You’ve met with a clinician, and the child has been fitted with an ankle foot orthoses (AFO) to help with mobility challenges. The AFO brace design matches the child’s needs, but does the brace fit as it should? A comfortable fit and proper foot and ankle alignment are critical to seeing improved results. Even if all other aspects are as they should be, a poor fit can potentially prevent the child from seeing the improvements he ore she might otherwise be able to achieve.

What exactly should you look for when evaluating the child’s brace fit, and how can you best work with a clinician to address these areas of concern? Here’s a Top-10 List of things to look for when evaluating the child’s brace, and how you can work with a practitioner to provide the best possible fit.  

First, let’s address fit around the foot and ankle portion of the brace.

1. The child’s heel fits fully into the brace’s heel cup without excess space.

If the heel volume is too small, the child’s heel will not seat well in the heel cup. This may throw the brace contours out of alignment with the foot, causing redness to occur. On the other hand, if there is too much heel volume, the heel will be free to move around more than it should. This can lead to blistering or a lack of foot control.

2. The contours of the brace’s foot bed match up well to the child’s foot.

When the child bears weight on the brace and the foot bed of the brace does not match the contours of their foot, the result can be very uncomfortable.

3. The width at the forefoot (ball of the foot or metatarsal heads) fits comfortably under weight bearing.

If the brace is too wide for the weight-bearing width of the forefoot, the child’s foot may use the extra space to move into an uncorrected position. It will also be more difficult to find a proper shoe fit if this is occurring. However, if the forefoot width is too small, there will be pinching and redness along the inner and outer sides of the foot.

4. If the brace has a wrap-around design, it closes snugly over the top of the foot, with some “give” for comfort and growth.

Some braces wrap fully over the foot, contributing to foot control through mild compression and offering considerable comfort (since there are fewer potential areas of edge pressure). When a child is fit with such a brace design, look for a mildly compressive wrap that includes some “give” or “bounce” if you press downward on the instep. If the fit is too tight, it will cause discomfort and redness; if too loose, alignment and support are diminished.

5. The toe length provided by the brace leaves 1/8- to 1/2-in. extra room for comfort and growth when the patient is standing in the device.

Naturally, growth room is gauged by the patient’s growth rate. Adults won’t need extra room for growth. Toddlers and teens, on the other hand, will need a generous allowance, but not so much extra length that it causes them to trip.

6. The space allowed for any boney prominences is correctly placed and contoured.

Ideally, a small amount of extra space is centered on the apex of a boney prominence. The fit remains close in the supporting contours around that apex.

Now that we’ve taken a look at fit around the brace’s ankle area, let’s consider the appropriate fit for the AFO’s lower leg section. There are three main things to check here.

7. The brace height is tall enough to control the alignment or support needs being addressed, while being short enough to allow freedom of movement without pinching or digging into the child’s calf or the back of their knee.

No one wants any more restriction than is needed in a brace. Taller AFOs might be appropriate when hyperextension of the knee or extreme pronation or supination is involved. If the issue is toe walking or excess plantarflexion (PF), you may be able to use a lower brace height. Your target is somewhere between the mid-calf and one to two inches below the crease of the knee. One thing to watch for at the fitting, especially for children, is that the brace’s top edge does not dig into the calf belly, back of the knee or the child’s thigh when moving from crouching to standing.

8. If the design is expected to allow the leg to move freely forward over the foot, the leg portion is wide enough to allow this action with ease.

Some AFOs are designed to be used without a strap across the front of the leg at the top of the brace. This allows the leg to move freely over the foot while continuing to block toe walking or excess PF. In this style, the brace’s front opening needs to be wide enough to allow the leg to move freely out of and back into the leg portion of the brace. If the brace is too tall, it could get caught in the pant leg as the leg flexes forward and away from the brace. The taller the brace, the further away from it the leg will go.

9. The width of the leg portion of the brace is wide enough for comfort over long periods of time, but it fits closely enough to help realign the leg-to-foot position.

Alignment of the leg in relation to the foot portion of the brace is important for improved positioning. Excess brace width decreases this alignment correction. Conversely, a fit that is too tight on the leg can be uncomfortable. We’re going for the happy medium here.

Finally, an overall look at the brace’s edges is useful.

10.  The edges of the brace allow a comfortable fit and room for expected movement.

The brace’s edges should not present a comfort problem—there should be no pinching or digging. (Look for redness on the skin at the brace’s edges.)   Also, the edges should allow movement: the ability to bend easily at the toes during walking, for example.

Working With a Clinician to Find the Best Fit

As the child’s parent or caregiver, it is helpful to be able to spot potential areas of concern in the child’s brace fit. Your close relationship will grant you an inside look at brace fit and usage, and you will be more likely to notice any fit issues early on, during the child’s day-to-day activities. Having at least a moderate knowledge and familiarity with typical fit issues will make you better prepared for working together with a practitioner to find the appropriate solution for the child’s needs. In some cases, the solution may be a simple brace adjustment for the Orthotist to make.

If you are able to answer “yes” to this entire checklist without needing to address any fit issues, things are going well. An initial fitting that goes well does not necessarily guarantee the child’s success, but it is a very good start. If the brace style is appropriate for the child and the fit looks good initially, the patient can begin habituation, or living with the device. Typically, a practitioner will schedule a follow-up appointment two to three weeks after the initial fitting to verify that the brace is working well for the patient. This is a good time to address any potential areas of concern you may have noticed since the initial fitting.

A more typical scenario is that the initial fit is very close but could be improved with a few minor adjustments. If you aren’t able to answer, “yes” to all of the above points, you should be able to work with the child’s practitioner to determine where the problems are. Referencing each of the items on the above fit list should provide some help when describing the problem to the clinician you’re working with.

Habituation: Adjusting to Brace Wear

When adjusting to a new brace, it’s best to break it in slowly, as you would a new pair of stiff leather dress shoes. The child’s clinician will have a good sense of the ideal brace wear time, but it’s typical to start with one to two hours of wear per day. Checking the skin for redness and asking the child for feedback on comfort when removing the brace will give you a sense of how the brace is fitting and if the wear time is appropriate. If the child isn’t experiencing any redness or problem areas, one to two hours of wear time will typically be added per day.

By the end of one week, an experienced brace wearer with no extraordinary sensitivities and good verbal feedback should have habituated completely to the new brace. However, it may take up to two weeks for a delicate patient or new wearer. If the child has not noticed any improvement from wearing the brace at the end of three weeks, or if they are still having trouble with comfort, there may be an issue that needs to be addressed. The first step here, again, is to rule out a fit issue. It may be helpful to start at item 1 and work your way through the fit checklist.

It’s not uncommon to jump to the conclusion that the brace design (its level of support and intended functional outcome) is at fault when in fact a minor fit problem may be the root of the issue. If, however, you’ve gone through the fit list and fit is not the problem, then the next step is to re-evaluate the brace’s level of support or function. Once you’ve ruled out fit challenges, a different brace design may be just the trick to helping the child wear their brace with comfort, confidence and joy in the freedom it provides.  

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Loretta Sheldon is an ABC Registered Orthotic Assistant and Certified Fitter of Orthotics. She is the clinical assistant to Don Buethorn and manages the Education Resource team at Cascade Dafo. In her 10 years of service at Cascade, Loretta has worked with many areas of the company from the technical support of practitioner customers to product development and clinical problem solving.