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AFO Ankle Foot Orthosis Orthotic Brace.JPG
An ankle foot orthosis (AFO) brace is a type of orthotic. Here it is being used to support the foot due to foot drop, caused by multiple sclerosis.

Orthotics (Greek : Ορθός, romanized: ortho, lit. 'to straighten, to align') is a medical specialty that focuses on the design and application of orthoses. An orthosis (plural: orthoses) is "an externally applied device used to modify the structural and functional characteristics of the neuromuscular and skeletal system". [1] An orthotist is the primary medical clinician responsible for the prescription, manufacture and management of orthoses. [2] An orthosis may be used to:


Orthotics combines knowledge of anatomy and physiology, pathophysiology, biomechanics and engineering. Patients who benefit from an orthosis may have a condition such as spina bifida or cerebral palsy, or have experienced a spinal cord injury or stroke. Equally, orthoses are sometimes used prophylactically or to optimise performance in sport. [3] At present, for prosthetic and orthotic interventions, the scientific literature does not provide sufficient high quality research to allow strong conclusions on their effectiveness and cost-effectiveness. [4]

Manufacture and materials

Orthoses were traditionally made by following a tracing of the extremity with measurements to assist in creating a well-fitted device. Subsequently, the advent of plastics as a material of choice for construction necessitated the idea of creating a plaster of Paris mould of the body part in question. This method is still extensively used throughout the industry. Currently, CAD/CAM, CNC machines and 3D printing [5] [6] are involved in orthotic manufacture. A real-time weight bearing orthotic can be created using a neutral position casting device and the Vertical Foot Alignment System VFAS. [7]

Orthoses are made from various types of materials including thermoplastics, carbon fibre, metals, elastic, EVA, fabric or a combination of similar materials. Some designs may be purchased at a local retailer; others are more specific and require a prescription from a physician, who will fit the orthosis according to the patient's requirements. Over-the-counter braces are basic and available in multiple sizes. They are generally slid on or strapped on with Velcro, and are held tightly in place. One of the purposes of these braces is injury protection. [8]


Codification of Orthoses Codification of Orthotics, Draw by Dr. Harry Gouvas.jpg
Codification of Orthoses

Under the International Standard terminology, orthoses are classified by an acronym describing the anatomical joints which they contain. [9] For example, an ankle foot orthosis ('AFO') is applied to the foot and ankle, and a thoracolumbosacral orthosis ('TLSO') affects the thoracic, lumbar and sacral regions of the spine. It is also useful to describe the function of the orthosis. Use of the International Standard is promoted to reduce the widespread variation in description of orthoses, which is often a barrier to interpretation of research studies. [10]

Upper-limb orthoses

Upper-limb (or upper extremity) orthoses are mechanical or electromechanical devices applied externally to the arm or segments thereof in order to restore or improve function or structural characteristics of the arm segments encumbered by the device. In general, musculoskeletal problems that may be alleviated by the use of upper limb orthoses include those resulting from trauma [11] or disease (arthritis for example). They may also be beneficial in aiding individuals who have suffered a neurological impairment such as stroke, spinal cord injury, or peripheral neuropathy. Disease is the standard respiratory rate.

Types of upper-limb orthoses

Lower-limb orthoses

A lower-limb orthosis is an external device applied to a lower-body segment to improve function by controlling motion, providing support through stabilizing gait, reducing pain through transferring load to another area, correcting flexible deformities, and preventing progression of fixed deformities. [12] The term caliper or calipers remains in widespread use for lower-limb orthoses in the United Kingdom.

Foot orthoses

Foot orthoses (commonly called "orthotics") are devices inserted into shoes to provide support for the foot by redistributing ground reaction forces acting on the foot joints while standing, walking or running. They may be either pre-moulded (also called pre-fabricated) or custom made according to a cast or impression of the foot. A great body of information exists within the orthotic literature describing their medical use for people with foot problems as well as the impact "orthotics" can have on foot, knee, hip, and spine deformities. They are used by everyone from athletes to the elderly to accommodate biomechanical deformities and a variety of soft tissue conditions. Foot orthoses are effective at reducing pain for people with painful high-arched feet, and may be effective for people with rheumatoid arthritis, plantar fasciitis, First metatarsophalangeal (MTP) joint pain [13] or hallux valgus ("bunions"). For children with juvenile idiopathic arthritis (JIA) custom-made and pre-fabricated foot orthoses may also reduce foot pain. [14] Foot orthoses may also be used in conjunction with properly fitted orthopaedic footwear in the prevention of foot ulcers in the at-risk diabetic foot. [15]

Ankle–foot orthosis

An AFO with ankle hinge worn on the left foot Ankle Foot Orthosis leg brace worn on the left foot with ankle hinge.jpg
An AFO with ankle hinge worn on the left foot
Schematic ankle-foot orthosis Ankle-foot-orthosis.png
Schematic ankle–foot orthosis

An ankle–foot orthosis (AFO) is an orthosis or brace that encumbers the ankle and foot. AFOs are externally applied and intended to control position and motion of the ankle, compensate for weakness, or correct deformities. AFOs can be used to support weak limbs, or to position a limb with contracted muscles into a more normal position. They are also used to immobilize the ankle and lower leg in the presence of arthritis or fracture, and to correct foot drop; an AFO is also known as a foot-drop brace. Ankle–foot orthoses are the most commonly used orthoses, making up about 26% of all orthoses provided in the United States. [16] According to a review of Medicare payment data from 2001 to 2006, the base cost of an AFO was about $500 to $700. [17] An AFO is generally constructed of lightweight polypropylene-based plastic in the shape of an "L", with the upright portion behind the calf and the lower portion running under the foot. They are attached to the calf with a strap, and are made to fit inside accommodative shoes. The unbroken "L" shape of some designs provides rigidity, while other designs (with a jointed ankle) provide different types of control. Focusing on children with cerebral palsy (CP), there are a wide variety of ankle foot orthoses used in clinical practice which are characterised by their design, the material used and the stiffness of that material. [18] Changing any of these three components will alter the effect of the ankle foot orthosis on gait. While, there are a wide variety of AFOs used in clinical practice, which are characterised by their design, the material used and the stiffness of that material, [19] there are calls for standardisation of the terminology. [20]

Obtaining a good fit with an AFO involves one of two approaches:

  1. provision of an off-the-shelf or prefabricated AFO matched in size to the end user
  2. custom manufacture of an individualized AFO from a positive model, obtained from a negative cast or the use of computer-aided imaging, design, and milling. The plastic used to create a durable AFO must be heated to 400 °F (200 °C), making direct molding of the material on the end user impossible.

The International Red Cross recognizes four major types of AFOs:

Flexible AFOsAnti-Talus AFOsRigid AFOsTamarack Flexure Joint
may provide dorsiflexion assistance, but give poor stabilization of the subtalar joint.block ankle motion, especially dorsiflexion; do not provide good stabilization for the subtalar joint.block ankle movements and stabilize the subtalar joint; may also help control adduction and abduction of the forefoot.provide subtalar stabilization while allowing free ankle dorsiflexion and free or restricted plantar flexion. Depending upon the design; may provide dorsiflexion assistance to correct foot drop. [21]

The International Committee of the Red Cross published its manufacturing guidelines for ankle–foot orthoses in 2006. [21] Its intent is to provide standardized procedures for the manufacture of high-quality modern, durable and economical devices to people with disabilities throughout the world.

Ulcer healing orthosis (UHO)

A custom-made ankle/foot orthosis for the treatment of patients having plantar ulcers is disclosed, which comprises a rigid L-shaped support member and a rigid anterior support shell hingedly articulated to the L-shaped support member. The plantar portion of the L-shaped member further comprises at least one ulcer-protecting hollow spatially located for fitted placement in inferior adjacency to a user's plantar ulcer, thus allowing the user to transfer the user's weight away from the plantar ulcer and facilitating plantar ulcer treatment. The anterior support shell is designed for lateral hinged attachment to the L-shaped member to take advantage of medial tibial flare structure for enhancing the weight-bearing properties of the disclosed orthosis. A flexible, polyethylene hinge member hingedly attaches the anterior support shell to the L-shaped member and securing straps securely attach the anterior support shell in fixed, weight-bearing relation about the proximal, anterior portion of the user's lower leg. [22]

Knee-ankle-foot orthosis (KAFOs)

A knee-ankle-foot orthosis (KAFO) is an orthosis that encumbers the knee, ankle and foot. Motion at all three of these lower limb areas is affected by a KAFO and can include stopping motion, limiting motion, or assisting motion in any or all of the three planes of motion in a human joint: sagittal, coronal, and axial. Mechanical hinges, as well as electrically controlled hinges have been used. Various materials for fabrication of a KAFO include but are not limited to metals, plastics, fabrics, and leather. Conditions that might benefit from the use of a KAFO include paralysis, joint laxity or arthritis, fracture, and others. Although not as widely used as knee orthoses, KAFOs can make a real difference in the life of a paralyzed person, helping them to walk therapeutically or, in the case of polio patients, on a community level. These devices are expensive and require maintenance. Some research is being done to enhance the design; even NASA helped spearhead the development of a special knee joint for KAFOs.

Knee orthosis (KO)

Knee brace Orthotics - Knee Brace (36209261475).jpg
Knee brace

A knee orthosis (KO) or knee brace is a brace that extends above and below the knee joint and is generally worn to support or align the knee. In the case of diseases causing neurological or muscular impairment of muscles surrounding the knee, a KO can prevent flexion or extension instability of the knee. In the case of conditions affecting the ligaments or cartilage of the knee, a KO can provide stabilization to the knee by replacing the function of these injured or damaged parts. For instance, knee braces can be used to relieve pressure from the part of the knee joint affected by diseases such as arthritis or osteoarthritis by realigning the knee joint into valgus or varus. In this way a KO may help reduce osteoarthritis pain, [23] however, there is no clear evidence to advise people with osteoarthritis of the knee about the most effective orthosis to use or the best approach to rehabilitation. [24] A knee brace is not meant to treat an injury or disease on its own, but is used as a component of treatment along with drugs, physical therapy and possibly surgery. When used properly, a knee brace may help an individual to stay active by enhancing the position and movement of the knee or reducing pain.

Prophylactic, functional and rehabilitation braces

Prophylactic braces are used primarily by athletes participating in contact sports. Evidence about prophylactic knee braces, the ones football linemen wear that are often rigid with a knee hinge, indicates they are ineffective in reducing anterior cruciate ligament tears, but may be helpful in resisting medial and lateral collateral ligament tears. [25]

Functional braces are designed for use by people who have already experienced a knee injury and need support to recover from it. They are also indicated to help people who are suffering from pain associated with arthritis. They are intended to reduce the rotation of the knee and support stability. They reduce the chance of hyperextension, and increase the agility and strength of the knee. The majority of these are made of elastic. They are the least expensive of all braces and are easily found in a variety of sizes.

Rehabilitation braces are used to limit the movement of the knee in both medial and lateral directions- these braces often have an adjustable range of motion stop potential for limiting flexion and extension following ACL reconstruction. They are primarily used after injury or surgery to immobilize the leg. They are larger in size than other braces, due to their function.

Spinal orthoses

Two different spinal orthoses used to treat scoliosis Scoliosis brace.jpg
Two different spinal orthoses used to treat scoliosis

Scoliosis, a condition describing an abnormal curvature of the spine, may in certain cases be treated with spinal orthoses, such as the Milwaukee brace, the Boston brace, Charleston bending brace, and Providence brace. As this condition develops most commonly in adolescent females who are undergoing their pubertal growth spurt, compliance with wearing is these orthoses is hampered by the concern these individuals have about changes in appearance and restriction caused by wearing these orthoses. Spinal orthoses may also be used in the treatment of spinal fractures. A Jewett brace, for instance, may be used to facilitate healing of an anterior wedge fracture involving the T10 to L3 vertebrae. A body jacket may be used to stabilize more involved fractures of the spine. The halo brace is a cervical thoracic orthosis used to immobilize the cervical spine, usually following fracture. The halo brace allows the least cervical motion of all cervical orthoses currently in use; it was first developed by Vernon L. Nickel at Rancho Los Amigos National Rehabilitation Center in 1955. [26]


Orthotists are healthcare professionals who specialize in the provision of orthoses. In the United States, orthotists work by prescription from a licensed healthcare provider. Physical therapists are not legally authorized to prescribe orthoses in the U.S. In the U.K., orthotists will often accept open referrals for orthotic assessment without a specific prescription from doctors or other healthcare professionals. [27]


In Canada, a Certified Orthotist CO(c) provides clinical assessment, treatment plan development, patient management, technical design, and fabrication of custom orthoses to maximize patient outcomes. To become CBCPO certified through Orthotics Prosthetics Canada (OPC) an applicant must successfully meet the following requirements:

Upon successful completion of the national certification exams, candidates are conferred the designation of Canadian Certified Orthotist CO(c). [28]

United Kingdom

In the UK orthotists assess patients, and where appropriate design and fit orthoses for any part of the body. Registration is with the Health and Care Professions Council and BAPO - the British Association of Prosthetists and Orthotists. The training is a B.Sc.(Hons) in Prosthetics and Orthotics at either the University of Salford or University of Strathclyde. New graduates are therefore eligible to work as an orthotist and/or prosthetist.

Podiatrists are the other profession involved with foot orthotic provision. [29] They are also registered with the Health and Care Professions Council . Podiatrists assess gait to provide orthotics to improve foot function and alignment or may use orthoses to redistribute stress on pressure areas for those with diabetes or rheumatoid arthritis.

United States

A licensed orthotist is an orthotist who is recognized by the particular state in which they are licensed to have met basic standards of proficiency, as determined by examination and experience to adequately and safely contribute to the health of the residents of that state. An American Board of Certification certified orthotist has met certain standards; these include a degree in orthotics, completion of a one-year residency at an approved clinical site, and passing a rigorous three-part exam. [30] A certified orthotist (CO) is an orthotist who has passed the certification standards of the American Board of Certification in Orthotics, Prosthetics and Pedorthics. Other credentialing bodies who are involved in orthotics include the Board for Orthotic Certification, the pharmaceutical industry, the Pedorthic Footcare Association, and various of the professional associations who work with athletic trainers, physical and occupational therapists, and orthopedic technologists/cast technicians.


Four universities including the Iran University of Medical Science, Isfahan University of Medical Science, University of Social Welfare and Rehabilitation Sciences and Iran Red Crescent University confer bachelor of science in the Prosthetics and Orthotics. Three universities including Isfahan University of Medical Science, the Iran University of Medical Science and University of Social Welfare and Rehabilitation Science also confer M.Sc. and Ph.D. New bachelor graduates are eligible to work as an orthotist and prosthetist after registration in the Medical Council of Iran.

See also

Related Research Articles

Human leg Lower extremity or limb of the human body (foot, lower leg, thigh and hip)

The human leg, in the general word sense, is the entire lower limb of the human body, including the foot, thigh and even the hip or gluteal region. However, the definition in human anatomy refers only to the section of the lower limb extending from the knee to the ankle, also known as the crus or, especially in non-technical use, the shank. Legs are used for standing, and all forms of locomotion including recreational such as dancing, and constitute a significant portion of a person's mass. Female legs generally have greater hip anteversion and tibiofemoral angles, but shorter femur and tibial lengths than those in males.

Bunion Deformity characterized by lateral deviation of the big toe

A bunion, also known as hallux valgus, is a deformity of the joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is typically gradual. Complications may include bursitis or arthritis.

Pes cavus Medical condition

Pes cavus, also known as high arch, is a human foot type in which the sole of the foot is distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot. A high arch is the opposite of a flat foot and is somewhat less common.

Plantar fasciitis Connective tissue disorder of the heel

Plantar fasciitis is a disorder of the connective tissue which supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

Genu valgum Medical condition

Genu valgum, commonly called "knock-knee", is a condition in which the knees angle in and touch each other when the legs are straightened. Individuals with severe valgus deformities are typically unable to touch their feet together while simultaneously straightening the legs. The term originates from the Latin genu, 'knee', and valgus which actually means 'bent outwards', but in this case, it is used to describe the distal portion of the knee joint which bends outwards and thus the proximal portion seems to be bent inwards. For citation and more information on uses of the words Valgus and Varus, see varus deformity.

Genu varum Varus deformity marked by (outward) bowing at the knee

Genu varum is a varus deformity marked by (outward) bowing at the knee, which means that the lower leg is angled inward (medially) in relation to the thigh's axis, giving the limb overall the appearance of an archer's bow. Usually medial angulation of both lower limb bones is involved.

Diseases of the foot

Diseases of the foot generally are not limited, that is they are related to or manifest elsewhere in the body. However, the foot is often the first place some of these diseases or a sign or symptom of others appear. This is because of the foot's distance from the central circulation, the heart and its constant exposure to pressures from the ground and the weight of the body.

Flat feet Medical condition

Flat feet is a postural deformity in which the arches of the foot collapse, with the entire sole of the foot coming into complete or near-complete contact with the ground.

A pedorthist is a professional who has specialized training to modify footwear and employ supportive devices to address conditions which affect the feet and lower limbs. They are trained in the assessment of lower limb anatomy and biomechanics, and the appropriate use of corrective footwear – including shoes, shoe modifications and other pedorthic devices.

Shoe insert

A removable shoe insert, otherwise known as a foot orthosis, insole or inner sole accomplishes many number of purposes, including daily wear comfort, height enhancement, plantar fasciitis treatment, arch support, foot and joint pain relief from arthritis, overuse, injuries, leg length discrepancy, and other causes such as orthopedic correction and athletic performance.

A Prosthetist and Orthotist, as defined by The World Health Organization, is a healthcare professional with overall responsibly of Prosthetics & Orthotics treatment, who can supervise and mentor the practice of other personnel. They are clinicians trained to assess the needs of the user, prescribe treatment, determine the precise technical specifications of prosthesis and Orthosis, take measurements and image of body segments, prepare model of the evaluation, fit devices and evaluate treatment outcome.

Foot and ankle surgery is a sub-specialty of orthopedics and podiatry that deals with the treatment, diagnosis and prevention of disorders of the foot and ankle. Orthopaedic surgeons are medically qualified, having been through four years of college, followed by 4 years of medical school to obtain an M.D. or D.O. followed by specialist training as a resident in orthopaedics, and only then do they sub-specialise in foot and ankle surgery. Training for a podiatric foot and ankle surgeon consists of four years of college, four years of podiatric medical school (D.P.M.), 3–4 years of a surgical residency and an optional 1 year fellowship.

Diabetic shoe Shoes intended to reduce the risk of skin breakdown in diabetics

Diabetic shoes are sometimes referred to as extra depth, therapeutic shoes or Sugar Shoes. They are specially designed shoes, or shoe inserts, intended to reduce the risk of skin breakdown in diabetics with pre-existing foot disease.

Swami Vivekanand National Institute of Rehabilitation Training and Research

Swami Vivekanand National Institute of Rehabilitation Training and Research is an autonomous institute functioning under the Ministry of Social Justice and Empowerment of India. It is the most prestigious institution in the field of rehabilitation. It is in Olatpur, 30 km from Cuttack.

Pet orthotics refers to the use of orthotics for pets. Orthotics is an allied health care field concerned with the design, development, fitting, and manufacture of orthoses. Orthoses, sometimes called braces or splints, are devices that support or correct musculoskeletal deformities and/or abnormalities of the body.

Genu recurvatum Orthopedic deformity

Genu recurvatum is a deformity in the knee joint, so that the knee bends backwards. In this deformity, excessive extension occurs in the tibiofemoral joint. Genu recurvatum is also called knee hyperextension and back knee. This deformity is more common in women and people with familial ligamentous laxity. Hyperextension of the knee may be mild, moderate or severe.

A DAFO is a brand name for some lower extremity braces that provide thin, flexible, external support to the foot, ankle and/or lower leg. They have the particularity to fit firmly the ankle and correct concisely the foot deformity within special pressure points. It is stated to help in improving mobility and stability of the ankle joint on CP patients, evidence shows that immediate gross motor function improved with the use of DAFO’s as well. Designed to help a patient maintain a functional position, a DAFO can improve stability for successful standing and walking.

Neuromechanics of orthoses refers to how the human body interacts with orthoses. Millions of people in the U.S. suffer from stroke, multiple sclerosis, postpolio, spinal cord injuries, or various other ailments that benefit from the use of orthoses. Insofar as active orthoses and powered exoskeletons are concerned, the technology to build these devices is improving rapidly, but little research has been done on the human side of these human-machine interfaces.

Proportional myoelectric control

Proportional myoelectric control can be used to activate robotic lower limb exoskeletons. A proportional myoelectric control system utilizes a microcontroller or computer that inputs electromyography (EMG) signals from sensors on the leg muscle(s) and then activates the corresponding joint actuator(s) proportionally to the EMG signal.

Podiatrists have molded custom orthotics to address patients' foot malformations. Over the years they have developed numerous means to create the basis for their molds; plaster casts, foam box impressions, or three-dimensional computer imaging. None is very accurate: all produce proper fit under 80% of the time.


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