate this posture, with the knee plumb line hedging toward the inside of the foot to help maintain this posture. This helps prevent postural sway and knee instability in the sagittal plane and coronal planes. The bottom line is that this helps prevent falls for the patient.
Right image: Shows someone’s weight line that is falling to the side. A compromised balance situation. With prefab AFOs, since we don’t know the casting position, can we assume that they have the same effect on the weight line?