AFOs vs. SMOs – Help! Thoughts?

As many of you know, we have been struggling with our AFOs.  They hinder Pooka’s crawling & standing.  Because she lacks adductor muscles, the AFOs act like long rigid levers that cause her hips to swivel into unnatural positions.

But she can’t stand properly without them.  Can’t live with them, can’t live without them! 😉

Without them, she stands on the tops of her feet/sides of her ankles. (Look Tracy, no pants!)

When we correct her foot positioning, making them flat, her feet instantly roll outward (supinating).

So I thought, maybe SMOs would be a better option for her.  She is strong, has hip & knee flexors and is highly motivated.  It seems like she would have more control over a smaller orthotic, like a SMO *and* it would allow for more natural movement.  It seemed like a great choice all around.

But all the SMO websites list supination as contraindicated.  And my question is WHY?  If supination is just the opposite problem to pronation (that’s probably oversimplifying things), why would they not make a SMO for supination too?   Does anyone know why?

Or even better, what functional/structural level/problem would make one need AFOs over SMOs?

Just so you know, when I asked my ortho about SMOs, he instantly rolled his eyes, made a scoffing noise and said, “No, she definitely needs AFOs!”  Helpful, right?

I would really appreciate all of your insights.

Thanks so much.



  • Great questions and pictures! I love the no pants! 😉

    I was always under the assumption that SMOs were good for both supination and pronation, but did not help stabilize dorsiflexion or plantarflexion. I very well could be wrong and look forward to others’ responses.

    Our ortho and PT discussed a hybrid brace for Caroline. We didn’t go with it this time based on their recommendations but are considering it for next time, especially since she shows improvement in her right foot and can almost walk as well with and without a brace on that side. Anyways, the hybrid brace is a SMO that you can easily (and quickly) slip on/off an attachment that turns it into an AFO. So, great for crawling around with only SMO in place, then when she is in the mood for weight bearing and needing more bracing, then just pop on the AFO attachment. Maybe that would work for Pooka? I think the downside is the width of the bracing at the ankle is even bulkier, making shoes even harder to fit.

    Speaking of hard to fit shoes, everyone knows to take the insole out of the shoe for orthotics, but I learned the other day to take the tongue out too. Genius! It opened up so much more room and made shoes fit almost perfectly! They are not as awesome as Plae shoes, but a good option for using all the big sis hand me downs 🙂

    • That hybrid sounds very interesting. I would love to see pictures of that. Was it something custom they make or an off the shelf product from a company like Cascade?

      Good thinking on the tongue. I’ll keep that in mind, for sure.

    • I know a lot of people have been really happy with those type of braces but for us the smo/afo combination was just too bulky. I could only find shoes 4 sizes too large and ultimately just had the braces remade into just afos.

  • Well I just took a look at the Cascade site (they make our DAFOs) and they have at least a couple SMO options listed to aid with supination. But! How is her ankle strength and control. I think she would need some decent ankle control to really best use the SMOs.

    • Thank you for those links. Unfortunately I think she has high supination (as opposed to the “mild” they list on the dafo-4).

      I found that video very interesting.

      And I do like the looks of the kangaroo, even though it is an afo. I like that it has no straps at the top. This would keep it from acting like a lever. The afo could move around her rather than forcing her hips to move with it.

      I wonder how I would gauge ankle control. Thoughts?

      • I’m not sure I know how to gauge it in your situation. And Camilla may well be correct about overpowering them. I do agree about the Kangaroo not levering her hips around.

        Maybe ask your orthotist what he thinks about that? Or maybe wait until you modify the old ones and then see what you think? Maybe once you can see how she does in those you can have a better idea what you might still want and how that might be complimented by something different.

  • If I were you I’d talk to dr. Jordan. The one that Anat recommends. You can send him pictures and videos and he will study them so thoroughly. He is brilliant and believes in not restricting movement. I think you’ll get some good ideas/solutions from him! I can get you his contact info if you don’t have it/can’t find it.

    • Interesting. Yes, I know him. He is listed on the Physicians & Therapists page. So are you saying he offers just consults? Or would the consult be based on the assumption that we would then travel to New York to have him make her braces?

    • I borrowed a pair of Jordan’s braces from a friend and brought them into my local orthotist and he made a very similar pair for C. We have been very, very happy with them!

      TSpar, when I asked Jordan’s secretary if he would just evaluate her videos and give suggestions, he said no. I think his consults are solely for the purpose of you traveling to NY. I know I told you all this before, but when I emailed him videos (at the time we were planning to go to NY) he did send a very detailed report back but only said what kind of bracing he felt she needed but did not describe that bracing in detail so the report really would not be of any use to give to a local ortho, if that makes sense.

  • I think the off the shelf smos would be worth trying just to see how she does and she may feel more comfortable moving in them but I think ultimately the reason P would need afos over smos is that she will probably overpower the smos (still turn inward) and they won’t offer her enough support (at least thats how it was for C). Also, as she stands more, I think you will find that the afos keep her upright –less crouching–over smos. Because the afos don’t just help foot position but help compensate for weak calve muscles.

  • Following. Meredith’s in AFOs right now post surgery because she needs the support. However, I am not convinced that when she is 100% “recovered” that she wont need some sort of orthotic assistance. She was not wearing any previous to surgery and that’s what got us into this mess (I believe). I just discussed SMOs with her PT this morning! She thinks it could go either way right now. She is noticing some supination and though SMOs could help with that. Her feeling was that SMOs were if the child needed help with pronation/supination, but had good dorsiflexion/plantarflexion.

  • So we spent yesterday morning playing with both sets of her AFOs as well as the compression pants & derotation straps that Camilla so graciously sent to us.

    We concluded that her hips might be her biggest obstacle.

    The pants seemed to help and the derotation straps have potential too (once we can attach them to her AFOs).

    I think we are going to make an appt to see orthotics & PT at Shriner’s to see if we can get her all set up with the straps & the AFOs. It will be interesting to get their feedback. And I can ask them all my questions too.

    I’ve been thinking about the ankle thing and it seems to me that pronation & supination are directly related to ankle strength/stability. Isn’t it the ankle that allows the foot to pronate or supinate? If that is the case, she has VERY weak ankles.

    I think Camilla may be right that she would overpower SMOs.

    I still plan to cut down her old pair of AFOs to SMO size. Then we can play with both AFOs & SMOs.

    I will report back after our Shriners visit with all I learn.

    Thanks so much for all your insights!


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