30 Seconds Of Therapy: Use AFOs for Tibial Control

START

1. Start With the Tibia in Your Gait Analysis

   1. The tibia plays a leading role during the stance phase, which makes up 60% of the gait cycle— with single-limb support (SLS) being the most mechanically demanding portion.

      1. During mid-stance, the ankle must achieve 10° dorsiflexion, while the tibia advances over the foot to support 70% of body weight (the HAT segment + pelvis).

      2. If tibial control fails here, compensations cascade upward—knee collapse, hip instability, and trunk sway.

         
         

2. Prescribing AFOs to Manage Tibial Instability

   1. Contrary to popular belief, the primary purpose of an AFO is to improve distal stance stability, not just prevent toe drag.

      1. An AFO helps maintain the tibia in an upright, aligned position—especially critical during mid and terminal stance, when plantar flexors are active to stabilize and propel.

      2. AFOs reduce energy cost and improve walking efficiency in patients.

         
         

3.  Addressing Proximal Issues as Secondary

   1. Hip or quad overactivity is often secondary to tibial collapse.

      1. For example, if plantar flexors are weak and the tibia collapses forward, the quads must stay active to prevent knee buckling, even though they’re typically quiet during mid-stance (EMG confirms this).

      2. By restoring tibial alignment, you restore natural muscle recruitment and reduce compensatory overuse.

STOP

1. Treating Swing Issues Without Fixing Stance

   1. If you’re only addressing foot drag, you’re missing the origin.

      1. 40° of the needed 60° knee flexion in swing occurs passively during pre-swing, which is dependent on proper tibial alignment on the contralateral stance side.

         
         

2. Believing That “Foot Drop” Is the Core Problem

   1. Most swing limitations stem from proximal issues—inadequate knee or hip flexion—not ankle dorsiflexion.

      1. In fact, during swing, the ankle only needs to reach neutral (0° dorsiflexion) for limb clearance.

3. Attributing Crouch Gait to Weak Quads

   1. A crouched knee during stance is not always a quad issue. If the plantar flexors are weak, the tibia collapses forward into dorsiflexion, requiring the quads to engage just to keep upright.

      1. Fixing tibial stability solves the actual problem—not just the symptom.

WHY

1. Why prioritize tibial stability in gait rehab?

   1. Because the tibia governs efficient weight acceptance and forward propulsion. Its alignment determines how the knee, hip, and trunk respond during gait. When it collapses, the whole system compensates—leading to poor movement economy, fatigue, and limited functional capacity. Stabilizing the tibia improves efficiency and performance across the entire kinetic chain.

      
      

2.  Why use AFOs for stance support—not swing assistance?

   1.  Because the greatest dysfunction occurs during stance, not swing.  An AFO that provides proper tibial alignment enables controlled movement through the heel rocker → ankle rocker → forefoot rocker, which are critical for efficient gait.

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