Physical Rehabilitation Programme

ankle-Foot orthosis
Manufacturing guidelines
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MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean François Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poestma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
© ICRC, September 2006
All photographs: ICRC/PRP
1 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Table of contents
Foreword 2
Introduction 4
Choosingbetweendiferentdesigns 4
Castingandrectifcation 5
1.FlexibleAFO 6
1.1MouldingofEVA 6
1.2Orthosistrimline 6
1.3Vacuummouldingofthepolypropylene 6
1.4Preparationofthepolypropyleneshell 7
1.5Preparationofthestraps 8
1.6Initialfttingandfnishing 8
2.RigidAFO 8
2.1MouldingofEVA 8
2.2Orthosistrimline 9
2.3Plasticreinforcement 12
2.4Vacuummouldingofthepolypropylene 13
2.5Preparationofthepolypropyleneshell 14
2.6Proximalstrap 14
2.7Distalstrap 15
2.8Instepstrap 16
2.9Initialfttingandfnishing 18
3.AFOwithTamarackFlexureJoint
TM
18
3.1MouldingofEVA 18
3.2Orthosistrimline 18
3.3Plasticreinforcement 18
3.4InstallationofTamarackFlexureJoint
TM
19
3.5Vacuummouldingofthepolypropylene 19
3.6Preparationofthepolypropyleneshell 20
3.7Preparationofthestraps 22
3.8Initialfttingandfnishing 22
4.AFOanti-talus(anteriorshell) 22
4.1MouldingofEVA 22
4.2Orthosistrimline 23
4.3Plasticreinforcement 24
4.4Vacuummouldingofthepolypropylene 24
4.5Preparationofthepolypropyleneshell 25
4.6Preparationofthestraps 26
4.7Initialftting 26
4.8Finishing 26
Listofmanufacturingmaterials 27
2 I CRC Physi cal Rehabi l i tati on Programme
Foreword
The ICRC polypropylene technology
Sinceitsinceptionin1979,theICRC’sPhysicalRehabilitationProgrammehaspromotedtheuse
oftechnologythatisappropriatetothespecifccontextsinwhichtheorganizationoperates,
i.e.,countriesafectedbywarandlow-incomeordevelopingcountries.
Tetechnologymustalsobetailoredtomeettheneedsofthephysicallydisabledinthecountries
concerned.
Tetechnologyadoptedmustthereforebe:
• durable,comfortable,easyforpatientstouseandmaintain;
• easyfortechnicianstolearn,useandrepair;
• standardizedbutcompatiblewiththeclimateindiferentregionsoftheworld;
• low-costbutmodernandconsistentwithinternationallyacceptedstandards;
• easilyavailable.
Techoiceoftechnologyisofgreatimportanceforpromotingsustainablephysicalrehabilitation
services.
Forallthesereasons,theICRCpreferredtodevelopitsowntechniqueinsteadofbuyingready-made
orthopaediccomponents,whicharegenerallytooexpensiveandunsuitedtothecontextsinwhich
theorganizationworks.TecostofthematerialsusedinICRCprostheticandorthoticdevices
islowerthanthatofthematerialsusedinappliancesassembledfromcommercialready-made
components.
WhentheICRClauncheditsphysicalrehabilitationprogrammesbackin1979,locallyavailable
materialssuchaswood,leatherandmetalwereused,andorthopaediccomponentswere
manufacturedlocally.Intheearly1990stheICRCstartedtheprocessofstandardizingthe
techniquesusedinitsvariousprojectsaroundtheworld,forthesakeofharmonizationbetweenthe
projects,butmoreimportantlytoimprovethequalityofservicestopatients.
Polypropylene(PP)wasintroducedintoICRCprojectsin1988forthemanufactureofprosthetic
sockets.Tefrstpolypropyleneknee-jointwasproducedinCambodiain1991;othercomponents
suchasvariousalignmentsystemswerefrstdevelopedinColombiaandgraduallyimproved.In
parallel,adurablefoot,madeinitiallyofpolypropyleneandEthylVinylAcetate(EVA),andnowof
polypropyleneandpolyurethane,replacedthetraditionalwooden/rubberfoot.
In1998,afercarefulconsideration,itwasdecidedtoscaledownlocalcomponentproductionin
ordertofocusonpatientcareandtrainingofpersonnelatcountrylevel.
3 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Objective of the manuals
TeICRC’s“ManufacturingGuidelines”aredesignedtoprovidetheinformationnecessaryfor
productionofhigh-qualityassistivedevices.
Temainaimsoftheseinformativemanualsareasfollows:
• TopromoteandenhancestandardizationofICRCpolypropylenetechnology;
• Toprovidesupportfortrainingintheuseofthistechnology;
• Topromotegoodpractice.
Tisisanotherstepforwardintheeforttoensurethatpatientshaveaccesstohigh-qualityservices.
ICRC
AssistanceDivision/HealthUnit
PhysicalRehabilitationProgramme
4 I CRC Physi cal Rehabi l i tati on Programme
Choosing between diferent designs
Withoutgoingintodetails,somefeaturesofdiferenttypesofAFOaresetoutbelowtoassistinthe
choiceofdesign.
Flexible AFO
• Dorsifexionassistance
• Poormedio-lateralstabilizationofthesubtalarjoint
Rigid AFO
• Blocksanklemovements
• Mediolateralstabilizationofthesubtalarjoint
• Possibilityofcontrollingforefootadduction/abduction
AFO with Tamarack Flexure Joint
TM
• Mediolateralstabilizationofthesubtalarjoint
• Freeankledorsifexion
• Freeorrestrictedankleplantarfexion
AFO anti-talus
• Blocksanklemovements.Particularlyefcientforpreventingankledorsifexion
• Poormediolateralstabilizationofthesubtalarjoint
Introduction
Teaimofthisdocumentistodescribeseveralmethodsformanufacturingankle-foot orthoses
(AFO),workingwiththepolypropylenetechnologyusedattheICRC’sphysicalrehabilitation
centres.
5 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Casting and rectifcation
Patientassessment,castingandrectifcationofpositivecastimpressionsareperformedin
accordancewithprostheticandorthotic(P&O)standards.
ForfexibleAFO,thecastcanbetakenwith5degreesofdorsifexionsoastoprovideapreloadand
ensuresomespringaction.
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1.1 Moulding of EVA
AfexibleAFOdoesnotusuallyrequireanyEVA.However,incaseswhereitisnecessarythe
proceduredescribedinsection2.1(page8)shouldbefollowed.
1.2 Orthosis trim line
Toachievethegoalofallowingdorsifexionoftheanklewhilepreventingpassiveplantarfexion,
thereareanumberofdesignoptions.
FlExIblE AFO 1
4Markthetrimlineasfollows:
A Tetopishorizontal,2cmbelowthe
fbulahead.
ß Attheankle,pass2cmbehindthetip
ofthemalleolitoallowfexionofthe
polypropylene.
C Attheforefoot,leavethesidesofthe
toesandtheheadofthemetatarsus
completelyclearandpassthetrim
linebelowthem.Tis will allow the
polypropylene to follow the movement of
the metatarso-phalangeal joints.
Pullastockingovertheplastermodel.
1.3 Vacuum moulding of the polypropylene
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
1 Calfcircumference+10cm.
2 Instepcircumference+10cm.
3 Legandfootlength+10cm.(Seenextpicture.)
Tickness3mm,4mmor5mm,dependingonthepatient’sweight.
7
2
1
3
Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthe
polypropyleneandtheefciencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheanteriorside.
Tightenthepolypropylenearoundthesuctionconebymeansofaropeorsomethingsimilar.
Openthevacuumvalve.
4CutoftheexcessPPwithapairof
scissorswhileitisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
1.4 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection1.2(page6).
Followingtheoutline,cuttheorthosiswithanoscillatingsaw.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
8 I CRC Physi cal Rehabi l i tati on Programme
IfanEVAhasbeenmoulded,transferthetrimlinetotheEVAandcutoftheexcesswithapairof
scissors.
1.5 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Adistalstrapmightbeneeded,dependingonthecapacityofthepatient’sshoetoholdthefoot
insidetheorthosis.Ifthisisneeded,followtheproceduredescribedinsection2.7(page15).
1.6 Initial ftting and fnishing
IfEVAisused,glueitpartiallyinsidetheorthosis.
TeinitialfttingisperformedaccordingtoP&Ostandards.
Carryouttherequiredmodifcationonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutofthesurplusandsmooththetrimline.
RIgId AFO 2
2.1 Moulding of EVA
EVA(6mm)maybemouldedpriortothedrapingofthepolypropylene,forthefollowingreasons:
• toimprovecomfort;
• topreventskinbreakageinpatientswithsensationloss;
• fororthosesusedatnight.
Followtheproceduredescribedbelowor,ifthecasedoesnotrequireEVA,goontothenextsection.
9 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Positiontheplastermodelwiththe
forefootpointingdownwards.
MeasurementoftheEVAsheet:
• width,instepcircumference;
• length,thatoftheplastermodel
(leg+foot);
• thickness,6mm.
HeattheEVAat120°for3to5minutes,
dependingontheefciencyoftheoven.
DrapetheEVAmanuallyovertheplaster
modelandholditinplaceuntilithas
cooledcompletely.
4Cutoftheexcesswithacutterorapairof
scissors.
StapletheEVAontothefrontoftheplaster
model.
2.2 Orthosis trim line
2.2.1 “Standard” trim line
4Markthetrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thefbulahead.
ß Attheankle,passtheline1cmanterior
tothetipofthemalleoli.
C Attheforefoot,leavethesidesofthe
toesandtheheadofthemetatarsus
completelyclearandpassthetrim
linebelowthem.Tis will allow the
polypropylene to follow the movement of
the metatarso-phalangeal joints.
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2.2.2 Trim line to correct forefoot adduction
Forefootadductioniscommonincasesofclubfoot.
4Markthetrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thefbulahead.
ß Increasecoverageofthelateralmid-
foot,passinginfrontofthecuboid,
to enlarge the area of pressure.
C Attheforefoot,thelinemustbe
proximaltothe5thmetatarsalhead.
D Decreasecoverageofthemedial
mid-footatthenavicular/malleoli,
to facilitate donning.
£ Attheforefoot,coverthemedialsideof
themetatarsalheadandtoe,to correct
forefoot adduction.
11 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
2.2.3 Trim line to correct forefoot abduction
Forefootabductionisofenseenincasesofcerebralpalsy.
4Markthetrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thefbulahead.
ß Decreasecoverageatthelevelofthe
lateralmalleoli,to ease donning.
C Attheforefoot,thelinemustbedistal
tothe5thmetatarsalhead,to avoid
metatarsus abductus.
D Increasecoverageofthemedial
mid-footatthelevelofthenavicular,
to increase mid-foot support.
£ Attheforefoot,thelinemustbe
proximaltothe1st

metatarsalhead.
12 I CRC Physi cal Rehabi l i tati on Programme
2.3 Plastic reinforcement
TeAFOmayneedreinforcement,especiallyatanklelevel.Ifnecessary,useoneofthefollowing
methods;otherwisegoontothenextsection.
2.3.1 double layer of polypropylene
4Asecondlayerofpolypropylene
coveringtheankleandthefootis
mouldedatthesametimeasthemain
layer.
Cutapieceofpolypropylene:
• thickness,3mm;
• width,instepcircumference;
• length,footlength+10cm
Grindthelast3cmattheproximal
endtograduallyreducethethickness
ofthepolypropylene.
4Tetwolayersareheatedatthesame
time.
Tereinforcementisplacedonthe
plastermodel,thenthesecondlayer
isvacuum-mouldedimmediatelyto
obtainaperfectsealbetweenthetwo.
A double layer of polypropylene has the disadvantage of reducing fexibility of the forefoot in relation to
the metatarso-phalangeal joint.
13 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
2.3.2 Channels in the polypropylene
Tepresenceofchannelsintheplasticsignifcantlyimprovesitsstrength.Tereareseveralwaysof
makingthesechannels.
4CuttwostripsofEVA:
• thickness,6mm;
• width,7mm;
• length,15cm.
Grindbothdistalandproximalendsto
graduallyreducethethicknessofthe
EVA.
Pullastockingovertheplastermodel.
Gluethestriplightlyontothestocking.
Te more anterior the position of the channel, the more the AFO will resist dorsifexion of the ankle.
Reinforcements prolonged along the side of the mid-foot increase the volume of the orthosis so that it
may no longer ft into the patient’s shoe.
2.4 Vacuum moulding of the polypropylene
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efciency, the EVA
used to make channels in the polypropylene must not be covered with a stocking.
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsence
ofadoublelayerofpolypropylene(section2.3.1,page12).
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2.6 Proximal strap
Useaready-madeVelcrostrap40mmwide,ormakeastrapwithPerlonwebbingorsomeother
strongmaterial.
4Withalargetubularrivet,fxthebelt
holdingthelooponthemedialside,1.5cm
belowtheproximaltrimline.
Teloopshouldbeplacedonthe
polypropyleneandnotbeincontactwiththe
patient’sleg.
2.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasdescribedinsection2.2(page9).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutoftheexcesswitha
pairofscissors.
15 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Insertthebeltthroughthelooptomeasure
therequiredlength.
Fixthestrapwithalargetubularrivetonthe
lateralside.Makesurethestrapisperfectly
horizontalbeforefxingit.
Coverthesurfaceofthestrapincontactwith
thepatient’slegwith3mmEVA.
4Fixthestrapwithalargetubularrivetonthe
lateralside.Makesurethestrapisperfectly
horizontalbeforefxingit.
Coverthesurfaceofthestrapincontactwith
thepatient’slegwith3mmEVA.
2.7 distal strap
Youmustchoosebetweenadistalstrapandaninstepstrap.Telatterhastheadvantageofholding
thecalcaneumfrmlyinsidetheorthosis(equinuscorrection).
UseaVelcrostrap25mmwide.
4Withalargetubularrivet,fxthebelt
holdingthelooponthemedialside,4cm
abovethemalleoli.
Teloopshouldbeplacedoverthe
polypropyleneandnotbeincontactwiththe
patient’sleg.
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2.8 Instep strap
UseaVelcrostrap25mmwide.
Twotechniquesarepresented,dependingonwhetherthebackofthefootisinaneutralpositionor
needsavalgus/varuscorrection.
2.8.1 Neutral position
4Withalargetubularrivet,fxthebelt
holdingthelooponthemedialside,atan
angleof45°passingthroughtheposterior
distaltipofthecalcaneum.
Teloopshouldbeplacedoverthe
polypropyleneandnotbeincontactwith
thepatient’sleg.
4Insertthebeltthroughtheloopto
measuretherequiredlength.
Fixthestrapwithalargetubularriveton
thelateralside,atthesameangleof45°.

Coverthesurfaceofthestrapincontact
withthepatient’slegwith3mmEVA.
2.8.2 Varus/valgus correction
Testrapwillpassthroughaslotcutinthepolypropylene.
4Teslotiscutonthelateralsideforvarus
correctionandonthemedialsidefor
valguscorrection.
Markthepositionoftheslot40mmfrom
thebackofthefootandperpendicular
toalinedrawnatanangleof45°passing
throughtheposteriordistaltipofthe
calcaneum.
Teslotshouldbe30mmlong.
17 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Makeholesalongtheslotaxiswithadrill
fttedwitha4mmbit.
4Withacutter,connecttheholeswitheach
other.
Finally,smooththetrimlinewithafle.
4Teloopisplacedonthemedialsidefor
varuscorrectionandonthelateralside
forvalguscorrection.
Fixthebeltholdingtheloopwithalarge
tubularrivet,atanangleof45°passing
throughtheposteriordistaltipofthe
calcaneum.
Teloopshouldbeplacedoverthe
polypropyleneandnotbeincontactwith
thepatient’sleg.
4Insertthebeltthroughtheslotonone
sideandthroughtheloopontheother
sidetomeasuretherequiredlength.
Fixthestrapwithalargetubularrivetjust
outsidetheslot.
Coverthesurfaceofthestrapincontact
withthepatient’slegwith3mmEVA.
18 I CRC Physi cal Rehabi l i tati on Programme
AFO wITh TAMARACk FlExuRE JOINT
TM
3
2.9 Initial ftting and fnishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TeinitialfttingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodifcationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutofthesurplusandsmooththetrimline.
3.1 Moulding of EVA
Followtheproceduredescribedinsection2.1(page8),orgoontothenextsectionifEVAisnot
required.
3.2 Orthosis trim line
Followtheproceduredescribedinsection2.2.1(page9).
3.3 Plastic reinforcement
Posteriorreinforcementforgreaterplantarfexioncontrolisrequiredwhentheorthosisisintended
topreventplantarfexion(notfullydescribedbelow).
Followtheproceduredescribedbelow,orgoontothenextsectionifplantarfexionisleffree.
AsecondlayerofpolypropyleneforpositioningattheleveloftheAchillestendonismouldedatthe
sametimeasthemainlayer.
4Cutapieceofpolypropylene:
• thickness,5mm;
• width,2cm;
• length,7cm.
19 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Firstthereinforcement(heatedat
thesametimeasthepolypropylene)
isplacedontheplastermodel,then
thesecondlayerisvacuum-moulded
immediatelytoobtainaperfectseal
betweenthetwolayers.
4Usethemouldingdummiestoforma
snuglyfttingcavityfortheTamarack
FlexureJoint
TM
.
Nailthemverticallyontotheplaster
modelsothatthemidpointislocated
ontheankleaxis.
3.4 Installation of Tamarack Flexure Joint
TM
Ontheplastermodel,markthepositionofthejointaxis:
• laterally,attheapexofthemalleoli;
• medially,slightlyposteriortothedistaltipofthemalleoli.
Makesurethatthejointsareatthesamelevelonbothsides.
3.5 Vacuum moulding of the polypropylene
Followtheproceduredescribedinsection1.3(page6),takingintoaccountthepresenceorabsence
ofaposteriorreinforcement(section3.3,page18).
Pullastocking(cottonstockinetistoothick)overtheplastermodel.
20 I CRC Physi cal Rehabi l i tati on Programme
3.6 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection3.2(page18).
Cutonlythecontouroftheorthosiswithanoscillatingsaw.Donotcutalongtheseparationbetween
footsectionandcalfsection.
Removetheplasticshellfromtheplastermodel.
ExtractthemouldingdummiesandthestockingfrominsidetheAFO.
4Drawtheseparationlinebetweenthefoot
sectionandthecalfsection:
• Markthemiddleofthecavitiescreated
bythedummies.
• Drawa“V”anteriortothemidlineof
eachcavity.Ensurethatthe“V”doesnot
extendbackwardspastthecentreofthe
cavity.
4ForAFOwith plantar fexion control,
drawahorizontallineposteriortothe
marksjoiningthetwosides.
4ForAFOwith free plantar fexion,draw
a“V”posteriortothemidlineofeach
cavity.Ensurethatthe“V”doesnot
extendforwardpastthecentreofthe
cavity.
Correct Incorrect
21 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Drillholesatthedimpleslefbytheholes
inthemouldingdummies:
• 5mmforlargesize;
• 4.5mmforsmallsize.
4Useathin-bladedsaw(1/16’’bladekerfor
less)toseparatethefootsectionfromthe
calfsection.
Do not use an oscillating saw because too
much material is lost along a ragged, wide
cut line.
Smooththetrimlineedgewithahanddeburringtoolorapieceofglass.Do not grind the trim line
because this will reduce fexure coverage and reduce the ability of the cavity to anchor and control the
fexure efectively.
4InserttheTamarackFlexureJoint
TM
and
securewithmetalfastenersandanchoring
screws.
Dependingonthethicknessofthe
polypropylene,itmaybenecessaryto
adjustthelengthofthescrewsiftheends
protrudeinsidetheAFO.
22 I CRC Physi cal Rehabi l i tati on Programme
3.7 Preparation of the straps
Fortheproximalstrap,followtheproceduredescribedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.Ifso,followtheproceduredescribedinsection
2.7(page15).
3.8 Initial ftting and fnishing
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TeinitialfttingisperformedinaccordancewithP&Ostandards.
Carryouttherequiredmodifcationsonthepolypropyleneandsmooththetrimline.
GluetheEVAcompletelyinsidethepolypropylene,cutoftheexcessandsmooththetrimline.
Gluethefexureanchoringscrewswitharemovablethread-lockingcompound(Loctite).
AFO ANTI-TAluS (ANTERIOR ShEll) 4
4.1 Moulding of EVA
EVA(6mm)maybemouldedpriortodrapingofthepolypropylene:
• toimprovecomfort;
• topreventskinbreakageforpatientswithsensationloss.
Do not cover the foot, to avoid an increase of volume which may prevent the patient from wearing
normal shoes.
Followtheproceduredescribedbelow,orgoontothenextsectionifthecasedoesnotrequireEVA.
Positiontheplastermodelwiththeforefootpointingupwards.
4CutapieceofEVA:
• width,calfcircumference;
• length,leglength;
• thickness,6mm.
HeattheEVAat120°for3to
5minutes,dependingonthe
efciencyoftheoven.
DrapetheEVAovertheplaster
modelmanuallyandholditinplace
untilithascooledcompletely.
23 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
4Cutoftheexcesswithacutterora
pairofscissors.
Grindthedistaltrimlineto
graduallyreduceitsthickness.
StapletheEVAontothebackofthe
plastermodel.
4Marktheorthosistrimlineasfollows:
A Tetopmustbehorizontal,2cmbelow
thetibialtubercle.
ß Ontheleg,1cmposteriortothe
mid-line.
C Ontheankle,atthetopofthemalleoli
tofacilitatedonning.
D Ontheforefoot,clearthesidesand
topofthetoesandtheheadofthe
metatarsuscompletely,passingbelow
them.Tis will allow the polypropylene
to follow the movement of the metatarso-
phalangeal joints.
4.2 Orthosis trim line
24
2
1
3
I CRC Physi cal Rehabi l i tati on Programme
4.3 Plastic reinforcement
Tepresenceofchannelsintheplasticsignifcantlyimprovesitsstrength.Tereareseveralwaysof
makingthesechannels.
4CuttwostripsofEVA:
• thickness,6mm;
• width,10mm;
• length,20cm.
Grindbothdistalandproximalendstogradually
reducetheirthickness.
Gluethestripsontotheplastermodel,1cmanterior
tothelateralandmediallongitudinalaxes.
Reinforcements prolonged along the side of the
mid-foot increase the volume of the orthosis so that it
may no longer ft into the patient’s shoe.
4.4 Vacuum moulding of the polypropylene
Te procedure described below ensures uniform thickness of the polypropylene all over the orthosis. Do
not try to make a single seam on the anterior side, because the creases gathering at the ankle will make
it necessary to stretch the polypropylene too thinly.
Ifthishasnotyetbeendone,pullastockingovertheplastermodel.For maximum efciency the EVA
used to channel the polypropylene must not be covered with a stocking.
Dustthestockingwithtalcumpowder.
Measurementofthepolypropylenesheet:
1 Calfcircumference+10cm.
2 Instepcircumference+10cm.
3 Legandfootlength+10cm.
PPthickness:4mmor5mm,dependingonthepatient’sweight.
25 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
Heatthepolypropyleneat180°for20to25minutes,dependingonthethicknessofthe
polypropyleneandtheefciencyoftheoven.
Drapethepolypropyleneovertheplastermodelandstickittogetheralongtheposteriorsideand
underthefoot.
Tightenthepolypropylenearoundthesuctionconewitharopeorsomethingsimilar.
Openthevacuumvalve.
4Cutoftheexcesswithapairofscissors
whilethepolypropyleneisstillhot.
Keepthevacuumonuntilthepolypropylenecoolsdown.
4.5 Preparation of the polypropylene shell
Drawthetrimlineonthepolypropyleneasexplainedinsection4.2(page23).
Cuttheorthosiswithanoscillatingsaw,followingtheoutline.
Removetheplasticshellfromtheplastermodel.
RemovethestockingfrominsidetheAFO.
Grindtheorthosistrimlineandsmoothit.
IfEVAhasbeenmouldedbeforehand,transferthetrimlinetotheEVAandcutoftheexcesswitha
pairofscissors.
26 I CRC Physi cal Rehabi l i tati on Programme
4.7 Initial ftting
IfEVAfoamisused,glueittemporarilyinsidetheorthosis.
TeinitialfttingisperformedinaccordancewithP&Ostandards.
4Itisofennecessarytofarethepolypropylene
attheposteriorpartoftheheelinorderto
facilitatedonningandtoavoidpainfulcontact
withtheedgeoftheplastic.
4.6 Preparation of the straps
Fortheproximalstrap,followtheprocedure
describedinsection2.6(page14).
Insomecasesthepatientmightneedadistalstrap.
Ifso,followtheproceduredescribedinsection2.7
(page15).
4.8 Finishing
Carryouttherequiredmodifcationsonthepolypropyleneandsmooththetrimline.
GluetheEVAinsidethepolypropylene,cutofthesurplusandsmooththetrimline.
27 Manuf actur i ng Gui del i nes Ankl e-Foot Or thosi s
ICRC Code Description
Unit of
measure
Quantity
For negative and positive cast :
ODROSTOCOT60 Tubular stockinet, 60 cm cm 70
According to size:
• MDREBANDP10
• MDREBANDP12
• MDREBANDP15
Plaster of Paris bandages
10, 12 or 15 cm x 3 m
Piece 3
OTOOPLASPW40 Plaster of Paris powder Each As required
For EVA and plastic moulding :
If required, according to
colour:
• OPLAEVAFERA06
• OPLAEVAFLIV06
• OPLAEVAFKIN06
EVA 6 mm
Terra, olive or beige colour
Each As required
None Nylon stockinet Piece 1
According to colour and
thickness:
• OPLAPOLYCHOC03
• OPLAPOLYCHOC04
• OPLAPOLYCHOC05
• OPLAPOLYLIV03
• OPLAPOLYLIV04
• OPLAPOLYLIV05
• OPLAPOLYSKIN03
• OPLAPOLYSKIN04
• OPLAPOLYSKIN05
Homopolymer
Terra, olive or beige colour
3, 4 or 5 mm thickness
Each As required
For the TAMARACK Flexure Joint
TM
:
According to size:
• OCPOSOOTTAL
• OCPOSOOTTAS
Large size (740L)
Small size (740S)
Piece 1
EHDWGLUEL243 Glue, Loctite 243, blue, threadlock, 50-ml bottle As required 4
For the proximal strap:
OSBOSTRVP440 Strap, Velcro, PVC, with loop, brown, 400 x 40 mm Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
or
OSBOVSBO30 Strap, polyester, black, 40 mm cm 25
None Strap, Velcro, 40 mm cm 20
None Loop, 40 mm x 100 pieces Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
For distal/instep strap:
OSBOSTRVP325 Strap, Velcro, PVC, with loop, brown, 300 mm x 25 mm Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
or
OSBOVSBO24 Strap, Perlon webbing, 25 mm cm 20
None Strap, Velcro, 25 mm cm 15
OSBOVSBO35 Loop, 25 mm x 100 pieces Piece 1
OHDWRIVET131 Rivet, tubular, 13 mm x 12 mm Piece 2
list of manufacturing materials
MISSION
The International Committee of the Red Cross (ICRC) is an impartial, neutral and
independent organization whose exclusively humanitarian mission is to protect the
lives and dignity of victims of war and internal violence and to provide them with
assistance. It directs and coordinates the international relief activities conducted
by the Movement in situations of confict. It also endeavours to prevent suffering
by promoting and strengthening humanitarian law and universal humanitarian
principles. Established in 1863, the ICRC is at the origin of the International Red
Cross and Red Crescent Movement.
Acknowledgements:
Jean François Gallay
Leo Gasser
Pierre Gauthier
Frank Joumier
Jacques Lepetit
Bernard Matagne
Joel Nininger
Guy Nury
Peter Poetsma
Hmayak Tarakhchyan

and all prosthetists-orthotists who have worked in ICRC-assisted physical rehabilitation centres.
International Committee of the Red Cross
19 Avenue de la Paix
1202 Geneva, Switzerland
T + 41 22 734 60 01 F + 41 22 733 20 57
E-mail: icrc.gva@icrc.org
www.icrc.org
© ICRC, September 2006
All photographs: ICRC/PRP
Physical Rehabilitation Programme
ankle-Foot orthosis
Manufacturing guidelines
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