Splints and Casts: Managing Foot Deformity in

Children with Neuromotor Disorders

Beverly D Cusick
PHYS THER. 1988; 68:1903-1912.

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Injuries and Conditions: Foot
Kinesiology/Biomechanics
Neurology/Neuromuscular System: Other
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Splints and Casts
Managing Foot Deformity in Children with Neuromotor Disorders
BEVERLY D. CUSICK

This article presents methods by which physical therapists can use splints and
casts to intervene directly in pediatric foot deformity management, preprescrip-
tion evaluation, rehabilitation, and new splint designs for children with neuromotor
disorders. Recent advances in biomechanics, engineering, and orthotics have
introduced new methods of preventing or reducing foot deformity while facilitating
optimal function. Several splint styles are described with current indications and
contraindications for their use. The use of casts in serial applications to reduce
soft tissue contracture rather than to reduce muscle tone is discussed.
Key Words: Biomechanics; Foot deformities; Orthotics/splints/casts, lower extrem-
ity; Pediatrics.

Lower extremity alignment, struc- chanics and orthotic intervention, the in pediatrics. The main target is the
tural integrity, and mobility differ mark- potential effectiveness of an orthosis can deforming influence of creep. Be-
edly in infants and toddlers with normal be anticipated but not predicted at the cause the process of ossification is
(unimpaired) neuromotor function com- time of prescription. Its functional im- incomplete in the young child, ab-
pared with older children and adults pact can only be ascertained after super- normal forces of weight-bearing and
with normal neuromotor function.1-10 vised implementation.26 The expense in- muscle tension will result in deform-
The child's foot is malleable and is af- curred in this process, both in time and ity of bone structure.1,2,21,26-29
fected by chronic deviations in postural financial resources, becomes prohibitive 2. Correction of soft tissue deformity.
alignment, laxity in the supporting liga- when the orthosis fails to meet the By using casts, splints, and orthoses
ments, or disturbances in motor func- team's goals and the patient's needs for to reduce deformity in the soft tissue
tion in the trunk and lower extrem- comfort, deformity prevention, and ad- structures in the foot of the growing
ity.2,11-18 The child with a neuromotor equate support for optimal function. child, creep is implemented in re-
disorder, therefore, is a predictable can- Clinicians, therefore, have turned to verse in the prolonged application of
didate for structural abnormality and plaster and low-cost splinting materials corrective (rather than deforming)
dysfunction in the lower extremities, for several reasons. The purpose of this forces. Body weight, size, and skin
particularly the feet, as a result of creep. article is to present some methods by tolerance are limiting factors in this
Creep is the slow development of de- which physical therapists can use splints application.1,26,30
formity related to soft tissue adaptation and casts to intervene directly in de- 3. Control of undesirable motions of
to the chronic application of abnormal formity management, preprescription the affected supporting segments
stresses.1,19 evaluation, rehabilitation, and design of while permitting motion where it oc-
The pediatric team that manages new devices for children with congenital curs normally.31
problems of foot deformity ideally con- and acquired neuromotor disorders. 4. Protection of weak stabilizing mus-
sists of physical therapists and occupa- Four aspects of current trends and ra- cles, either following surgery11,17,29,32
tional therapists, a pediatric orthopedist, tionale for the implementation of splints or secondary to hypotonia.33
an orthotist, and, in some facilities, a and plaster casts are discussed: 1) recent 5. Control of deviations associated with
physiatrist, a podiatrist, and an ortho- events that helped establish principles of tonus abnormality (N. Hylton and
pedic technician. The team's resources orthotic intervention and the applica- R. P. Jordan; personal communica-
include an increasingly sophisticated tion of those principles to the design of tion; March 18, 1988).13,23,29,33
knowledge of age-specific biomechanics splints for the foot and ankle, 2) new 6. Enhancement of experience. The
related to the lower extremity and such findings in developmental biomechan- child who is otherwise unable to
principles as floor-reaction forces and ics, 3) clinical research and experience stand or walk can experience upright
the closed kinetic chain.1,2,6,7,20-25 related to the use of casts, and 4) avail- posture with biomechanical support
Management of motor disorders that ability of improved splinting materials. devices while gaining the physiologic
involve abnormalities in muscle tone benefits of the standing position.14,34
regulation and unique functional com-
pensations is a complicated process. De- GOALS OF PEDIATRIC
spite recent developments in biome- ORTHOTIC INTERVENTION HISTORICAL PERSPECTIVE
The following goals of pediatric or- Well-documented, diverse events in
B. Cusick, MS-CCT, PT, is a physical therapy
consultant, Cardinal Hill Hospital, 2050 Versailles thotic intervention were drawn from the recent decades contributed to our cur-
Rd, Lexington, KY 40504, and a part-time staff literature, although the authors varied rent management of foot deformity in
member and consultant, Lexington Physical Ther- in their emphases. children with nonparalytic neuromotor
apy, Inc, Lexington, KY. Address correspondence
to 332 Lafayette Ave, PO Box 11426, Lexington, 1. Prevention of deformity. This is the disorders. Changes occurred simultane-
KY 40502 (USA). most common orthotic application ously in the design and use of casts and

Volume 68 / Number 12, December 1988 1903

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orthoses. The developmental process tendon-bearing, knee-locking ankle-foot thoses for follow-up.51 Although the
continues with the recent emergence of orthosis for paralytic disability42 were casts were bivalved, their cumbersome
lower extremity functional splints as an applied to the problem of crouch de- features and functional limitations high-
alternative intervention. formity in children with cerebral palsy. lighted the need for techniques that
Beginning in the 1950s, the high-top The anterior floor-reaction orthosis would offer minimum stabilization and
shoe with double-upright, short leg (AFRO) was created as a result.43 The optimal biomechanical alignment and
brace was commonly used and has since solid crouch-control ankle-foot splint function.
been recognized for its shortcomings in (AFS) was developed concurrently with In recent years, several authors have
securing the spastic foot and ankle in the AFRO, although without the benefit described their experience using in-
neutral alignment and a plantigrade po- of influence. hibitive casts and orthoses47,50,52-54 and
sition. The leather shoe quickly con- neurophysiological and tone-reducing
forms to the shape dictated by the de-
CHANGING CONCEPTS ankle-foot orthoses (TRAFOs).55,56
forming forces that cross the ankle and These devices incorporate design fea-
IN CASTING
foot 11,23,33 In the 1950s, however, the tures that inhibit hypertonus resulting
Helfet heel seat—a small, U-shaped in- The rationale and techniques related from four potential problems: 1) spasti-
sert—was developed to treat flexible to the use of casts in the management city, 2) tonic reflexes in the foot, 3) the
flatfoot (pes planus) in children and of neuromotor disorder has varied over positive-support reflex, and 4) abnormal
helped usher in a new concept in mini- time and among different regions of the toe grasp. The TRAFO also purportedly
mum stabilization of the calcaneus.35 world. In the 1950s, physicians in Cali- uses biomechanical alignment of the
In the late 1960s, high-temperature fornia and South Africa used plaster foot structure to facilitate improved
plastics such as polypropylene appeared casts to conservatively manage both function.55 Researchers, however, have
as an orthotic medium and sparked structural (soft tissue) and functional yet to quantify or substantiate the effects
the development of lightweight, total- limitations imposed by lower extremity of TRAFOs,57-59 despite an abundance
contact devices and the need for a spasticity.44,45 Westin and Dye reported of clinical and empirical evidence of
systematic, biomechanical approach to on 27 years of success in using long leg improved joint mobility and function.*
design and implementation of orthotic casts to manage contractures in patients Given the improved alternative man-
systems.22,23,31,32,36,37 With total-contact, with cerebral palsy.44 In 1960, the iden- agement options, since 1984 I have
devices came an abundance of clinical tification of the tonic reflexes of the foot joined numerous authors in advocating
problems related to functional impact led to the design of a contoured foot- the use of casts in only serial applica-
and skin tolerance, particularly in indi- board, which was incorporated into the tions to conservatively reduce fixed con-
viduals with neuromotor impairment. A "inhibitive cast," known also as the Se- tracture related to chronic hypertonus
shift occurred in the concept of bracing attle cast.46,47 The footboard is designed (see article by Selby in this is-
as a shoring up of falling structures to a to reduce the pressure stimuli that elicit sue).2,17,26,44,62-64 The main tissues in-
more dynamic definition of promoting the tonic foot reflexes. By 1970, long leg volved in serial casting for children with
improved functional efficiency.31,38 casts were an integral part of cerebral neuromotor impairment are the knee
The University of California Biome- palsy management in Australia.48 flexors, ankle plantar flexors, and neigh-
chanics Laboratory (UCBL) shoe insert During the late 1970s, below-knee boring connective tissues. Serial plaster
was developed in the 1960s to treat flex- "plasters" (K. Bobath and B. Bobath, casts are used to increase joint mobility.
ible pes planus. The UCBL shoe insert unpublished article, November 1966), If serial cast treatment fails, surgery is
applied principles of floor-reaction also known as inhibitory casts, were in- considered, and a postsurgical splint or
forces to the goal of using minimum troduced in the eastern United States in orthosis is used as necessary for main-
stabilization to reduce foot deformity.39 conjunction with training in neurode- tenance and protection of weakened tis-
By 1977, research showed that both the velopmental treatment.49 Built with a sues or to enhance stability in upright
Helfet heel seat and the UCBL shoe toe support and posted to flatten the positions.
insert effectively reduced flexible flat- sole for optimal efficiency in weight- Selection criteria among the alterna-
foot deformity with a plantar-flexed bearing, plasters offered a primitive tive cast and orthotic interventions have
talus in healthy children under the age means by which to apply the principles changed as increasingly sophisticated re-
of 9 years.30 Other researchers later ad- of floor-reaction forces to promote sta- search supports and discards their effi-
vocated the use of properly fabricated bility. Plasters were used as an extra pair cacy. Current trends reflect new tech-
UCBL shoe inserts for certain children of hands to enhance therapeutic exercise nologies, making improved materials
with cerebral palsy.23,40 aimed at promoting equilibrium and available to the innovator. Splints have
By 1975, research showed that a fixed- control against gravity in the proximal emerged in this process.
ankle, below-knee orthosis with the an- joints and trunk (J. D. Mohr, personal
kle set at 5 degrees of dorsiflexion effec- consultation, March 1977).
tively reduced the genu recurvatum In 1977, therapists at the Children's SPLINTS—A NEW ALTERNATIVE
(knee hyperextension) that occurs in Rehabilitation Center (CRC) in Char-
combination with equinus deformity in lottesville, Va, initiated the use of plas- At CRC in 1981, we learned that
children with cerebral palsy.41 Floor- ters in the treatment of children with Aquaplast® splinting material† had been
reaction principles were effectively ap- functional rather than fixed equinus de- revised to eliminate stickiness and was
plied to the problem of minimizing formity and related postural disturb- being used in foot-deformity manage-
external apparatus to control knee align- ances.50 In 1979, the CRC began to use
ment and function. bivalved casts and footboards48 (L.
* 44, 45, 47-52, 54, 55, 57-62.
Early in the 1980s, the floor-reaction Yates, personal consultation, April † WFR/Aquaplast Corp, PO Box 635, Wykoff,
principles at work in Saltiel's patellar 1979) and relied on polypropylene or- NJ 07481.

1904 PHYSICAL THERAPY

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ment for children with myelodysplasia hip adductor tenotomy, iliopsoas silience is often desirable, particu-
at Children's Hospital in New Orleans, muscle release, or selective dorsal rhi- larly for infants and older children.
La. We began to use Aquaplast® for zotomy, however, do not warrant 4. Design creativity. Team members
children with cerebral palsy after, and plaster casts on the distal lower ex- can experiment with logical design
eventually instead of, bivalved below- tremities, although a measure of dis- adaptations to meet individual needs
knee casts. By 1985, nearly all bivalved- tal stability provided by a splint for support or function. The cost ef-
cast use had ceased at CRC. might be helpful during the postop- fectiveness of the creative process
The orthosis has become an estab- erative rehabilitation process (R. P. promotes the development of new
lished and valuable tool in the effective Jordan; personal communication; design concepts. The fit and func-
management of children with a neuro- November 11, 1987).65 Because the tional impact of the design is readily
motor disorder. The use of orthoses is desired period of postoperative pro- apparent at fitting, and failures can
not likely to diminish as new materials tection for weakened muscles is often be discarded while their lessons are
and design concepts improve their effec- less than six months, an orthosis retained.
tiveness. The introduction of functional made to last for years exceeds the The disadvantages of using Aqua-
splints for the lower extremity offers a needs for short-term, immediate dis- plast-T® in its current formula include
management option that supplements tal stability. One or two splints can 1) bulkiness, 2) limited durability with
orthoses and casts as interventions for be expected to suffice for the desired increased loading forces, 3) slighl
selected children. A distinction, there- duration and can be discontinued shrinkage (up to 2%), and 4) the capac-
fore, has developed between orthoses gradually at the surgeon's request. ity for the finished splint to melt in a
and splints according to three factors: Periodic monitoring is advised. sunny window or near a strong heal
1) materials, 2) durability, and 3) the 4. Evaluation before prescribing spe- source. An alternative material, Orfit®,§
provider. cific designs in high-temperature or- resembles Aquaplast® in handling prop-
Orthoses are usually fabricated from thoses. A splint replicating the pro- erties, does not shrink, softens at a lowei
high-temperature plastics, acrylics, posed orthosis can be tested to deter- temperature, and must be applied di-
leather, or metal, individually or in mine the potential functional impact rectly to the skin during molding. Orfit®
combination, and are intended for long- of the suggested orthosis. devices also melt near a strong heat
term use. They are made by certified 5. Training aids in a rehabilitation set- source.
orthotists and some podiatrists. Lower ting or program. Splints can be im-
extremity splints, although often mod- plemented promptly, and any
eled after orthoses, are made of low- changes that occur with the patient's PROBLEM-SPECIFIC
temperature thermoplastics and are lim- recovery (eg, those observed in reha- MANAGEMENT WITH SPLINTS
ited in durability. Splints are made by bilitation after head injury) can be Most problems of deformity and
trained therapists, orthopedic techni- accommodated expediently by mod- function in the lower extremities of chil-
cians, and some podiatrists and ortho- ifying the splint design. dren with nonparalytic neuromotor dis-
tists. Training in splint- and cast- 6. Interim support. If a time lag is ex- orders occur in the presence of one of
fabrication methods usually requires pected between molding and provid- two conditions: 1) hypertonus, includ-
one day of supervised practicum after a ing a high-temperature orthosis, a ing spasticity and compensatory muscle
thorough review of normal and abnor- splint can be used during the waiting overactivity of the stabilizing type, or 2)
mal developmental and closed-chain period. Necessary support is pro- weakness, either as a feature of hypo-
biomechanics, and a discussion of selec- vided without compromising consist- tonia or as a consequence of surgical
tion criteria and other management ency of care. lengthening of the supporting muscula-
concerns (see article by Lockard in this At CRC, we discovered that the use ture.2,7,11,19 Primary or secondary laxity
issue). ofAquaplast-T®†to make splints offered of the supporting ligaments can occur
Six primary uses for splints have been several advantages: with either abnormality.2,11 Manage-
identified in the management of chil- 1. Low cost. Splints often cost only 20% ment approaches differ for each type of
dren with neuromotor disorders: to 25% of the price of orthoses of problem.
1. An alternative to high-temperature comparable design. Reduced costs
orthoses for small, active children. for replacement required by growth
Splints provide months of support eliminate substantial health care ex- Hypertonicity
for most ambulatory children who penses.
Limitation of full ankle dorsiflexion
weigh less than 50 lb‡ and can easily 2. Speed and simplicity of fabrication. mobility, diagnosed as equinus, is the
be revised or replaced to accommo- After the practitioner (ie, the physical most common problem of foot and an-
date changes in functional ability or therapist, orthotist, orthopedic tech- kle alignment and function in children
growth. nician, or physical therapist assistant) with hypertonic neuromotor disor-
2. Night splints. Lightweight and easily is trained, most devices can be fab- ders.11Lack of full ankle mobility results
fabricated and revised. ricated within 20 to 60 minutes. In in severe biomechanical consequences
3. Immediate postoperative immobili- most cases, two trained individuals, at the foot, knee, and hip in standing
zation of the distal lower extremity. one of them a therapist, collaborate and gait.6,7,11,13,23,41,66
Muscle lengthenings at the knee and to take the mold, which sets within 5
The beginning walker normally re-
ankle usually require a brief period minutes. The remaining time is spent
veals excessive coactivation of the knee
of immobilization in plaster. Partial trimming and finishing the device.
3. Flexibility of the splint material. Be-
cause the foot is an intricately adap- § Available through Se Pro Healthcare, Inc, 140
‡ 1 lb = 0.4536 kg. tive segment, a small measure of re- Domorah Dr, Montgomeryville, PA 18936.

Volume 68 / Number 12, December 1988 1905

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and ankle muscles on electromyo-
graphic analysis, contacting the floor
with the whole foot and demonstrating
a gradual increase in reciprocal and
timely activation of the extensor and
flexor muscles in the swing and stance
phases of gait.67,68 This initial coactiva-
tion period is replicated when a solid
AFO is worn by a child with neuromo-
tor impairment who cannot actively
provide such distal stability.
The normal gait pattern at the knee
and ankle is mature at the age of 3 years
when the knee extends before heel-strike
during the swing phase.67,68 As stance
progresses before heel-off, the ankle dor-
siflexes up to 10 to 15 degrees past neu-
tral as the tibia rotates forward over the
stable plantigrade foot.6,68-70 By con-
trast, equinus gait lacks both normal
heel-strike with knee extension and mid-
stance motion of the tibia over the plan-
tigrade foot. The tibia remains posterior
to the ankle, resulting in one of two
compensations: 1) The knee hyperex-
tends as the child attempts to lower the Fig. 1. Child exhibiting knee hyperexten-
sion associated with functional equinus.
heel to the ground, or 2) toe-standing
persists with knee flexion to allow for-
ward progression.2,6,66,69 The result is a Equinovalgus (equinus with pronation
shortened stride length and a reduction of the foot). Over half of the children
in walking velocity.66,68,70 Equinus de- with bilateral hypertonus have equino- Fig. 2. Child wearing ankle-foot splint set in
formity commonly occurs in combina- valgus.11 Structurally, the hypertonic 5 degrees of dorsiflexion to reduce knee
hyperextension using floor-reaction forces.
tion with other deformities (ie, knee muscles within the triceps surae muscle
flexion contracture, knee hyperexten- group elevate the posterior calcaneus,
sion, equinovalgus, or equinovarus). causing it to plantar flex within the foot tentially valid explanations that may ap-
Knee flexion contracture. Knee flex- (equinus). Simultaneously, the elements ply to individual cases.
ion contracture is caused by overactivity of pronation of the subtalar and midtar- Children normally demonstrate a cal-
in the gastrocnemius or hamstring mus- sal joints are expressed, usually imposed caneal valgus deviation of no more than
cles, or both.2,11,13,44 Any device applied by excessive weight-bearing on the me- 10 degrees through the age of 3 years
at the ankle to reduce equinus must be dial (internal) aspect of the forefoot. The and less than 5 degrees by the age of 6
accompanied by intervention to regain plantar-flexed calcaneus everts at the years.2,72 In early life, a measure of cal-
knee extension mobility. One or more subtalar joint; the talus plantar flexes caneal valgus deviation can be attrib-
of the following methods are commonly and migrates medially and forward; the uted to the angled distal articulating sur-
used: 1) reciprocal innervation via acti- forefoot abducts and everts, uncovering face (plafond) of the tibia, which inclines
vation of the quadriceps femoris most of the medial surface of the head upward on the lateral aspect relative to
musculature49; 2) mobilization at the of the talus; the rays rotate inwardly; the transverse plane.8,11 The infant foot
posterior hip joint capsule71; 3) night and the toes claw with a lateral (external) also reveals a forefoot varus of up to 10
splinting15; 4) long leg serial cast- deviation.6,7,11,70 The tibia and fibula fol- degrees that gradually diminishes to 0
ing2,26,43,44,63; 5) positioning in long sit- low the talar motions by way of the degrees in early childhood. This devia-
ting, maintaining the pelvis in a vertical ankle mortice.6,7 Shortening develops in tion can cause the foot to pronate as the
position15,49; or 6) surgical lengthening.11 the peroneal muscles and lateral liga- varus forefoot seeks the ground (see ar-
Knee hyperextension. The child ments at the subtalar and ankle joints. ticle by Tiberio in this issue).6,7
stands with limited range of ankle dor- Persistence of femoral antetorsion In the child with bilateral hypertonus,
siflexion and attempts to lower the heel often contributes to pronation in chil- however, the hypertonic forces imposed
of the plantar-flexed foot to the ground dren with spastic diplegia. The abnor- on the calcaneus and the inability to
by hyperextending the knee joint (Fig. mal medial twist of the femoral shaft shift the body weight over the heel and
1).2,6,23,26,41,66 Knee hyperextension of imposes medial weight-bearing forces the lateral segments of the foot threaten
less than 10 to 15 degrees is often man- on the foot and vice versa.2,6,7,11 to overstretch the medial ligaments sup-
aged successfully by maintaining the an- The causative mechanism of equino- porting the subtalar joint.11,33 The result
kle in 5 degrees of dorsiflexion (Fig. 2).41 valgus deformity is currently being de- is an increase in lateral deviation (ever-
Floor-reaction forces impose flexion at bated, questioning whether the primary sion) of the calcaneus into a valgus
the knee by applying pressure to the problem is tightness in the triceps surae position, forming an angle with the
posterior aspect of the proximal tibia on muscle or spasticity in the peroneal tibia that exceeds the age-appropriate
weight-bearing.23,26,41 muscles.7,11 Both viewpoints offer po- maximum.

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 Protection of the medial and plantar mechanical alignment of the structures in standing and as a distal stabilizing
supporting ligaments, therefore, is the of the foot and ankle. The treatment support for the child whose pream-
first concern of intervention for equin- goal should be balanced, dynamic con- bulatory skills are emerging or who
ovalgus deformity.2,7 In a well-built or- trol of the ankle joint and the long and has undergone surgical tendo
thotic device for the ankle and foot, intrinsic muscles that control the foot Achillis lengthening or selective dorsal
calcaneal valgus is prohibited within the and toes within the limits imposed by rhizotomy.
structural limits of the talocrural joint the severity of the neuromotor disorder. For the ambulatory child with func-
configuration; the forefoot is prohibited In the past five years, the plastic- tional equinus deformity, the solid AFS
from deviating into abduction; and the overlap, hinged AFO has been used in stimulates the function of the anterior
medial, lateral, and transverse arches are several children's rehabilitation facili- tibialis muscle at heel-strike and of the
supported.23 Ankle position is addressed ties, although its originator is unknown. soleus muscle as a stabilizing force on
only after the structures of the foot are The availability of an articulating ankle the tibia during stance, while it prohibits
aligned.7,55 The improved alignment within the structure of a total-contact both desirable (normally occurring) and
provided by designing an orthosis with AFO necessitates a review of the func- undesirable (abnormal) plantar flex-
these corrective features has been dem- tional criteria for selecting AFOs. ion.23,29,69 Velocity and stride length
onstrated on roentgenograms.23 In certain circumstances, despite the were shown to be enhanced in children
Equinovarus. More than 90% of chil- desire for dynamic systems, a solid ankle with cerebral palsy after AFOs were
dren with spastic hemiparesis demon- or a partial restriction of ankle motion applied.23
strate equinovarus, in which equinus is is used to help the child achieve dynamic The solid-ankle device, however, also
evident in heel raise while the posterior control of the ankle joint.44 In other prohibits normal excursion of the tibia
tibialis muscle forces the elevated cal- circumstances, a thin polypropylene su- forward over the plantigrade foot during
caneus into medial deviation (supina- pramalleolar orthosis (SMO) might be postural transitions (eg, squatting and
tion). Upon initial stance, the foot adequate. The SMO, also known as the rising to a standing position from a sit-
supinates rather than pronates.11 (This Dynamic AFO,|| is a very thin, low- ting position). In gait, the solid AFS also
response differs from the compensation cut AFO that applies the principles of prohibits normal motion of the tibia
described by Tiberio [see his article in the inhibitive footboard described by over the plantigrade foot after mid-
this issue] in which the foot has the Duncan and Mott47 as it secures the stance. The limitations of ankle motion
necessary flexibility to compensate by structures of the foot in neutral align- imposed by the solid AFS, therefore,
pronating.) Because the supinated foot ment. The SMO extends proximally to compete with its advantages for the
is relatively rigid compared with the cover the dorsum of the foot and the child who is active and ambulatory.
flexible pronated foot, weight-bearing malleoli.53 The solid AFS and the hinged Hinged ankle-foot devices. The total-
occurs on the lateral aspect of the fore- AFS are among the Aquaplast® splints contact hinged AFO or AFS features a
foot, imposing a laterally-directed force commonly used to manage equinus- free-hinge joint and plastic overlap stop
on the loaded knee during stance. Be- related foot deformities and are dis- that permit ankle dorsiflexion and pro-
cause the problem of supination com- cussed below. hibit a preset measure of plantar flexion
bines with contracture of the triceps (Fig. 3). The maximum angle of plantar
surae muscle group, the weight-bearing Splint Description flexion is determined by the contact be-
knee might also compensate, either by and Development tween the shaft piece and the foot piece
flexing during stance, possibly to absorb at the posterior aspect of their articula-
shock, or by hyperextending, promoting Solid ankle-foot splint. The solid- tion.
elevation and retraction of the pelvis ankle, total-contact AFO has become a Criteria for selecting hinged AFOs
above, and limiting forward progres- standard prescription for the child with and AFSs are 1) a hypertonus that
sion.16 Both compensations limit stride problems related to functional equinus
length and stance duration on the af- deformity.11,23,29 The AFO is usually de-
fected side. signed with the ankle set at 90 degrees
To reduce the deviations apparent in (neutral position). The solid AFS en-
functional equinovarus deformity, the cases the ankle and the foot, excluding
splint is built to align the calcaneus in the dorsum, in a position of neutral
the neutral position, prohibit adduction subtalar and midtarsal joint alignment.
of the forefoot and lateral rotation of The ankle, however, is usually posi-
the tibia and fibula, and set the ankle in tioned in slight dorsiflexion (up to 5°) in
5 degrees of dorsiflexion if necessary to the solid AFS to simulate the normal
overcome knee hyperextension.23,26,41 If position of the ankle in standing and in
the equinovarus deformity is fixed, a the stance phase in early walking and to
series of casts might be instituted to facilitate a functional rather than hyper-
regain mobility without surgical inter- extended knee position.2,69
vention. Any evidence of hamstring Solid-ankle devices are useful as pro-
musculature contracture must also be tection for the medial ligaments of the
reduced.2 feet of the nonambulatory, severely in-
volved child who is positioned regularly
Options in Splint Design
Fig. 3. Hinged ankle-foot splint allowing full
for Hypertonicity ankle dorsiflexion. Posterior overlap prohibits
|| For further information on the Dynamic
Management of deformities related to AFO, contact Nancy Hylton, c/o Children's Ther- plantar flexion. Total contact supports the
hypertonus should secure optimal bio- apy Center, 26461 104th Ave SE, Kent, WA 98031. foot.

Volume 68 / Number 12, December 1988 1907

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causes equinus deformity and related
problems at the foot and knee or 2) an
equinus deformity that is functional
rather than fixed (see article by Oatis in
this issue).
Additional guidelines for using hinged
devices include the following:
1. The hypertonic child is ambulatory.
Most children with spastic diplegia
and nearly all children with spastic
hemiparesis become ambulatory by
the age of 48 months, despite diffi-
culties imposed by hypertonus.11,34
Given adequate knee extension
range, strength, and timing of action,
the hinged device provides the oppor-
tunity to experience heel-strike. The
hinged ankle also allows an extended
period of plantigrade foot support
during terminal stance before heel-
off.
Fig. 4. Child wearing hinged ankle-foot
2. The hypertonic child is at a pream- splint to protect foot structures and maintain
bulatory functional level. The child plantigrade foot position during postural
spontaneously pulls to a standing po- transitions to and from standing.
sition and cruises along furniture but
exhibits equinus or a related deform-
ity in the process.
3. Preambulatory activities are an im-
portant feature of the management
program. Positional transitions (eg,
squatting from a standing position
and standing from a half-kneel posi-
tion) are a focus of management. The
hinged device could be implemented
to maintain the equinus foot in a
neutral plantigrade position during
such transitions and to enhance fron-
tal-plane stability (Fig. 4).
The same child, however, might dem-
onstrate weakness or an inability to sta-
bilize the ankles to stand alone or to
walk, and flexion might result at the
ankles and knees. The need for greater Fig. 6. Child exhibiting crouch posture. Pri-
mary source is weakness in triceps surae
distal stability could then be addressed muscle group (ie, soleus muscle). Pronation
temporarily, either by adding an ante- is evident.
rior shell to prohibit dorsiflexion or by
adding a strap to the posterior aspects
connecting the shaft to the foot piece Fig. 5. Hinged ankle-foot splint with dorsi- children 4 to 6 years of age, the posture
until the child shows improved active flexion strap stop combines elastic and non- often becomes distressing when the
stretch materials.
distal stability (Fig. 5) (J. M. Carlson; child approaches adolescence and com-
personal communication; November plaints (eg, onset of knee pain, fatigue,
25, 1987).73 Weakness in Antigravity Muscles or deterioration of posture or ambula-
Contraindications for the hinged de- and Ligaments tory capability) emerge. Other features
vices include the following abnormali- are hip flexion contracture, hip internal
ties: Two deformities, crouch posture and rotation with adduction, femoral ante-
1. Fixed equinus deformity. The avail- flexible pes planus (pronation), will be torsion, quadriceps femoris muscle
able range of unresisted passive ankle discussed in this section. Crouch posture weakness or overwork in the lengthened
dorsiflexion, keeping the subtalar is noted in the standing position or dur- position, patella alta, hamstring muscle
joint in neutral alignment, is limited ing the stance phase of gait when the contracture, calcaneus deformity, hind-
to less than 5 degrees past neutral.2,6,69 hips and knees flex excessively over the foot valgus and pronation, exaggerated
2. Strong resistance to passive ankle dor- plantigrade foot (Fig. 6). Angles exceed- arm swing, and increased vertical trunk
siflexion throughout the available ing 30 degrees can occur at the hip, knee, displacement.43,68,74
range. and ankle joints.68,74 Throughout the normal stance phase
3. Crouch deformity. Although crouch posture is seen in of gait, the knee joint is maintained

1908 PHYSICAL THERAPY

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 within 20 degrees of flexion and the locked at the knee joint and are soon flexion, compromising a measure of
ankle within 15 degrees of dorsiflexion discarded as less useful than they are alignment for function.
by the stabilizing activation of the tri- inconvenient. Within this decade, new Parallel with, although unaware of,
ceps surae muscle group, assisted early orthotic designs have appeared that ac- the development of the AFRO, I devel-
in stance by the quadriceps femoris knowledge the primary problem of oped the solid crouch-control AFS (Fig.
muscle.24,74 After terminal stance, the weakness at the ankles, but no design 7) late in 1982 with the assistance of
triceps surae and posterior tibialis mus- before 1986 provided a sturdy guard CRC's orthopedic technician, Michael
cles continue to maintain the foot in against sinking into dorsiflexion while Smith. The primary aims for the crouch-
supination as ankle plantar flexion of allowing plantarflexionto occur in gait. control AFS were to align the joints of
up to 20 degrees occurs between heel- If the ankle joint is rigidly supported the foot and to mechanically prohibit
off and toe-off, and body weight is trans- against dorsiflexion, the brace that sup- excessive ankle dorsiflexion. In the en-
ferred to the opposite foot.67,68,75 ports it functions as a first-class lever suing years, we encountered the same
Weakness in the triceps surae muscle with the fulcrum, located at the distal limitations on function noted above,
group, particularly in the soleus muscle, end under the metatarsal heads, trans- while the need for strengthening the
has been identified as the primary prob- ferring the floor-reaction forces to the plantar-flexor muscles became apparent
lem producing a crouched posture.74 Ex- anterior aspect of the proximal tibia both clinically and in the literature.74,75
cessive forward excursion of the tibia (Fig. 4).22,29,42,43 In June of 1986, to address the prob-
over the talus occurs in standing and This concept was applied to the design lems of triceps surae muscle weakness
results in knee flexion and progressive of the AFRO.43 The AFRO is built like and gait difficulty imposed by a bilateral
tightness of the hamstring muscles.70,74,77 a standard solid AFO in the area of the rigid ankle support, I designed the
Sutherland and Cooper74 and Bleck11 foot and ankle but sweeps anteriorly and hinged crouch-control AFS. Like the
suggested that triceps surae muscle proximally to cover the anterior surface AFRO, the hinged crouch-control AFS
group weakness is caused primarily by of the proximal tibia. The proximal an- uses floor-reaction forces, through a
surgical tendo Achillis lengthening that, terior band pushes backward on the rigid sole and ankle dorsiflexion stop, to
if undertaken before reducing flexion proximal tibia as the child puts weight apply an extension force to the anterior
contractures at the hips and knees, re- on the foot section. aspect of the lower leg on weight-
sults in overlengthened heel cords. Two Harrington et al, at Newington Chil- bearing. Close attention is paid to align-
areas of postoperative management that dren's Hospital in Newington, Conn, ing the joints of the foot in a neutral
can contribute to the development of studied the criteria for favorable results position because this splint encompasses
crouch deformity are 1) inadequate im- using the AFRO, which they designed the foot like a rigid ski boot. The reduc-
mobilization using stabilizing AFSs or for crouch deformity. (The same criteria tion of pronation is a factor in reducing
AFOs that can result in overstretching apply to the hinged crouch-control AFS crouch posture proximally.
of the weakened plantar-flexor muscles discussed below.) The criteria they de-
with standing and walking activities and veloped are 1) presence of some trunk
2) a therapeutic exercise program that balance or ability to use auxiliary walk-
denies the opportunity and the need to ing aids, 2) a minimum grade of Fair
regain strength in the weakened triceps quadriceps femoris muscle strength, and
surae muscle group. Given the needed 3) flexion contractures at the hip and
mobility at the knee joint, therapeutic knee not exceeding 10 degrees. Of 11
training after tendo Achillis lengthening children with crouch posture who were
should incorporate active and func- evaluated, all required elongation of the
tional strengthening for the gastrocne- hamstring muscles, either by serial cast-
mius and soleus muscles and for knee ing or surgery, before they could use the
and hip extensors while maintaining AFRO.43
mobility. Crouch deformity can also be The results of the Newington study
attributed to factors such as hamstring were encouraging. All 11 children
muscles' overactivity and contracture43 showed significant immediate reduction
and pronation deformity in the foot. in the severity of crouch gait after AFRO
Pronation facilitates knee and hip flex- intervention. Three children who under-
ion and adduction through the closed- went computerized gait analysis re-
chain biomechanics related to the rear- vealed improvement in the gait charac-
foot complex (see article by Oatis in this teristics of single-limb support time and
issue).7 stability, stride length, walking velocity,
and endurance. Although energy con-
Crouch Posture Intervention sumption (measured in joules per kilo-
gram per meter) remained unchanged,
The problem of effectively reducing stride length and velocity gains sug-
crouch posture with orthotic interven- gested that overall gait was more effi-
tions has not yet been solved. Typically, cient.43 The main limitation of the
when the deformity threatens to defeat AFRO device was the rigid ankle, set at
the child's efforts to continue ambulat- 90 degrees of flexion or in slight plantar
ing, a desperate attempt to prevent such flexion. When applied bilaterally, for- Fig. 7. Solid crouch-control ankle-foot
splint applies anterior floor-reaction forces to
progression leaves the child lumbering ward progression was prohibited until reduce knee flexion while prohibiting prona-
around in a pair of knee-AFOs that are the ankle was adjusted into slight dorsi- tion and ankle dorsiflexion.

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 The hinged crouch-control AES, how- control AFS in facilitating strengthening the foot is advised by some researchers
ever, allows plantar flexion to occur dur- and timely activity of the ankle plantar- throughout the period of bone
ing the stance phase of gait 1) after heel- flexor muscles in standing and gait. In- maturation.2'7'33
strike, when the foot can lower into full dividuals with normal neuromotor The history of interventions with var-
contact as a separate segment from the function who wear it describe a lever- ious combinations of corrective shoes;
lower leg (Fig. 8), and 2) after mid- type mechanism apparently related to high-top orthopedic shoes; wedges at the
stance, during the push-off stage, which the rigid fulcrum at the toe portion of heel or the heel and sole; and the inser-
is more mechanical than active.69,72,75 the sole that seems to facilitate activa- tion of arch supports, scaphoid pads,
The stress tolerance of Aquaplast® tion of the calf musculature as the body and navicular pads has shown that such
splinting material requires that the weight is carried forward in the stance interventions are ineffective in correct-
heavy forces of crouch posture be sup- phase. More research is needed to revise ing flexible pes planus.11,30,33,79,80
ported from the dorsum of the leg and the design to minimize bulky excess. The foot orthosis uses close conform-
foot. By contrast, the solid AFS and The flap-like extension of the foot piece ity between the neutrally-aligned plantar
AFO buckle into ankle dorsiflexion, and up to the distal shaft piece could be surface of the foot and the inner contour
both devices prohibit ankle plantar flex- reduced and reshaped considerably us- of the device and implements floor-
ion. The hinged crouch-control AFS, by ing high-temperature plastics. reaction forces with a well-built (usually
its dorsal approach to the foot and ankle, athletic) outer shoe to stabilize the
offers the falling tibia a reliable support Flexible Pes Planus with subtalar and midtarsal joints against
and prohibits excessive elongation of the Plantar-flexed Talus collapse.40,78-80
quadriceps femoris and triceps surae (Hypermobile Flatfoot or In 1965, Bleck and Berzins undertook
muscles. Flexible Pronation) a 10-year prospective study of the effec-
Contraindications for using the tiveness of the Helfet heel seat and the
hinged crouch-control AFS are 1) con- Pronation of the foot is the most com- UCBL shoe insert.30 They used these
tracture of hip flexor muscles exceeding mon compensation for laxity in the sup- devices to treat "flexible pes valgus" (pes
10 degrees,43 2) hamstring muscle con- porting ligaments of the foot or for planus), apparently in children with nor-
tracture resulting in a popliteal angle medial rotary weight-bearing forces im- mal muscle tone.30 The mean age of the
greater than 20 degrees with the same posed by other joints or structures in the 71 children in the study group was 4.7
hip flexed to 90 degrees and the opposite leg and foot (see article by Tiberio in years. The mean duration of orthotic
hip extended,11 3) equinus (functional this issue).2,6 In flexible pes planus, un- use was 14.5 months. The overall failure
or fixed), 4) genu recurvatum or knee like equinovalgus, pronation occurs in rate, in which no change in talar or
hyperextension, and 5) poor trunk weight-bearing and resolves off weight- talocalcaneal angles was noted radiolog-
control. bearing, but ankle mobility is full and ically, averaged 20%. The remaining
Research is needed to ascertain the unresisted by hypertonus.6,7,30,73,74,78-80 80% of the subjects showed either im-
effectiveness of the hinged crouch- Eventually, contracture can develop in proved or corrected talar plantar flexion
the peroneal muscles and in the connec- (within the authors' accepted maximum
tive tissue structures on the lateral aspect of 35° for children under 5 years of age).
of the foot and ankle. Correction was significantly greater
On a standing lateral roentgenogram when 1) the devices were used to treat
of the foot of a child between the ages children younger than 3 years, although
of 18 months and 16 years, the average they were effective up to the age of 8
normal angle between the longitudinal years, and 2) the devices were imple-
bisection of the talus and the transverse mented for longer durations, comparing
plane is 26.5 degrees (s = 5.3).30 Any treatment periods of 6 months or less
increase in that angle indicates that the with those that spanned a range of 24 to
talus has plantar flexed on the calcaneus. 46 months.30
Instability of the subtalar joint is a Several other authors reported excel-
common finding in children with neu- lent results with the same or similar foot
romuscular disorders.33,40 In the pres- orthoses.20'23'40'78"80 Rosenthal advised
ence of hypotonia, or developmental using the UCBL shoe insert for cerebral
delay, the potential for spontaneous palsied children with associated prob-
correction of the valgus foot is limited lems of pes valgus, pes varus, and meta-
by the lack of refinement of antigravity tarsus adductus.23
strength and control for weight The stabilizing foot splint (SFS) ap-
shifts.19'33'78'81'82 plies the same design concepts as the
Intervention with the stabilizing foot UCBL shoe insert, and the basic design
splint. The goal of intervention for flex- is similar, cupping the calcaneus and
ible pes planus is to alleviate any de- extending under and alongside the tar-
forming stresses on the structures within sals and metatarsals. The main differ-
the foot itself, while remaining aware of ence is that the heel is posted to prohibit
the interrelationship between the foot rolling of the device within the shoe,
and rotational forces from the super- because children with hypotonia usually
Fig. 8. Hinged crouch-control ankle-foot
splint prohibits excess dorsiflexion and pro-
structures (see article by Bernhardt in demonstrate more severe problems of
nation. Plantar flexion can occur after heel- this issue).2,6'7 Care in maintaining the stabilization than children with normal
strike and mid-stance phases. normal neutrally aligned architecture of muscle tone.

1910 PHYSICAL THERAPY

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 foot abduction is a significant feature antigravity trunk control as a founda-
of pronation and if the toe box of the tion for the development of dynamic
shoe is roomy (Fig. 9). stability in the lower extremities.33,83,84
3. Hylton's Dynamic AFO, or SMO, With the availability of improved
adds another dimension of control if splinting materials, physical therapists'
these modifications fail and can be skills are expanding to include func-
replicated using splint material. tional splinting for the lower extremity.
Clinical evidence of the success of The issues that must be addressed in the
these modifications supports their con- comprehensive management of neuro-
tinued use, but objective measures of motor disorders in children include the
Fig. 9. Stabilizing foot splint. Basic design
can be modified to address severity of pes
their comparative effectiveness are not provision of consistent systems of inter-
planus: (L) medial forefoot varus post; (R) available, and research is recommended. vention that support the goals of de-
lateral extension to reduce forefoot When the severity of pronation over- formity prevention and functional gain.
abduction. comes these modifications of the SFS, I Thoughtful application of the principles
use a modified hinged AFS with no of lower extremity biomechanics, inter-
plantar-flexion stop to gain mediolateral woven with a knowledge of the impact
Trim lines for the SFS can be varied stability without prohibiting sagittal of motor development on the design and
according to the child's need for sup- plane motion at the ankle. function of the developing foot and leg,
port. For severe problems of flexible can be expected to foster continued
pronation, I frequently use one of the improvements in the functional and
following modifications: structural effectiveness of splints and
SUMMARY
1. An extension of the plantar surface orthoses as an adjunct to a general pro-
of the splint under thefirstmetatarsal Several factors associated with the de- gram of pediatrics therapeutic inter-
head, using splint material or a velopment of normal foot alignment vention. Research is needed comparing
closed-cell, high-density padding ma- and function are beyond the scope of splints with similar orthotic devices and
terial. This extension acts as a post this article (see article by Bernhardt in no orthotic device to determine radio-
to prohibit a varus forefoot from this issue) and should be noted in the logic evidence of the relative impact on
stressing the hindfoot into valgus management of developmental neuro- alignment and the influence of splints
as the forefoot lowers to the floor motor disabilities. They include re- on various features of gait (eg, stride
(Fig. 9).6 searchfindingsdetecting evidence of an- length, velocity, and energy efficiency).
2. A padded extension of the lateral ticipatory postural adjustment,82 the Such findings would facilitate the crea-
forefoot wall to the end of the fifth possible influence of the tonic reflexes tive process currently underway in this
toe. This extension is useful if fore- of the foot,46,47 and the achievement of area of pediatric management.

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1912 PHYSICAL THERAPY

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 Splints and Casts: Managing Foot Deformity in
Children with Neuromotor Disorders
Beverly D Cusick
PHYS THER. 1988; 68:1903-1912.

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