Bracing

Any orthotic device for the lower limb that encloses the ankle and foot, does not extend above the knee, and is intended to prevent a foot from dropping due to inadequate dorsiflexion.

Definition of a knee-ankle-foot orthosis (KFO):

Any orthotic device for the lower limb that extends from above the knee to the ankle and foot, and is intended to control the knee joint in addition to the foot and ankle.

Foot drop and balance loss are the most common complaints CMT patients have when evaluating for AFOs. Balance loss can cause pathological gait to be more exaggerated. With balance loss, CMT patients will need to rely on objects to lean against while standing, and to touch objects, such as walls, while walking.

Bracing for children with CMT should consist of all the same clinical evaluations and goals as for adults. One primary difference is consideration for growth. As growth rates cannot be controlled or clinically predicted, it is in the discretion of practitioners as to whether they could build in extra length to the device for potential growth without compromising fit, stability, and function.

Another difference in treating children is that there may be a more intense focus on correction than with adults, to the point of even over-correction, knowing the ongoing progression of deformity that often occurs in CMT patients. Adults can still achieve significant correction in gait, and this should be the goal in orthotic treatment.

• Tibialis anterior strength
• Gastrocnemius strength
• Quadriceps strength
• Age
• Overall strength
• Hand involvement
• Extent of damage to muscles, tendons, ligaments, bones, joints and balance.

• Foot drop
• Pes cavus deformity
• Varus deformities
• Valgus deformities
• Muscle atrophy
• Balance loss

• Foot drop
• Loss of balance
• Gastrocnemius weakness
• Foot and ankle deformity
• Slow walking speed

• Increases oxygen consumption
• Overtaxes the existing musculature that is working
• Early fatigue
• High risk for tripping and falling

• Contractures—the achilles tendon becomes shortened from a lack of dorsiflexion
• Ligamentous laxity—ligaments become overstretched due to improper joint alignment. This causes further instability at the foot and ankle and creates more balance loss

Triplanar Correction: The patient’s foot and ankle need to be corrected as much as possible in all 3 planes of movement;

1. Ankle Joint-or Talocrural Joint
2. Subtalar Joint
3. The midtarsal joint (transverse tarsal joint)

• Posterior leaf spring Ankle-foot orthosis (AFO)
• Solid ankle AFO
• Floor reaction AFO
• Jointed AFO
• Range-of-motion adjustable jointed AFO
• Energy storing carbon fiber AFO
• Knee-ankle-foot orthosis (KAFO)
• Energy storing KAFO
• Off-the-shelf AFOs (not recommended for CMT patients with moderate or severe deformity, or edema)

• Custom made AFOs are made from a mold of the patient’s leg, in order to fabricate a custom fit device which can address different structural deformities.
• Off the shelf are not made from molds. They are pre-manufactured, and are typically fit by sizes; small, medium, large, left and right.

• Triplanar correction
• Corrected alignment
• Balance restoration
• Prevention of further deformity
• More functional gait through energy storing mechanics

• If the patient cannot stand with balance, they cannot walk with balance.
• Balance requires a stable foundation. If the foot and ankle are not corrected in the brace’s footplate, balance can be poor.
• Balance restoration also requires practice. Physical therapy should be incorporated if needed.
• Floor reaction brace design helps CMT patients with balance.
• Energy storing designs can help patients reduce fatigue.

• Thermoplastics
• Metal
• Leather
• Carbon fiber