Who should I refer a patient to for an ankle‑foot orthosis (AFO)?

AFO Referral: Orthotist or Prosthetist-Orthotist

Refer patients requiring an ankle-foot orthosis (AFO) to a certified orthotist (CO) or certified prosthetist-orthotist (CPO) for proper fitting, customization, and prescription. 1

When to Refer for AFO

Refer to an orthotist when patients demonstrate:

• Ankle instability or dorsiflexor weakness requiring orthotic stabilization 1
• Foot drop affecting gait safety and efficiency 1
• Ankle or knee instability that increases fall risk or impairs functional mobility 1
• Need for long-term bracing after initial trial with prefabricated devices 1

Initial AFO Strategy

Start with a prefabricated brace initially, and only refer patients who demonstrate long-term need for bracing to have customized orthoses made. 1 This approach allows you to assess tolerance, compliance, and functional benefit before investing in custom fabrication.

The Orthotist's Role

The certified orthotist will:

• Conduct careful assessment of the patient and the environment where the AFO will be used 1
• Verify proper fit and comfort to improve compliance with regular AFO use 1
• Customize the device by modifying density, geometry, and materials as needed 1
• Ensure the AFO addresses specific impairments such as ankle kinematics, knee stability in stance phase, and energy cost of walking 1

Clinical Indications by Condition

Stroke Patients

• AFOs are recommended (Class I, Level B evidence) for ankle instability or dorsiflexor weakness to compensate for foot drop and improve mobility, paretic ankle and knee kinematics, kinetics, and energy cost of walking 1
• AFOs improve walking speed, step/stride length, and balance (weight distribution in standing) 1
• Consider referral when rehabilitation goals are hindered by persistent lower limb motor impairments 1

Contracture Prevention

• Resting ankle splints used at night and during assisted standing may be considered for prevention of ankle contracture in the hemiplegic limb 1
• AFO use can prevent ankle plantarflexion contractures that affect gait quality and safety 1

Critical Compliance Factors

Patient willingness to wear the AFO regularly is essential for success. 1 The orthotist should:

• Verify correct and comfortable fit 1
• Address any physical discomfort early, as this is a major barrier to adoption 2
• Educate patients that initial negative reactions are common but often resolve with continued use 2

Common Pitfalls to Avoid

• Do not prescribe custom AFOs immediately without first trialing prefabricated options to assess need and compliance 1
• Do not assume all patients will adopt AFO use - approximately 40% may withdraw due to discomfort or preexisting health issues becoming barriers 2
• Do not neglect follow-up - patients need reassessment to ensure the AFO continues to meet their functional needs as recovery progresses 1

Alternative to Orthotist Referral

Neuromuscular electrical stimulation (NMES) is reasonable to consider as an alternative to an AFO for foot drop (Class IIa, Level A evidence). 1 This may be appropriate for patients who refuse orthotic devices or have contraindications to AFO use.