Ankle-Foot/Knee-Ankle-Foot Orthosis Evaluation Note (AFO/KAFO)

Date of Service: [Date of service]

Patient Name: [Full name]

Date of Birth: [DOB]

Laterality: [Right / Left / Bilateral]

Encounter Type: [Initial evaluation / Re-evaluation]

Referral Source and Diagnosis: [Referring clinician and primary diagnosis relevant to orthosis]

Current Assistive Device: [none / cane / walker / wheelchair]

Existing Orthosis: [Type and condition, if applicable]

Reason for Evaluation

[Primary gait or stability problem prompting evaluation] (1–3 sentences; may include brief patient quote for chief concern. Do not infer—document only what is stated.)

Patient Goals and Preferences

• Functional goals: [Walking distance, stairs, community ambulation, work tasks]
• Safety goals: [Fall reduction, improved confidence]
• Device preferences: [Footwear constraints, bulk/weight tolerance, donning ability, cosmetic concerns]

(If goals unobtainable, state reason such as cognitive or communication barriers.)

History

(Include only details affecting orthotic fit, safety, or selection. Omit unrelated medical history.)

• Onset and course: [Acute vs progressive; stable vs fluctuating]
• Primary gait complaint and triggers: [Terrain, fatigue, stairs, dual-tasking]
• Pain: [Location, severity, aggravating factors] (Include only if reported.)
• Fall history: [Number in past 12 months, circumstances, injuries, near-falls, fear of falling] (Use explicit counts; if unknown, state "Unknown—patient unable to recall.")
• Ambulatory status: [Household vs community ambulator; supervision/assist level; distance tolerance] (If not assessed, state "Not assessed.")
• Current assistive devices: [Device type and effectiveness]
• Prior orthoses: [Type, what worked/failed, skin issues, fit problems]
• Typical footwear: [Style, heel height, fastening]
• Relevant medical factors: [Skin fragility/wounds, edema fluctuations, sensory loss, material allergies, cognitive factors affecting adherence, caregiver availability]

Objective Examination

Observation and Skin

[General standing posture and alignment]

• Skin integrity at pressure points: [Malleoli, heel, tibial crest; add fibular head if KAFO considered]
• Wounds: [Location, size, stage, drainage] (Include only if present.)
• Edema: [Location; pitting vs non-pitting]
• Other findings: [Temperature/color changes, scars affecting trimlines]

(If skin exam deferred, document reason and mitigation plan.)

Sensation

• Protective sensation: [Method and results]
• Areas of impaired sensation: [Locations relevant to orthosis contact]
• Proprioception: [Findings] (Include if balance deficits are a factor.)

Range of Motion

• Ankle: [Dorsiflexion/plantarflexion] (Note knee position if assessing gastrocnemius length.) [Inversion/eversion if relevant]
• Knee: [Extension/flexion; note any flexion contracture]
• Limitations: [Fixed vs non-fixed; functional impact on gait or orthosis alignment]

Strength

• Ankle: [Dorsiflexors, plantarflexors, invertors, evertors—MMT grades]
• Knee: [Extensors, flexors—MMT grades]
• Hip: [Abductors, extensors—MMT grades] (Include if relevant to gait pattern.)

(If MMT not feasible, provide observation-based assessment with explanation.)

Tone and Spasticity

(Include only if neurologic tone is present or suspected; omit entirely for orthopedic cases.)

• Scale used: [e.g., Modified Ashworth]
• Findings: [Muscles tested, grades, clonus if present]
• Gait impact: [How tone affects gait pattern]

Fall Risk Assessment

• Fall history: [Count, timeframe, circumstances, injuries]
• Subjective instability: [Patient-reported instability and fear of falling]
• Objective testing: [Test performed, result, testing conditions: assistive device, orthosis worn, guarding level] (If not safely performed, state reason and base assessment on history and observation.)

Gait Assessment

• Assistive device and assist level: [Device; independent / supervision / contact guard / minimal / moderate / maximal assist]
• Gait speed and endurance: [Slow / functional / community speed; endurance limitations]
• Key deviations: [Toe drag, foot slap, equinovarus/valgus, ankle instability, knee hyperextension/recurvatum, knee buckling, reduced knee flexion in swing, circumduction, hip hiking, trunk lean, pelvic drop, step asymmetry]

Gait Summary: [Narrative description of baseline gait pattern, most safety-relevant deficits, and linkage to exam findings] (3–5 sentences; label interpretations explicitly, e.g., "Interpretation: pattern consistent with dorsiflexor weakness.")

Orthosis Trial

(Include if trial performed; otherwise state briefly why no trial was done.)

• Conditions compared: [Shoes only vs current brace vs trial AFO/KAFO]
• Observed changes: [Clearance, knee stability, gait speed, effort, safety]
• Skin tolerance: [Redness, pressure points]

Assessment

[Summary of key impairments, resulting activity limitations, participation impact, and overall fall risk synthesis] (Keep concise and evidence-linked.)

Problem List:

• [Problem 1]
• [Problem 2]
• [Problem 3]

Device Selection Rationale

If AFO Recommended

(Include only if recommending AFO.)

• Functional targets: [Swing clearance, controlled plantarflexion, frontal plane ankle stability, stance-phase knee control via ankle mechanics]
• Knee stability statement: [Explicit statement that knee stability is adequate without knee joint]

If KAFO Recommended

(Include only if recommending KAFO.)

• Knee problem requiring control: [Buckling, severe recurvatum, ligamentous instability, quadriceps insufficiency]
• Why AFO insufficient: [Reason AFO alone cannot address knee stability deficit]
• KAFO mechanism: [How KAFO will address knee stability—locking, stance control, extension assist]

Alternatives Considered

• [Alternative and reason ruled out] (e.g., footwear modification, ankle brace, SMO, knee orthosis alone, FES, PT gait training, assistive device upgrade)
• [Alternative and reason ruled out]

Customization Rationale

Customization level: [Off-the-shelf / custom-fitted / custom-fabricated] — [Justification]

(For custom-fabricated: document need for multi-plane control, tissue injury risk, expected use >6 months, or anthropometric factors preventing adequate prefab fit.)

Medical Necessity Statements

• Ambulatory status and functional potential: [Statement]
• Impairment requiring stabilization: [Weakness, deformity, or instability requiring orthotic control]
• Knee deficit (KAFO only): [Specific knee stability deficit requiring knee-level control beyond what AFO provides]

Recommended Orthosis

Laterality and Type: [e.g., Right AFO, Bilateral KAFO]

Design: [Orthosis subtype and control objectives by gait phase]

Key Features: [Ankle joint configuration; footplate length; tibial section trimlines and strapping; for KAFO: knee joint type, locking strategy, thigh section design]

Interface: [Sock/liner plan; padding for pressure relief]

Footwear: [Recommended heel height, shoe depth, fastening]

Plan

• Measurements/casting/scanning: [Method and key measurements obtained today]
• Fabrication timeline: [Expected completion]
• Fitting and delivery: [Plan and anticipated adjustments]
• Gait training: [In-clinic training and/or PT referral]
• Follow-up: [Schedule and outcome targets]
• Education provided: [Donning/doffing, wear schedule, break-in, skin checks, stop-wear criteria, cleaning, red flags]
• Coordination: [Communication to referrer, prescription updates, medical clearances needed]

Clinician Signature

Evaluator Name and Credentials: [Name, degree(s), license/certification]

Date/Time: [Date and time of documentation]

Template Note: For missing high-impact information (fall history, knee stability, skin status), document "Not assessed (reason)" or "Unknown (patient unable to recall)" rather than omitting. Never infer ambulatory status, fall history, knee instability, or skin breakdown. Label clinical interpretations explicitly. Omit Tone and Spasticity section for orthopedic cases. Device Selection Rationale requires explicit justification for device level and customization.