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Customising my AFO
Written by Chloe on Saturday, February 19, 2011
It took me six weeks of making adjustments to my new AFO to reach the point where I was comfortable walking much while wearing it. I am a complete newbie with a molded AFO, so I was very grateful for long discussions with resident experts Kim and Lane.
I had not been aware that even with a custom molded AFO it is normal to require some post-manufacture customisation. It is all the more necessary with an off-the-shelf model such as I have. Peoples’ legs and feet differ markedly in shape.
The first step is to figure out exactly where are the pressure points that could cause potential problems. This is trivially easy for me, since I have complete sensation in my right leg and foot. Without sensation, it would seem that a molded AFO presents a significant risk of pressure sores unless great care is taken with the customisation.
There are different techniques for customisation. Sometimes an orthotist will use a blowtorch to heat parts of the AFO such that they become pliable. This did not sound like something I wished to attempt at home. I had visions of a molten bubbling glob of plastic on the carpet, issuing jets of flame. Hmm…
Attaching pieces of foam to the AFO in strategic places is another standard technique. I decided to start off with minimally invasive moleskin, to get a feel for the process. At the suggestion of a friend, who wears bilateral molded KAFOs, I had successfully used moleskin for fixing a problem with the upper thigh cuff of my left KAFO. It works extremely well for this purpose, but for the task at hand it was much too thin. Off came the moleskin, but it had given me some confidence for the next step.
I looked around in my boxes of junk and found some thick foam with a heavy duty self adhesive. My recollection is that it came with one of my shoulder immobilisers, for fibromyalgia, in order to customise the fit. It turned out that I didn’t need the foam for that purpose, but I’m glad I kept it.
I paid attention to my mentors’ advice of not gluing anything permanently until I had tested it. It seemed like a big step to press in that first large piece of adhesive foam, but it worked like a charm. The pressure was taken off my jutting pointy heel, and transferred evenly to my my lower calf.
After a few weeks I added a couple more smaller pieces of foam for fine tuning. This helps keep the heel a little more stable in the correct alignment.
Customized AFO
The other main pressure point is due to the unusual depth of my feet. After measuring my feet a couple of years ago, my orthotist found that I would have precious little choice of orthopedic shoe, due to this depth and the 4E width. With the AFO inside the shoe, the depth becomes a problem again, causing a pressure point on top of the foot. After digging out all insoles and removing the shoelace from the bottom holes, the system works well enough.
A slight problem is gradually developing with the calf strap. It is perfectly comfortable, with a nice foam pad in front. However, it is gradually slipping where it is glued to the back of the AFO. The glue is not strong enough! You’d think they would test drive prototype models to check for this kind of thing. Oh well. For now it’s not an issue, but it seems like eventually I’ll have to remove the strap and glue it correctly in place with something stronger.
I hate velcro! Yes, I know it’s easier if one has limited dexterity; but, for anyone who can use a buckle, velcro seems to have zero advantages. If there is a choice I always buy something with a buckle, rather than a velcro version. My AFO automatically came with a velcro calf strap; no choice. The main problem is that the velcro is gradually getting enmeshed with cat hair. It doesn’t help that the plastic AFO easily acquires an electrostatic charge, thereby attracting cat hair. A conductive plastic, and buckling calf strap would have been in my own design. But then I did go for the cheapest AFO without any bells and whistles.
It is interesting that my right calf muscle has already noticeably tightened up after just six weeks of wearing the AFO, on account of the minimal dorsiflexion.
Anybody else have any molded AFO tips?
Tags: Adhesive Foam, AFO, Customisation, Feet, KAFO
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18 Comments
@Mark: Thank you so much for all that excellent information. Does it look from the photo that I have done things in a reasonable way? All I can say is I’m not currently having any problems with it. Lane had mentioned to me about being careful to pad *around* the pressure points (hence the little gap in the foam going down the right side of the ankle).
Last week I wore ankle socks to work with the AFO for the first time, to see how that would work. It was warm enough that my bare legs did not get cold, but cold enough that they didn’t get sweaty. We’re supposed to be in the grip of an arctic blast all next week.
About three years ago I had a long conversation with my friend, who wears bilateral molded KAFOs, about the pros and cons of her switch from metal/leather to plastic. The big con was the sweating in hot weather. Her mitigating solution is to wear stockings all the time. I guess I’ll find out about it in due course. The average daytime high here in July is in the 90s(F).
The holes sound like a good idea too. Kim did warn me though that she’s had polka dot sunburn from her holy AFO!
I do have one of those high temperature heat guns (I work in a chemistry lab). However I don’t feel sufficiently confident about using it on the AFO. Seems like I could totally mess things up if I didn’t know what I was doing.
Good idea to rivet the calf strap. I really do appreciate all your helpful suggestions, Mark.
Actually it looks like you did a fine job of padding- especially the horseshoe shaped one at the heel, letting the calcaneus (heel bone) settle into a gully at the bottom. If there’s no discomfort, rubbing, or pressure, you’ve done the right thing. First goal is function, second is comfort, third is aesthetic, fourth is cramming the sucker into a shoe.
The dotted sunburn is a drawback. I’ve had patients with edema which forced their flesh into the holes, making a pattern of bumps in their legs. Perhaps in the future I should drill holes in their braces in a pattern of braille cells spelling their name!
Yes, best to avoid taking the heat gun to the plastic. There is a certain “Zen” to this, it does require practice. I’m glad I was helpful!
I have the same problem with my “plastic” foot plate on the new KAFO. It won’t fit in the boots that are already 4E like yours. I was thinking of cutting back from a full foot plate to a 3/4. Do I saw with a hacksaw or cut with huge shears?
If all fails on this I’ll just remove the lower part at the ankle joint and use it as a replacement for the old brace which has split stirrup or caliper ends. The old one is getting a bit wobbly at the knee after over 9 months of every day use.
Peter
@Peter: We use a bandsaw, but a hacksaw should do well. Using shears may distort the plastic a little bit, but they’re usable, too.
If you have some sort of buffing wheel to smooth the edges it will make the footplate more comfortable. Or use a Dremel with a felt wheel.
Boots aren’t usually recommended for use with plastic AFOs- the general rule is to use what works, though, and if you can cram it into a boot and still stuff your foot on top of it, go for it!
@Phil: I posted earlier, but I think I got the grass color wrong…
You can use a hacksaw or a scrollsaw to cut the plastic, but you need to buff the edges- a buffing wheel works best, or use a Dremel tool with a felt cone.
Huge shears usually distort the plastic. If your brace is polypropelene (the usual material) make sure that *ALL* of the nicks are sanded or buffed out- they present an opportunity for cracking, especially in cold weather. Copolymer is softer and a little more resistant to cracking, but it can still happen if cold enough.
I think it may have been Peter who mentioned some time ago the importance of remembering that the color of grass is five.
Chloe, you know very well the issues I have with the number five. I usually disconnect and wait for the snow.
Five inches of yellow snow? What all has been peeing there??
(Have to use the f number to send this, sorry! Hope the curse doesn’t transmit!)
Talking of snow, we often spend time in the mornings trying to identify the animals that have left footprints in the night. One day we found a very strange print: one big foot, two very small ones and a long continuous track. Must have been a big lame Bear!
I should take a picture next time I drag myself to the garage.
(Ha! Ha! Today’s question is the snow one)
The calf strap finally worked its way completely loose today. I had to take the AFO off before going into the grocery store, otherwise it would have just been flopping around even in the chair. Time for the rivets I guess.
15 On 2 April, 2011, Sean said:
Rivets, or a KAFO to replace the AFO :D
Right on, Sean.
My thoughts/advice are the same.
/Art
(KAFO symmetry)
Hmm… It looks like a clear majority in favor of me wearing bilateral KAFOs. I shall have to abide by the formal vote. Just remember guys; it’s all your fault! HA!
I’m going to give it at least a week. I have not yet figured out what to say to people at work if they ask about it. I have an excuse for the left one because I really do have nerve damage affecting that leg… but not the right! What am I going to say?
Okay, that is a serious question. I am indeed open to suggestions. No lies please!
OK…
1. You’ve had the kafo set all along and have worn both braces on select occasions for mobility options. Thus,
nothing ‘new’ and you now feel that wearing them into the workplace might be suitable, too. It’s a trial.
2. You’ve noted extra security and comfort from the support that double leg braces provide along with
a little less fatigue. Just that you feel your mobility needs are a bit more enhanced.
3. Their strength is reassuring to you at times,
and you feel a pleasing sense of balance by way of the custom design crafted into the orthotics worn on each leg. It just FEELS
right to you.
4. (option) You’ve received several unanticipated and positive comments about your appearance and poise while using the bi-lateral KAFOs. No need to go into TMI, even if said comments cleary carry a distinct devotee bias.
5. You are rather encouraged by these recent experiences and comments; you are now exploring the noted ‘double braced’ option for a time and you’ll certainly be open to continued feedback. Engage your ‘audience’. LOL
6. You might even appear pleasantly surprised that someone would notice or ask about the difference in your hardware alignment, and the progression to two KAFOs.
You asked!
/Art
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1 On 21 February, 2011, Mark said:
Although we try to account for rubbing and pressure spots by building up the plaster molds in the most likely areas, some pressure points may occur, notably at the medial and lateral malleoli, the fifth metatarsal base, the navicular, and the first and fifth metatarsal heads. The body moves, the plastic doesn’t.
Most of these types of AFOs will have a velcro strap, but thanks for the clue- I’ll try one with leather strapping and a buckle! I get most of my ideas from my patients and that one hasn’t ever come up.
These suckers are hot and sweaty- get your orthotist to drill a pattern of 1/2″ holes in the calf area to make it cooler. Wear tall socks as well to give you a barrier between your skin and the sticky sweaty plastic. The molded AFO gives you more choices in shoes, but I still prefer the metal uprights- they have a more “machine” look to them, but you are then limited to fewer shoes that also need the metal stirrup or channel installed.
If the calf strap is coming loose, tell your orthotist to use some self-stick hook velcro and use a speedy rivet to connect it- it won’t come loose.
If you have reservations about using a propane torch on your plastic, go to a hardware store and buy a heat gun. It looks like a hair dryer (**** DO NOT STORE THIS IN YOUR BATHROOM! ****) and will not burn the plastic. Heat the plastic until it just becomes translucent- if it is completely clear you have gone too far.
One more thing- a posterior flare is a good idea- heat the top edge of the brace from the inside to outside and flare that half of the circumference outward on a round metal bar (tell your orthotist to do this- it requires some practice!). This reduces the feeling of the edge of your brace on your calf.
One trick for padding a pressure point is that you pad *around* the pressure point and not directly over it. If you do this you are just adding additional thickness at that point and increasing the pressure.
Polypropelene does neat things when it burns- it melts, and the molten drops make a zzzzzit- zzzzzit- zzzzzit sound as the flaming droplets fall through the air. This is the same material that milk jugs are made from. Setting a milk jug on fire was a fun thing to do while on LSD, but alas, you just can’t get good acid these days…