AFOs for Children: A Parent and Provider Guide to Ankle-Foot Orthoses

If your child has been told they need an AFO, you may be wondering what that means, and why they need a "leg brace."

AFO stands for ankle-foot orthosis. An AFO is a type of orthosis, or brace, designed to support and/or control the foot and ankle. Children may simply call it a leg brace, you may also hear it called an ankle brace, foot brace, or orthotic.

AFOs are commonly used for children who have differences in muscle strength, muscle tone, range of motion, balance, foot alignment, or walking. They may be recommended for children with cerebral palsy, spina bifida, neuromuscular conditions, toe walking, weakness, foot and ankle instability, or after certain surgeries or injuries.

An AFO is not simply something that "holds the foot straight." Depending on its design, it can influence how the ankle, foot, knee, and even the rest of the leg move during standing and walking. The design is therefore selected based on the child's individual needs and goals.

This guide explains what parents and providers should know about pediatric AFOs, including why different types exist, how they are fitted, what shoes work best, how to introduce a new AFO, and how to recognize when an AFO needs to be checked or adjusted.

Why Does a Child Need an AFO?

AFOs can be prescribed for many different reasons.

A child may benefit from an AFO if they have difficulty:

• keeping the foot and ankle in a stable position;
• keeping the foot from turning inward or outward;
• lifting the foot while walking;
• controlling the ankle during standing or walking;
• maintaining an appropriate ankle position;
• maintaining ankle range of motion;
• controlling excessive toe walking or plantarflexion;
• maintaining alignment after surgery;
• managing weakness or instability.

Children with cerebral palsy are one of the largest groups of pediatric AFO users. Research suggests that AFOs can influence gait characteristics such as ankle position, stride length, walking speed, and stability, although the effects depend on the child's individual gait pattern and the design of the AFO (Limpaninlachat et al., 2021; Miccinilli et al., 2024).

Other children who may use AFOs include those with spina bifida, neuromuscular disorders, developmental conditions affecting walking, hemiplegia, drop foot, toe walking, and certain orthopedic conditions.

Importantly, a diagnosis does not automatically determine what type of AFO a child needs. Two children with the same diagnosis may have very different strength, range of motion, muscle tone, alignment, walking patterns, and functional goals.

What Does "Orthosis" Mean?

You may hear several terms used during your child's care:

Orthosis: A device designed to support, align, protect, or control part of the body.

AFO: An ankle-foot orthosis. It surrounds some portion of the lower leg, ankle, and foot.

Orthotist: The healthcare professional who evaluates, designs, fits, and/or provides orthoses.

Orthotic: This word is commonly used to describe an orthosis or the field of orthotic care.

Brace: The everyday word many families use for an orthosis.

Why Are There Different Types of AFOs?

You may see several different names for AFOs, including:

• Solid AFO
• Hinged or articulated AFO
• Floor-reaction AFO
• Carbon-fiber or carbon-composite AFOs

The important thing to understand is that different AFOs allow and restrict different amounts of movement. The appropriate design depends on what the child needs the AFO to accomplish. Your orthotist or “brace maker” specializes in designing a brace that will meet your, your doctors, your child’s physical therapists, and your child’s goals. They will determine those goals in the evaluation and perform a physical evaluation to determine what type of AFO is most appropriate.

The goal is to provide the amount and type of control that matches the child's functional needs.

Why Are AFOs Made From Different Materials?

Most traditional pediatric AFOs are made from thermoplastic. This material can be heated and molded to create a custom shape from an impression, or cast of the child’s leg.

Other AFOs may incorporate materials such as carbon fiber.

Different materials can provide differences in:

• stiffness
• flexibility
• weight
• durability
• energy return
• Thickness
• appearance

The material is therefore part of the design—not simply a matter of choosing the "best" or most advanced material.

The orthotist considers the child's size, strength, movement, activity, goals, and the amount of control needed when determining the appropriate design and material.

Custom vs. Prefabricated AFOs

AFOs may also be custom-made or prefabricated.

A prefabricated AFO comes in predetermined sizes and shapes. These can work very well for children whose needs match the design of the device.

A custom AFO is designed specifically for a child's anatomy and clinical needs. The orthotist considers factors such as foot alignment, range of motion, strength, muscle tone, gait, activity, and growth.

If a child has significant deformity, unusual anatomy, substantial tone abnormalities, or complex functional needs, a custom design may provide more appropriate control.

What Happens When Your Child Is Cast for a Custom AFO?

If your child needs a custom ankle-foot orthosis (AFO), one of the first steps is creating a model of their leg and foot. This is called casting or scanning. The orthotist uses this information to make an AFO that is shaped specifically for your child's body and designed to provide the support their healthcare team has prescribed.

Today, orthotists may use either traditional casting materials or a digital 3D scanner to capture the shape of the leg and foot. The exact process varies between clinics and depends on the child's needs.

What happens during a traditional cast?

Your child's orthotist will first position the foot and ankle in the position needed for the AFO. Getting the position right is an important part of the process because the AFO will be made from this model.

The orthotist then wraps the lower leg and foot with casting material. The material is molded around the leg while it sets. Your child will need to remain relatively still for a short period while the material hardens.

Once the cast has set, the orthotist carefully removes it. The resulting cast provides a model of your child's leg and foot that can be used to fabricate the custom AFO.

The process generally does not require your child to be put to sleep or undergo a medical procedure. It is performed while your child is awake in the orthotist's office.

What if the orthotist uses a scanner?

Some orthotic clinics use a digital scan instead of a physical cast. A handheld scanner captures the shape of the child's leg and foot and creates a digital model that the orthotist can use to design the AFO.

For some children, scanning may be easier because there is no wet or sticky casting material and no cast that has to be removed. However, the child still needs to keep their leg and foot in the appropriate position while the scan is performed.

Ask your orthotist which method they use when scheduling the appointment.

What might my child experience?

For many children, casting is quick and straightforward. For others—particularly children with sensory sensitivities, autism, anxiety, or previous negative experiences with medical care—the experience can be overwhelming.

Children may react to:

• The sensation of something being wrapped tightly around their leg
• The feeling of wet or sticky casting material
• Pressure around the foot or ankle
• Someone touching or holding their foot
• Having their leg positioned in an unfamiliar way
• The smell of casting materials
• The sound of scissors or other equipment
• Having to remain still
• Not knowing what is going to happen next

A child who becomes upset during casting isn't necessarily being "uncooperative." The sensations and loss of control can genuinely be difficult for some children.

Tips for a more successful appointment

Talk about the appointment ahead of time.
Explain what will happen using simple, concrete language. A social story, pictures, or a short video can help your child understand what to expect.

Practice at home.
You can play "orthotist" with your child using a sock or an ACE wrap. Practice having someone touch their foot and lower leg and keeping the leg still for short periods.

Avoid surprises.
Tell your child what they will see, hear, and feel. For example: "The material will feel wet and cool at first, then it will get firm. Your leg will be wrapped, but it will only be there for a short time."

Give your child choices when possible.
Allow them to choose a favorite show to watch, which toy to bring, what to listen to, or which arm to hold a comfort item with. Small choices can give children a sense of control.

Bring familiar comfort items.
A favorite stuffed animal, blanket, tablet, headphones, fidget, or other preferred item can help make the environment more predictable.

Use distraction.
Videos, music, books, bubbles, games, or conversation can give your child something else to focus on while the orthotist works.

Consider noise protection.
If your child is sensitive to sound, headphones or ear defenders may help. Ask the orthotist before the appointment whether your child will encounter any loud equipment.

Tell the orthotist about sensory sensitivities beforehand.
Don't wait until the appointment to explain that your child has difficulty with touch, being held, unexpected movements, or certain textures. The orthotist may be able to modify the process or allow additional time.

Ask whether your child can watch.
Some children feel better when they can see exactly what is happening. Others become more anxious when they watch. Follow your child's lead.

Build in extra time.
If your child needs additional time to become comfortable, let the clinic know when scheduling the appointment. A rushed appointment can make an already stressful experience much harder.

Let the orthotist know what works for your child

You know your child best. Tell the orthotist about strategies that have worked during previous medical or therapy appointments.

For example:

"Please tell her before you touch her."

"He does better if he can watch a video during the procedure."

"She doesn't like anyone touching her toes unexpectedly."

"He needs a few minutes to get comfortable before you begin."

These details can make a significant difference.

What if my child cannot tolerate casting?

If your child becomes extremely distressed, talk with the orthotist rather than simply trying to force the process. Depending on the child's needs and the clinic's capabilities, there may be alternative approaches, such as digital scanning, additional preparation, breaks, distraction, or scheduling the appointment differently.

The goal is to obtain an accurate model while keeping the experience as safe and manageable as possible.

The AFO and Shoe Work Together

One of the most important things for families to understand is that the AFO(s) and the shoes are a team.

Most daytime AFOs are intended to be worn with shoes. The shoe provides traction and helps the AFO interact with the ground appropriately.

AFOs can also be slippery on hard floors when worn without shoes, so children generally should have appropriate footwear when standing or walking in their AFO unless their clinical team has given different instructions.

This means that choosing shoes is actually part of the orthotic process.

What Kind of Shoes Work With an AFO?

Whenever possible, take the AFO with you when shopping for shoes.

Do not simply buy the next larger shoe size based on your child's usual shoe size. An overly long shoe can make walking more difficult and may increase the risk of tripping.

Instead, look for shoes that are:

• wide enough for the AFO
• (usually E or W width is most appropriate)
• deep enough to accommodate the brace
• (low cut converse might slip off the heel)
• easy to open widely
• (detached tongue of the shoe is best)
• secured with laces, Velcro, or another adjustable closure
• (don’t use shoes with sewn in tongues)
• equipped with a removable insole when possible
• long enough to accommodate the AFO without excessive extra space

Some children may need a different shoe size or style from what they normally wear. This does not necessarily mean they need a dramatically larger shoe.

The goal is to find the smallest shoe that comfortably accommodates the AFO without squeezing the foot or creating unnecessary extra length.

Best shoe brands

BILLY: Best dedicated adaptive/AFO option
New Balance : Best mainstream athletic option
See Kai Run Adaptive: Best for younger children
Stride Rite: Good readily accessible children's option
Hatchbacks: Excellent when getting the foot/AFO into the shoe is the primary problem

Mainstream athletic shoes that may work

New Balance • ASICS • Nike FlyEase • KEEN • Skechers • Tsukihoshi

For example, Zappos currently has a dedicated AFO-friendly category that includes children's Tsukihoshi models, which is useful evidence that some mainstream children's shoes can accommodate orthoses.

And if you prefer to shop online by brand name:

* Typical retail range; individual models, sales, sizes, and adult vs. children's shoes can vary significantly.

** Durability is an EmBRACE editorial estimate, not a manufacturer rating.

What Should My Child Wear Under the AFO?

AFOs are generally worn over a sock rather than directly against the skin.

Choose a sock that:

• extends above the top of the AFO;
• fits smoothly;
• does not bunch or wrinkle;
• does not have bulky seams over pressure-sensitive areas.

A longer, smooth-fitting sock can help protect the skin and make the AFO more comfortable.

If your child is prone to sweating, moisture-wicking socks may also be helpful.

Note: Sometimes AFO socks can be covered by insurance (if they are on the prescription) or you can use a FSA for the purchase.

How Do I Put an AFO On Correctly?

The exact process depends on the AFO, but one of the most important steps is making sure the heel is fully seated in the back of the AFO.

A typical sequence is:

1. Put on the sock and smooth out any wrinkles.
2. Place the child's foot into the AFO.
3. Make sure the heel is fully down and back.
4. Secure the ankle strap first, if instructed by your orthotist.
5. Secure the remaining straps, they should not be too snug
6. Check that the heel has not lifted while the straps were being fastened.
7. Put the shoe on over the AFO.

Your orthotist should demonstrate exactly how tight each strap should be, they can even draw a line for your reference.

If you are unsure whether the heel is positioned correctly, ask your orthotist to watch you put the brace on. A perfectly designed AFO cannot work correctly if the child's foot is not positioned properly inside it. Shoe horns can also be a helpful tool to slide the AFO in at the heel.

How Long Should My Child Wear the AFO?

There is no universal number of hours that every child should wear an AFO.

The schedule depends on:

• why the AFO was prescribed;
• the type of AFO;
• whether it is intended for daytime or nighttime use;
• the child's skin and tolerance;
• postoperative restrictions;
• activity level;
• the child's rehabilitation goals.

A new AFO is often introduced gradually so that the child can adjust to the sensation and the changes in movement.

Your orthotist or rehabilitation provider should give you a specific break-in schedule.

Do not assume that wearing the AFO for more hours is automatically better. The goal is appropriate use for the child's clinical needs.

What Should My Child's Skin Look Like After Wearing the AFO?

This is one of the most common questions parents have.

Some temporary redness can occur when an AFO is removed. What matters is how the skin looks and how long the redness lasts.

After removing the AFO, check the skin for:

• redness;
• blisters;
• swelling;
• bruising;
• cuts or abrasions;
• unusual tenderness;
• pressure marks.

As a general guideline, redness or darkened skin should fade in approximately 30 minutes. For persistent redness call the orthotist.

Children who have reduced sensation may not be able to tell you that an area hurts, making regular visual skin checks especially important, every time you remove the AFO.

What If the AFO Hurts?

An AFO should not cause pain.

If your child complains that the brace hurts, try to determine:

• Where does it hurt?
• Does it hurt immediately or after wearing it for a while?
• Is there redness in that location?
• Did the problem start after your child grew?
• Does it happen only with a particular shoe?
• Has the AFO changed or been repaired recently?

Pain can be a sign that the AFO needs to be adjusted, that the shoe is too small, or that your child's anatomy or movement has changed.

Do not modify or cut the AFO yourself unless specifically instructed by your orthotist.

What If My Child Refuses to Wear the AFO?

Research involving children with cerebral palsy and their families shows that comfort, appearance, daily routines, and participation can all affect AFO acceptance and use (Lana et al., 2021; Stockman et al., 2026).

Whenever possible, involve the child in age-appropriate decisions about the brace. Choosing colors, patterns, socks, or shoes may seem like a small thing, but giving children some control can make the experience more positive.

Sometimes the reason is simply that the child does not like wearing it. But refusal can also be a child's way of communicating that something is wrong.

Possible reasons include:

• a pressure area
• growth
• a shoe that is too tight
• difficulty getting the brace on
• changes in muscle tone
• sensory sensitivity
• the brace feeling different as the child grows

What Happens as My Child Grows?

Children grow quickly, and an AFO does not.

A brace that fit perfectly several months ago may eventually become too small.

Signs that an AFO may need to be reassessed include:

• toes extending beyond the footplate
• the brace becoming difficult to put on
• edges digging into the leg
• new redness or pressure areas
• new pain
• changes in walking
• the child suddenly refusing the brace
• the brace appearing noticeably smaller relative to the child's leg

Sometimes an AFO can be adjusted. Other times, a new AFO is needed.

Do not wait for a major skin problem before having a growing child's AFO checked.

Regular follow-up allows the orthotist to evaluate fit, function, wear, and whether the design still matches the child's needs. Scheduling a check up every six months might be beneficial, you can cancel the appointment about three weeks out, if it seems unnecessary at that time.

What Should Providers Consider?

For providers, AFO prescription should begin with the functional problem and treatment goal, rather than simply the diagnosis.

Important considerations include:

What are we trying to change?

For example:

• excessive plantarflexion
• toe walking
• poor foot clearance
• instability
• abnormal foot alignment
• loss of range
• crouched gait
• weakness
• postoperative protection

What does the child actually do during walking?

An AFO changes more than the ankle. Changes in ankle position can influence the tibia, knee, hip, balance, and overall gait.

What are the child's goals?

The goal may be improved:

• stability
• walking speed
• Endurance
• alignment
• range of motion
• Participation
• safety
• postoperative protection

What can the family realistically manage?

AFO success depends partly on whether the family can realistically incorporate the device into daily life.

The 2025 Delphi study by Firouzeh and colleagues emphasized the importance of incorporating child and family circumstances, routines, function, and collaboration into AFO prescription and monitoring (Firouzeh et al., 2025).

AFOs and Physical Therapy

An AFO and physical therapy are often complementary rather than competing treatments.

The AFO can provide a particular mechanical position or level of control while therapy works on:

• strength
• balance
• motor control
• walking
• endurance
• transfers
• functional activities
• adaptation to the orthosis

The orthosis should therefore be considered as part of the child's overall rehabilitation plan. It is beneficial for the physical therapist and the orthotist to be able to communicate their goals with each other. Bring a business card of each to the other, so they are able to call and discuss the overall treatment plan.

Common AFO Problems

The Bottom Line

An AFO, or "leg brace,"is much more than a plastic brace around the lower leg.

It is a clinical tool designed to influence movement, alignment, stability, and function. Because children have different needs, there are different AFO designs, materials, and levels of control.

The goal is to find the AFO that is appropriate for your child.

A successful AFO should:

• address the child's clinical goals
• fit the child's anatomy
• work with appropriate footwear
• be comfortable
• support participation in daily activities
• be reassessed as the child grows and changes

For parents, understanding the basics can make AFO use much less intimidating. For providers, successful orthotic care means looking beyond the device itself and considering the child's movement, family routines, footwear, activities, comfort, preferences, and goals.

The best AFO is one that works for the child—not just one that works on paper.

References

Alberta Health Services. (2025, May 9). Your child's equipment: Buying shoes to fit an ankle foot orthosis (AFO). MyHealth Alberta.

Alberta Health Services. (2025, May 15). Your child's equipment: Ankle foot orthosis. MyHealth Alberta.

Children's Wisconsin. (2023). How to use an ankle-foot orthosis (AFO) splint.

Firouzeh, P., Morris, C., Sonnenberg, L. K., Manns, P., & Pritchard, L. (2025). Development of clinical considerations for ankle-foot orthosis prescription and monitoring in young children with cerebral palsy: A Delphi study. Disability and Rehabilitation, 47(15), 3989–4001. https\://doi.org/10.1080/09638288.2024.2435516

Gillette Children's. (n.d.). Ankle-foot orthosis (AFO).

Hanger. (2025). AFO wear and care guide.

Lana, M. R. V., Maia, J. P., Horta, A. A., Fonseca, S. T., & Assis, M. G. (2021). “What if it were like this?” Perception of mothers of children with cerebral palsy about the ankle-foot orthosis of their children: A qualitative study. Child: Care, Health and Development, 47(2), 252–260. https\://doi.org/10.1111/cch.12840

Limpaninlachat, S., Prasertsukdee, S., Palisano, R. J., Burns, J., Kaewkungwal, J., & Inthachom, R. (2021). Multidimensional effects of solid and hinged ankle-foot orthosis in children with cerebral palsy. Pediatric Physical Therapy, 33(4), 227–235. https\://doi.org/10.1097/PEP.0000000000000826

Miccinilli, S., Santacaterina, F., Della Rocca, R., Sterzi, S., Bressi, F., & Bravi, M. (2024). Efficacy of lower limb orthoses in the rehabilitation of children affected by cerebral palsy: A systematic review. Children, 11(2), 212. https\://doi.org/10.3390/children11020212

Stockman, J., Alriksson-Schmidt, A., Jason-Åndell, E., & Jeglinsky-Kankainen, I. (2026). The perceptions and experiences of ankle-foot orthosis use among youth with cerebral palsy and their parents: A qualitative study with focus on activity and participation. Prosthetics and Orthotics International. Advance online publication.

Tabaie, S. A., et al. (2022). Approach to diagnosis and management of the pediatric foot and ankle in cerebral palsy patients. Journal of Clinical Medicine, 11(8), 2211.