[Orthopedic shoe treatment: Inserts]. / Orthopädische Schuhversorgung: Einlagen.

The use of inserts and orthopedic shoe adjustment represents an essential component of the conservative therapy of degenerative diseases and deformities of the musculoskeletal system. Inserts can have supportive, bedding and corrective effects and are used in particular for complaints of the feet and ankles. The combination of diverse materials allows a high level of cushioning and supporting features and corresponding longevity to be accomplished. The production is carried out on an individual basis and if necessary computer-assisted in order to achieve an optimal fit. For severe and rigid deformities the formation of pressure ulcers can be prevented by orthopedic shoe adjustment and by the use of orthopedic tailor-made shoes.

Offloading effect of therapeutic footwear in patients with diabetic neuropathy at high risk for plantar foot ulceration.

AIMS: Custom-made therapeutic footwear is often prescribed to patients with diabetic neuropathy, foot deformity and a healed plantar foot ulcer. Offloading these feet is important to prevent ulcer recurrence. The aim was to evaluate the offloading effect of custom-made footwear in these patients. METHODS: In 171 patients with diabetic neuropathy (336 feet) with foot deformity and a recently healed plantar foot ulcer, plantar pressures walking barefoot and inside new custom-made footwear were measured. At the previous ulcer location and at locations of highest barefoot pressure attributable to the deformity, in-shoe pressures were compared with non-deformed feet. The footwear was considered effective in offloading when in-shoe peak pressure at these locations was < 200 kPa. RESULTS: Mean in-shoe peak pressures ranged between 211 and 308 kPa in feet with forefoot deformity (vs. 191-222 kPa in non-deformed feet) and between 140 and 187 kPa in feet with midfoot deformity (vs. 112 kPa in non-deformed feet). Offloading was effective in 61% of all feet with deformity, 81% of feet with midfoot deformity, 44% of feet with forefoot deformity and 62% of previous ulcer locations. Inter-subject variability in measured in-shoe plantar pressure was large. CONCLUSIONS: Offloading in custom-made footwear is often not sufficiently achieved in high-risk diabetic feet with deformity. Highest offloading success rates were seen at known high-risk locations such as previous ulcer locations and Charcot feet, the lowest success rates in forefoot deformities. Together with the large inter-subject variability in pressure outcomes, this emphasizes the need for evidence-based prescription and evaluation procedures to assure adequate offloading.

[The organization of specialized care in case of pathology of foot and talocrural articulation].

The nozoological structure of podiatric pathology in Novosibirsk oblast is represented mainly by the injuries of talocrural articulation (39.2% of examined patients), deformation of foot (20.7%) and degenerative lesion of foot (15.9%), fractures of heel bone (4.2%). This pathology has higher social significance. The main cause of disability is the deforming arthritis of talocrural articulation (48.5%) and subtalar articulation (20.3%). The model of specialized podiatric care was developed and approved in the functioning of Novosibirsk specialized podiatric center. The model includes outpatient, diagnostic, treatment, rehabilitation stages. The implementation of this approach permits to avoid the re-appealability to municipal medical care system and application to the specialized medical institution. This approach precipitates the period of care delivering and decreases the possibility of disabling patients due to non-effective treatment of podiatric pathology in common curative institution.

Quantifying lower limb inter-joint coordination and coordination variability after four-month wearing arch support foot orthoses in children with flexible flat feet.

INTRODUCTION: Flat feet in children negatively affect lower limb alignment and cause adverse health-related problems. The long-term application of foot orthoses (FOs) may have the potential to improve lower limb coordination and its variability. AIM: To evaluate the effects of long-term use of arch support FOs on inter-joint coordination and coordination variability in children with flexible flat feet. METHODS: Thirty boys with flexible flat feet were randomly assigned to the experimental (EG) and control groups. The EG used medial arch support FOs during daily activities over a four-month period while the control group received a flat 2-mm-thick insole for the same time period. Lower-limb coordination and variability during the 3 sub-stance phases were quantified using a vector coding technique. RESULTS: Frontal plane ankle-hip coordination in EG during mid-stance changed to an anti-phase pattern (156.9°) in the post-test compared to an in-phase (221.1°) in the pre-test of EG and post-test of CG (222.7). Frontal plane knee-hip coordination in EG during loading response (LR) changed to an anti-phase pattern (116°) in the post-test compared to an in-phase (35.5°) in the pre-test of EG and post-test of CG (35.3). Ankle inversion/eversion-knee internal/external rotation joint coupling angle in EG changed to an in-phase pattern (59°) in the post-test compared to a proximal phase (89°) in the pre-test. Coupling angle variability increased in the post-test of EG for sagittal plane ankle-hip during push-off, transverse plane ankle-hip during LR and mid-stance, and transverse plane knee-hip during LR and mid-stance compared to pre-test of EG and post-test of CG. CONCLUSION: The long-term use of arch support FOs proved to be effective to alter lower limb coordination and coordination variability during walking in children with flexible flat feet. This new insight into coordinative function may be useful for improving corrective exercise strategies planned for children with flat feet.

Venous insufficiency and foot dysmorphism: effectiveness of visco-elastic rehabilitation systems on veno-muscle system of the foot and of the calf.

Chronic venous disease is very common and widespread. Chronic Venous Insufficiency (CVI) is a condition characterized by hypertension of the venous system of the lower limbs which manifests itself through a large range of symptoms. The main cause of CVI is hypertension of the venous system of lower limbs, which in most cases is due to reflux for the incontinence of the valvar system of veins. Other causes are related to obstruction of the venous outflow, or at a reduced venous emptying due to inefficiency of the system of the veno-muscular pumps of the calf and of the foot. The purpose of this study was to evaluate if the use of a non-invasive rehabilitative mode to improve the efficiency of the veno-muscular pumps of the foot and of the calf using photoplethysmography in reflected light. Fifty (50) patients suffering from flatfoot and ped cavus, were studied doing a stabilometric and baropodometric test to evaluate the angle of the foot and the podalic angle. Patients were evaluated by examining vascular examination and venous reography in basal condition, using corrective visco-elastic insoles for the correction of dysmorphisms that we were studying. An improvement of the angle of the Right and Left axis (p<0.05) and the podalic angle (p<0.001), using the right insole both in the flatfoot and cavus foot, was shown by the podobarographic examination. A not important tendency to improvement was also shown by the use of non-specific insole in both pathologies. The vascular examination showed an improvement of 38 percent in venous emptying capacity of the foot/calf veno-muscular pump in cavus foot with the specific B insole (p<0.002). An important improvement of 24 percent, using the specific A insole (p<0.05), was documented in flatfoot. The photoplethysmography examination documented a significant improvement of the venous emptying capacity of foot-calf veno-muscular system due to the use of specific insoles for the studied dysmorphism, with an improving tendency even with the use of non-specific insoles. The hemodynamic improvement is correlated with the improvement of the analyzed biomechanical parameters: contact time, lenght of the halfstep, podalic angle and angle of the foot. The partial normalization of biomechanical parameters allows a reorganization of relationships of forces between ground and foot, as well as the improvement of the function of the subtalar joint, causing a partial recovery of the complex physiological mechanism of activation of the veno-muscular pumps of the foot and of the calf.

Scientific assessment of over-the-counter foot orthoses to determine their effects on pain, balance, and foot deformities.

BACKGROUND: A scientific study was conducted to evaluate the effects of non-custom-molded (over-the-counter) foot orthoses. METHODS: Several parameters were examined, including foot, knee, hip, and back pain; balance; and reduction in flexible deformities, such as hammer toes and hallux valgus. Wherever possible, objective measurements were used, including measurements of shifts in center of pressure to assess balance and changes in bone position examined on radiographs. Forty-one individuals were analyzed using one of two types of prefabricated, non-custom insoles. Insoles were fit by an assistant trained to follow the fitting recommendations of the manufacturer under the direct supervision of a podiatric physician. RESULTS: Use of these arch supports resulted in a significant reduction in some types of foot pain associated with hallux valgus (P = .04) and pain in the arch area (P = .004), knee (P = .002), and back (P = .007) by week 4. We also measured changes in foot position documented by radiography, although some changes may be attributed to parallax associated with measurement techniques. Improvement in balance was not observed to be significant when the orthoses were worn. CONCLUSIONS: Using both subjective and objective measures, we found that these over-the-counter foot orthoses were effective in bringing about changes in foot shape and concomitant relief of certain specific painful conditions. This study indicates that there is a scientific basis for attempting to relieve pain with orthoses.

Immediate weight bearing following first metatarsophalangeal joint fusion with Kirschner wire fixation.

UNLABELLED: The general consensus regarding the postoperative management of patients who have undergone first metatarsophalangeal joint arthrodesis is to maintain non-weight bearing for 4 to 6 weeks. However, a number of studies indicate that immediate postoperative weight bearing does not result in a higher rate of nonunion. A retrospective case series investigation was performed to evaluate the fusion rate of first metatarsophalangeal joint arthrodesis using various forms of pin and wire fixation, and a postoperative protocol that involved immediate weight bearing with a padded surgical shoe. The impetus behind allowing immediate postoperative weight bearing stems from the desire to avoid difficult non-weight-bearing forms of ambulation in patients at risk for falling, and to enhance postoperative rehabilitation in patients at risk for other joint maladies, as in those suffering with rheumatoid and other polyarticular forms of arthritis. A total of 22 fusions (20 patients) were reviewed. Nonunion developed in 2 feet (9.1%), and a delayed union occurred in 1 additional foot (4.55%), for a total complication rate of 13.64% (3/22 cases) and a fusion rate of 86.36%. The remaining patients demonstrated radiographic consolidation of the arthrodesis. A crude rough comparison to previously published reports, wherein weight bearing was initiated anywhere from immediately to up to 2 weeks postoperative, showed that the rate of fusion observed in the patients described in this report was similar. This study demonstrated that immediate ambulation following first metatarsophalangeal joint fusion with wire fixation was safe and effective. LEVEL OF CLINICAL EVIDENCE: 4.

Interventions for the prevention and treatment of pes cavus.

BACKGROUND: People with pes cavus frequently suffer foot pain, which can lead to significant disability. Despite anecdotal reports, rigorous scientific investigation of this condition and how best to manage it is lacking. OBJECTIVES: To assess the effects of interventions for the prevention and treatment of pes cavus. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (April 2007), MEDLINE (January 1966 to April 2007), EMBASE (January 1980 to April 2007), CINAHL (January 1982 to April 2007), AMED (January 1985 to April 2007), all EBM Reviews (January 1991 to April 2007), SPORTdiscuss (January 1830 to April 2007) and reference lists of articles. We also contacted known experts in the field to identify additional published or unpublished data. SELECTION CRITERIA: We included all randomised and quasi-randomised controlled trials of interventions for the treatment of pes cavus. We also included trials aimed at preventing or correcting the cavus foot deformity. DATA COLLECTION AND ANALYSIS: Two authors independently selected papers, assessed trial quality and extracted data. MAIN RESULTS: Only one trial (custom-made foot orthoses) fully met the inclusion criteria. Two additional cross-over trials (off-the-shelf foot orthoses and footwear) were also included. Both studies assessed secondary biomechanical outcomes less than three-months after randomisation. Data used in the three studies could not be pooled due to heterogeneity of diagnostic groups and outcome measures. The one trial that fully met the inclusion criteria investigated the treatment of cavus foot pain in 154 adults over a three month period. The trial showed a significant reduction in the level of foot pain, measured using the validated 100-point Foot Health Status Questionnaire, with custom-made foot orthoses versus sham orthoses (WMD 10.90; 95% CI 3.21 to 18.59). Furthermore, a significant improvement in foot function measured with the same questionnaire was reported with custom-made foot orthoses (WMD 11.00; 95% CI 3.35 to 18.65). There was also an increase in physical functioning of the Medical Outcomes Short Form - 36 (WMD 9.50; 95% CI 4.07 to 14.93). There was no difference in reported adverse events following the allocation of custom-made (9%) or sham foot orthoses (15%) (RR 0.61; 95% CI 0.26 to 1.48). AUTHORS' CONCLUSIONS: In one randomised controlled trial, custom-made foot orthoses were significantly more beneficial than sham orthoses for treating chronic musculoskeletal foot pain associated with pes cavus in a variety of clinical populations. There is no evidence for any other type of intervention for the treatment or prevention of foot pain in people with a cavus foot type.

The effect of three levels of foot orthotic wedging on the surface electromyographic activity of selected lower limb muscles during gait.

BACKGROUND: Some types of foot orthoses have been researched for their effect on lower limb electromyographic muscle activity during walking. However, foot orthoses with high levels of medial rearfoot wedging ('inverted' foot orthoses) have not been investigated. METHODS: In a cross-sectional study, asymptomatic participants with a pronated foot type (n=15) were each issued with a pair of 0 degrees, 15 degrees and 30 degrees inverted custom-made foot orthoses. After four weeks of habituation to the orthoses, surface electromyography was used to measure the onset and maximum EMG amplitude of tibialis anterior, peroneus longus, medial gastrocnemius and soleus muscles using five conditions [barefoot, shoe-only, 0 degrees, 15 degrees and 30 degrees inverted foot orthoses conditions]. FINDINGS: A statistically significant increase in tibialis anterior maximum EMG amplitude occurred using the shoe only (30% increase), 0 degrees (33% increase), 15 degrees (38% increase) and 30 degrees (30% increase) inverted orthoses conditions compared to walking barefoot (P<0.01). Peroneus longus maximum EMG amplitude increased significantly using the 15 degrees inverted orthosis condition compared to walking barefoot (21% increase, P=0.04). INTERPRETATION: Footwear and orthoses can significantly alter the maximum EMG amplitude of leg muscles during walking. Foot orthoses appear to increase peroneus longus EMG amplitude compared to footwear alone. However, the level of medial rearfoot posting within an orthosis does not appear to significantly alter maximum EMG amplitude. The individual responses to foot orthoses are highly variable. The changes in EMG amplitude with the use of foot orthoses and shoes may have clinical implications.

Therapeutic footwear for the neuropathic foot: an algorithm.

Neuropathy may bring about changes in form and function of the foot, which may lead to ulceration and progressive deformity. These manifestations often require specially adapted footwear. A comprehensive concept of the medical, functional, and technical requirements for this type of footwear is still lacking to date. In this article, We present an algorithm that should facilitate prescription and manufacture of adequate shoes. This algorithm attempts to establish a link between the requirements from a medical and functional point of view and the technical possibilities of orthopedic shoe technology.

Effects of custom-made insoles on idiopathic pes cavus foot during walking.

From a subject group of pes cavus, the purpose of this study was to evaluate the biomechanical characteristics of lower limbs, based on plantar foot pressure and electromyography (EMG) activities, by the effects on two kind of custom-made insoles. Ten individuals among thirty females with a clinical diagnosis of idiopathic pes cavus (mean age (SD): 22.3 (0.08) years) were selected for the study. The plantar foot pressure data and EMG activities of four lower limb muscles were collected, when subjects walked on a treadmill, under three different experimental conditions. The plantar foot pressure data was analyzed, after the bilateral foot was divided into three areas of masks and into four sections of stance phase, to compare plantar foot pressure. The EMG activities were analyzed for integrated EMG (IEMG) value. The results show that plantar foot pressure concentrated in particular parts is decreased by custom-made insoles. In the case of EMG, all the muscle activities decreased significantly. The custom-made insoles dispersed pressure concentrated by the higher medial longitudinal arch and improved the efficient use of muscles. In particular, the extension structure in the forefoot of custom-made insoles was more efficient for pes cavus. Therefore, it could help patients to walk, by offering support to prevent the disease of pes cavus deformity, and to relieve the burden and fatigue in the lower limbs on gait.

Surgical rehabilitation of the planovalgus foot in cerebral palsy.

The objectives of this study were to quantitatively determine the effects of subtalar arthrodesis on the planovalgus foot using three-dimensional (3-D) gait analysis and plantar pressure measurements. Twelve children and adolescents with planovalgus foot deformity secondary to spastic cerebral palsy participated in this outcome study. The pediatric population were evaluated preoperatively and following subtalar fusion. Seventeen feet were operated for the correction of the planovalgus foot deformity. A Holter-type microprocessor-based portable in-shoe data acquisition system was used in this study to collect the multistep dynamic plantar pressure history, while a five-camera Vicon-based gait analysis system was used to track the lower extremity joint kinematics. The results obtained from the plantar pressure measurement showed significant increases in mean peak vertical plantar pressures postoperatively at the lateral midfoot and lateral metatarsal heads. Mean contact durations and mean pressure-time integrals were also significantly increased at these plantar locations following foot surgery. This redistribution in pressure metrics suggests the formation of new lateral plantar weight bearing areas. The 3-D gait analysis system, using standardized lower extremity measurements, was unable to reveal any significant changes in joint kinematics, particularly at the foot and ankle where the surgery was performed. This suggests the need for a more refined system to track the complex motion of the pediatric foot and ankle during gait.

Torsional and angular deformities.

A general understanding of the cause and natural history of rotational and angular malalignment of the lower extremity allows accurate differentiation between pathologic and physiologic conditions. One can then educate the involved and often concerned family and proceed with observational management of physiologic conditions as spontaneous improvement of alignment can be expected. Aside from treatment for resistant metatarsus adductus, other forms of treatment, such as special shoes, casts, or braces, are rarely beneficial and have no proven efficacy. Persistent deformity beyond skeletal maturity is unusual and rarely causes significant functional disability. In rare cases of severe residual deformity, operative correction is the only effective treatment.

Effects of three different posting methods on controlling abnormal subtalar pronation.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the effects of different orthotic posting methods on controlling abnormal foot pronation during ambulation. SUBJECTS: Twenty-two individuals with forefoot varus deformities of at least 8 degrees (13 women, aged 21-40 years, and 9 men, aged 20-50 years) participated in the study. The female subjects had an average height and weight of 162.6 cm (64 in) and 55.3 kg (122 lb), and the male subjects had an average height and weight of 175.3 cm (69 in) and 80.7 kg (178 lb). METHODS: The subjects were examined with a computerized video motion analysis system. A control trial consisted of walking at 4.0 km/h in running shoes. Experimental trials included walking at 4.0 km/h in running shoes with unposted orthotic shells and with orthotic shells posted in the forefoot, the rear foot, and both forefoot and rear foot. RESULTS: Maximal calf-to-calcaneus and calcaneus-to-vertical angles were decreased more by orthoses posted in both the forefoot and the rear foot than by orthoses posted only in the forefoot. No difference in maximal calf-to-calcaneus and calcaneus-to-vertical angles were found with combined forefoot and rear-foot posting compared with posting in the rear foot alone. The maximal calf-to-calcaneus angle was decreased by orthoses posted in any of the three methods and by the orthotic shell alone when compared with shoes alone. The maximal calcaneus-to-vertical angle was decreased by orthoses posted in any of the three methods, but not by the orthotic shell alone when compared with shoes alone. CONCLUSION AND DISCUSSION: Clinicians should consider combined posting or rear-foot posting alone when maximal control of rear-foot frontal-plane pronation is desired, though forefoot posting alone and the orthotic shell also provide control of rear-foot frontal-plane pronation.

Questionnaire for usability evaluation of orthopaedic shoes: construction and reliability in patients with degenerative disorders of the foot.

OBJECTIVE: To develop a self-report questionnaire for patients with degenerative disorders of the foot to evaluate the usability of their orthopaedic shoes, and to assess the reproducibility and responsiveness of the instrument. DESIGN: Development of the Questionnaire for Usability Evaluation of orthopaedic shoes was based on a literature search, structured expert interviews and a ranking procedure. A cross-sectional study was carried out to determine the reproducibility and internal consistency of the questionnaire. SETTING AND SUBJECTS: The study population comprised 15 patients with degenerative disorders of the foot, who had worn their orthopaedic shoes for at least 3 years and 15 patients with degenerative disorders of the foot, who had never worn orthopaedic shoes, but would receive them within 1 month. RESULTS: Within the questionnaire 4 effectiveness items (pain, instability, callus, wounds), 1 efficiency item (putting on and taking off shoes) and 7 satisfaction items (pinch, slip, weight of shoes, cold feet, perspiration, maintenance, cosmetic appearance) were developed. All items in the questionnaire met the test-retest criteria. The smallest real difference ranged from 0.23 to 3.82 cm on a Visual Analogue Scale (10 cm). Cronbach's alpha's for the domains of pain and instability ranged from 0.70 to 0.92. CONCLUSION: The Questionnaire for Usability Evaluation should provide a good rationale to assess the usability of orthopaedic shoes and can be considered reliable.

The effect of simple insoles on three-dimensional foot motion during normal walking.

BACKGROUND: The purpose of this study was to establish the effect of simple non moulded flat based insoles on three-dimensional foot motion during normal walking. Excessive foot pronation is considered a major contributing factor to lower limb injuries. Moulded foot orthoses have been shown to decrease maximum foot eversion. Simple insoles are widely used in clinical practice as an alternative to moulded orthoses. However, there has been little research into the kinematic effects of simple insoles. METHODS: All subjects had an inverted rearfoot and forefoot position when the subtalar joint was placed in neutral, which was assessed by a weight bearing goniometer. Rotations of the whole foot about three orthogonal axes relative to the shank were estimated using a five camera motion analysis system. FINDINGS: Biplanar insoles significantly (P < 0.05) reduced maximum eversion by an average of 3.1 degrees when compared to the no insole condition. The cobra insole reduced maximum eversion by an average of 2.1 degrees when compared to the no insole condition. This difference approached statistical significance (P = 0.058). INTERPRETATION: Biplanar and cobra insoles had no significant effect on maximum dorsiflexion, abduction or rate of eversion, when compared to the no insole condition. These results provide some limited support for the use of simple insoles to control for excessive foot pronation during walking.

Pressure relief and load redistribution by custom-made insoles in diabetic patients with neuropathy and foot deformity.

OBJECTIVE: To study the effects of custom-made insoles on plantar pressures and load redistribution in neuropathic diabetic patients with foot deformity. DESIGN: Cross-sectional. BACKGROUND: Although custom-made insoles are commonly prescribed to diabetic patients, little quantitative data on their mechanical action exists. METHODS: Regional in-shoe peak pressures and force-time integrals were measured during walking in the feet of 20 neuropathic diabetic subjects with foot deformity who wore flat or custom-made insoles. Twenty-one feet with elevated risk for ulceration at the first metatarsal head were analysed. Load redistribution resulting from custom-made insoles was assessed using a new load-transfer algorithm. RESULTS: Custom-made insoles significantly reduced peak pressures and force-time integrals in the heel and first metatarsal head regions; pressures and integrals were significantly increased in the medial midfoot region compared with flat insoles. Custom-made insoles successfully reduced pressures in and integrals at the first metatarsal head in 7/21 feet, were moderately successful in another seven, but failed in the remaining seven. Load transfer was greatest from the lateral heel to the medial midfoot regions. CONCLUSIONS: Custom-made insoles were more effective than flat insoles in off-loading the first metatarsal head region, but with considerable variability between individuals. Most off-loading occurred in the heel (not a region typically at risk). The load transfer algorithm effectively analyses custom-made-insole action. RELEVANCE: Because similar insole modifications apparently exert different effects in different patients, a comprehensive evaluation of custom designs using in-shoe pressure measurement should ideally be conducted before dispensing insoles to diabetic patients with neuropathy and foot deformity.

Reliability of visual measurement of forefoot alignment.

BACKGROUND: The purpose of this study was to determine the interrater reliability of visual rating of forefoot frontal plane deformities among clinicians with different training. METHODS: Thirty individuals (16 men and 14 women) between the ages of 22 and 52 years of age participated in the study. None of the patients had a history of congenital deformity, pain, or trauma in the lower extremities during the 6 months before the study. Three clinicians of different educational backgrounds and experience visually evaluated each of the patients and rated forefoot alignment. None of the clinicians knew the rating assigned by either of the other two clinicians. RESULTS: The results of this study showed that two of the clinical raters agreed 61.7% of the time, but neither of them agreed with the third clinician more than 15% of the time. CONCLUSION: This study indicates that the commonplace method of visually rating forefoot frontal plane deformities is unreliable and of questionable clinical value.

Outcome of orthoses intervention in the rheumatoid foot.

This study was carried out to determine the effect of foot orthoses on pain, gait, and energy expenditure in patients with rheumatoid arthritis. Eighteen patients were evaluated for these parameters. Each patient was given a foot insert or shoe modification suitable for his or her foot deformity. Following 3 months of orthosis use, a significant difference was found in regards to pain (p < .05), step length and stride length (p < .05), and physiological cost index (p < .05). The results suggest that foot orthoses are an important feature in the rehabilitation of the rheumatoid foot.

Orthotic and bracing principles in neuromuscular foot and ankle problems.

The gait cycle involves a closely linked interplay among the joints of the lower extremity, notably the complex joints of the foot and ankle. The goals of bracing and orthoses in the management of neuromuscular foot and ankle problems are to prevent further deformity, passively correct deformity, and modulate motor tone. Tone-reducing AFO, in effect, improves the position of the lower extremity and facilitates the pathologic gait. The type of deformity present and its natural history by virtue of the pathologic origin must be considered when embarking on a conservative nonoperative course. Associated issues and thought processes are elaborated in the article. The biomaterials of which the orthotic brace is constructed, the design considerations, and expected goals of an orthosis must be appropriate to accommodate the pathomechanical forces encountered in the face of the cutaneous insensitivity. It is evident from the multiple facets of rehabilitative care that a team of professionals, including the orthopedist, physical therapist, and orthotist, along with involved health care workers, must be in communication and agreement to manage the challenges of these patients successfully.