Section: CME Category: Orthotics & Prosthetics

Treatment of Complex Ankle and Hindfoot Deformities with AFO Bracing

Douglas Richie, Jr,, DPM

Douglas Richie, DPM offers excellent examples from his own cases using AFO bracing. Dr Richie further discusses the application of specific types of braces and key criteria for evaluation of the patient for choosing the appropriate bracing.

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Goals and Objectives
  1. Understand how AFO (ankle foot orthoses) Ankle Braces can be integrated into podiatric practice to optimize patient outcomes
  2. Recognize specific clinical indications for AFO’s and appropriate brace selection for each condition
  3. Demonstrate key clinical examination techniques for AFO prescription
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  • Author
  • Douglas Richie, Jr,, DPM

    Clinical Associate Professor, Department of Biomechanics
    California School of Podiatric Medicine
    Clinical Associate Professor of Podiatric Medicine and Surgery
    Western University of Health Sciences
    Past President, American Academy of Podiatric Sports Medicine

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  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker: And our next speaker has been a friend of mine for many years, very well-respected in our profession, Douglas Richie. Oh, you’re obviously familiar the Richie Brace. He’s an innovator, he’s a thinker, he’s outside the box and he’s very bright and has a firm knowledge in the area of biomechanics.

    He’s certainly is involved with bracing, which he is going to be sharing some of his thoughts with ankle pathology. He’s certainly done a lot with the American College of Sports Medicine. He’s board certified in foot and ankle surgery. And he is going to share his thoughts on treatment of complex ankle and hindfoot deformities with AFO bracing. So please welcome, Dr. Richie.

    Douglas Richie: Thank you. That is great. Thank you very much. Good, good. The clicker is here.

    Well, thank you. It’s a pleasure to… it’s always a pleasure to speak to residents. I always learn from you. And if anything, the enthusiasm you have is always infectious. I want to share with you a dimension of podiatric practice that many of you may not have had much exposure to. And hopefully, by the time I’m done, I will have achieved these objectives to teach you how we integrate AFO devices into podiatric practice, what specific clinical indications we use when we implement AFOs and I want to teach you some real simple clinical examination findings for how we come up with a proper prescription.

    So Darrell [phonetic] you will recognizes this picture. This is a diagram from Root’s set in old text called normal and abnormal function of the foot. And this book was published when I was a junior at CCPM in the late 70s.

    And I have to say that when by the time I graduated from podiatry school, I was very well trained in understanding how the foot and the leg and the femur and the pelvis interacted with each other and it allows us to ambulate and also how aberrations in certain aspects of that translate into pathologies.

    But what’s interesting is, despite everything I knew about biomechanics, the only treatment regimen I was trained in was this. So in spite of learning all these pathologies, it was the foot orthotic that we used when we had to intervene or chose to intervene.

    Occasionally, when I was in practice, patients would walk in the office wearing one of these big thick plastic braces called an AFO and they would think that I knew how to implement them or adjust them or even replace them. And it was quite embarrassing for me to tell patients, I never had one lecture or one class or workshop in AFO devices and I couldn’t dispense that or treat it.

    And so back then, when I graduated, if a patient walked in my office with this pathology, I couldn’t have treated them. This is a 26-year-old gentleman who was hit by an automobile and dislocated his left knee. He’s had knee surgeries, wearing a knee brace and he lacerated the common peroneal nerve leaving him with a footdrop.

    Now, we have several ways we could intervene here. We could make him an AFO device or we could do a surgical procedure to fix the footdrop. But what is the surgical procedure we do for footdrop? So anybody out there know, just shout it out. What’s it called? All right, I’ll show you at the end of the lecture. I did not treat him surgically. I treated him with a podiatric AFO device. And you can see the remarkable resolution of his problem and the restoration of a normal gait pattern.

    So when we use AFO devices, we think of different applications for it when we look at just the simple biomechanics of the lower extremity. We can use AFO devices to limit range of motion. And a great example of that is chronic ankle instability or degenerative arthritis of the ankle or the hindfoot. We may want to restore motion. And in this case, I restored dorsiflexion to that patient with a drop foot. I didn’t limit motion. I provided dorsoflectory motion with a specific AFO device.

    We can use these devices to decrease load on soft tissue structure, such as tendons around the foot and ankle, and I’ll show you that. And finally, we can use them to offload the plantar surface of the foot like we do with diabetes, Charcot arthropathy and other ulcerative conditions.

    So let’s talk about the most popular way podiatric physicians in this country use AFO devices.

    [0:05:03]

    They use it to treat tendinopathy and most commonly, tibialis posterior tendinopathy. But I will tell you, we’re seeing a rampant rise of patients all over the country with peroneal tendinopathy and tibialis anterior tendinopathy as well as lateral ankle ligamentous disruption in the active athlete. These are all excellent applications for ankle bracing or custom AFO devices.

    So we're going to talk about the adult acquired flatfoot just briefly. I tell students and residents, we don't call this posterior tibial tendon dysfunction anymore because it's much more than that. As you read this definition, it is not just a rupture of the posterior tibial tendon, it's a rupture of key ligaments that lead to collapse of the foot. We know now from 20 years of biomechanical research that the following events occur when a patient presents with a symptomatic adult acquired flatfoot.

    First of all, they've had preexisting flatfoot condition all their life. This leads to increase gliding resistance of the posterior tibial tendon. The position of the hindfoot everted unlocks the midtarsal joint. This then leads to increased strain on key supportive ligaments of the ankle and hindfoot. This then leads to attenuation and rupture of the posterior tibial tendon, but the deformity doesn't end right here. That isn't what these patients come in with. It is the sequential rupture of the spring ligament, superficial deltoid ligament and other ligaments that leads to collapse of the foot. These are the key ligaments that attenuate in rupture in adult acquired flatfoot, the spring ligament complex, the superficial deltoid ligament and the interosseous talocalcaneal ligament. We have to address that either surgically or with functional bracing to make these patients asymptomatic. We stage the adult acquired flatfoot based on whether it is flexible or rigid or whether there is ligamentous rupture that leads to dysfunction in the foot. And I'm going to show you how to do that.

    When we evaluate these patients, we have to look at the severity of deformity, the presence of ligamentous disruption and we have to learn how to assess muscle function. And we can evaluate the patient with the adult flatfoot in less than 10 minutes, Darrell, less than 10 minutes especially when you're in private practice.

    So I’m going to take you through what we do. So this is a patient who's presenting with symptomatic left side adult acquired flatfoot. Both feet show a valgus alignment of the heel but the left foot is more severe and that's very typical of these patients. And she shows the so-called too many toes sign on the left foot and that's simply showing that the forefoot is more abducted on the left foot than the rear foot. We can actually learn more if we look at these patients from the front. This is a patient whose right foot has collapsed. Even though both feet look flat, look at the position of her fibular malleolus on her right ankle compared to her left ankle demonstrating this marked internal rotation of the tibia and fibula driving the talus medial and the forefoot abducting. That clear deformity you see here and you don't see here, earmarks the stage two adult acquired flatfoot.

    In this patient, it’s a little more subtle. Here's the fibular malleolus, sagging of the talonavicular joint and more abduction of the forefoot on the rear foot. We put the patient in relax stance and we want to see if we can reduce the deformity. If we can, it's a flexible stage two adult flatfoot. This is not a rigid deformity.

    The first test we do is called the single foot heel rise. This test is thought to be a gold standard to detect rupture of the tibialis posterior tendon. It's interesting that the loss of the posterior tibial tendon by itself does not make the patient lose the ability to do a heel rise. The heel rise test really checks for the integrity of the stability of the midtarsal joint. When a patient elevates their heel and contracts the gastroc soleus, if their arch is stable, the forefoot plantar flexes across the toes. The metatarsals flex on the fixed proximal phalanges. That's if the arch of the foot is stable right here.

    When you take a patient in stage two or three adult flatfoot and ask them to do a heel rise, they can't get their heel off the ground because the mid foot joints are so unstable, they don't get a leverage and deliver a lever arm to the metatarsal heads.

    [10:08]

    Therefore, this test is really detecting ligamentous disruption of the mid-foot joints.

    Here's a patient attempting a heel rise and instead of the heel coming off the ground, the tibia translates anteriorly while the rear foot planar flexes on the forefoot. That's the only motion you see. That's a completely unlocked midtarsal joint from rupture of the spring ligament complex. Some patients will get the heel off the ground but you'll still see some creasing across the mid-foot. Others more severely barely get the heel off the ground.

    Now, not all patients with flat feet are unable to do a heel rise. Watch this guy. No problem doing a good heel rise test because his midfoot joints are stable, yet he still has a flatfoot. This is a functioning flatfoot. The other patients had dysfunctional flatfeet.

    The next test we do is we detect for forefoot supination deformity. We invert the calcaneus and we see the forefoot come off the floor. This is demonstrating a phenomenon we see universally in patients with stage 2 adult acquired flatfoot. That is not a forefoot varus deformity. That is forefoot supinatus deformity because it’s flexible, it’s reducible and it’s an acquired deformity.

    Forefoot supinatus is a compensation of the forefoot from walking with an everted rear foot. As the rear foot everts, the forefoot does not lift off the ground in the eversion, but instead it inverts so that the forefoot stays plantigrade. Any patient standing on an everted heel, if the fifth metatarsal is on the ground, you know the forefoot has supinated on the rear foot to an equal and exact amount in reciprocal rotation to the hind foot. The rear foot pronates, the forefoot supinates.

    Who first described that? Who first described that? Merton Root? No. Steindler described it back on 1929 in this wonderfully written paper called the supinatory compensatory torsion of the forefoot in pes valgus. And he describes how the forefoot is driven into supination by the rear foot or conversely the opposite.

    This supination deformity in adult flat foot is so critical that our orthopedic colleagues wrote a paper in 2011 reclassifying the adult acquired flatfoot based primarily on supination deformity of the forefoot on the rear foot, whether it’s reducible, flexible or whether it has an abduction component to it. And the level of that deformity dictates how we do surgical procedures to realign the medial column and reduce forefoot supinatus, whether it’s with a fusion or possible tendon balancing.

    It is critical when you cast for functional foot orthotics or AFO devices where we, in the right-hand picture, reduce the forefoot supination deformity when we cast them for an AFO brace or a foot orthotic.

    This is how we cast for podiatric AFO devices. We use as an STS sock and we always cast off the weight bearing. We load the midtarsal joint, just like Mert Root taught us, we put the subtalar joint in neutral and we always push down on the 1st ray to reduce supination deformity in the forefoot.

    Manual muscle testing is done by placing the thumb against the medial aspect of the head of the 1st metatarsal. We’re testing the strength of the tibialis posterior by having the patient actively invert the foot against resistance. We don’t do the test this way because it activates, as you see in the picture, the tibialis anterior. This is how we do the test. It’s very easy to detect a rupture of the posterior tibial tendon with this test.

    Finally, if the posterior tibial tendon is ruptured, the patient cannot supinate their foot past the midline when hanging off the edge of the exam table. This is a patient who has ruptured is tibialis posterior on his left foot. This is a patient who’s ruptured on the right foot. They’re simply asked to invert their feet. And in every case, when they’ve ruptured that tendon, the foot will not invert past the midline. It’s a great way to demonstrate to your patient, look at the difference between your two feet.

    [0:15:03]

    This is a test for spring ligament integrity where we abduct the forefoot on the rear foot and we feel a sponginess across the talonavicular joint comparing the symptomatic to the asymptomatic foot.

    So let’s go back to AFO devices. How do we use AFOs to treat the adult acquired flatfoot? These are our goals of treatment mainly to restore mobility to these patients because they’re severely disabled. And the best way to do it is to reconnect the leg to the foot through the ankle joint complex with an AFO device.

    This is what we call a podiatric AFO. It has a custom balanced foot orthosis connected to limb operates which are adjustable with Velcro straps. The power of the device is to control internal and external rotation of the tibia while controlling the midtarsal joint and the subtalar joint in the foot orthotic.

    We want to push against the medial aspect of the tibia at the medial malleolus to prevent adduction of the rear foot which is coupled with abduction of the forefoot.

    What makes a podiatric AFO device different than the devices orthotists and prosthetists make? It’s the way we cast. We cast in the way Mert Root taught us, off-weight bearing, neutral suspension, lock the midtarsal joint and capture the forefoot to rear foot deformity. In that, we capture the podiatric magic of biomechanics, stabilizing the 1st ray, locking the midtarsal joint, establishing the subtalar joint in a neutral position for proper functioning.

    And if you do it right, it works. And I’m going to show you right now so we catch up. This is patient number one. He’s a 62-year old gentleman who suffered a rupture of his left side posterior tibial tendon. He failed with traditional foot orthotic therapy, which is usually the case. Look at the asymmetry and the abduction of his fore foot on the left compared to the right on the symptomatic foot.

    Here he is with his podiatric AFO. Now he’s wearing this in a work boot and he works in an industrial setting. And this type of brace works beautifully in a work boot and allows them return to the workplace, in this case he’s functioning relatively pain free.

    Here he is before, after, pretty powerful correction you obtain using these principles I just outlined.

    This is a fellow… I practice in a beach community and he suffered a left side posterior tibial tendon rupture, unresponsive to foot orthotics. He asked me if this brace I’m going to make him will be worn in sandals. And I said, "no, you can’t wear sandals. You have a ruptured posterior tibial tendon." Here’s how he came in for his first recheck after wearing the brace. He’s wearing a pair of Teva Sandals and I quickly realized this brace works beautifully with sandals because the brace is attached to the leg, and because it’s attached to the leg, it doesn’t go anywhere. It doesn’t slide out the back of the sandal the way foot orthotics do and in fact the system works really well. So that was kind of a nice discovery just a few years ago.

    This is a very challenging case, a somewhat tragic case, of a 63-year old flight attendant who went in for lumbar laminectomy and wakes up with a paralyzed lower leg. This is an unfortunate but not uncommon case where a surgeon may accidentally nick part of the sciatic nerve. And she not only has a stage 3 flatfoot but a drop foot. She is real challenged biomechanically. We made her a special type of podiatric AFO with an arch suspender device to stabilize the talonavicular joint and here is the difference. And I took this video after she took a three-mile fitness walk which she takes five days a week in our community and this brace literally changed her life and allowed her to return to normal activities and enjoy, otherwise, excellent health in her case. Before, after, pretty powerful transverse plane correction there, showing you the ability of these devices to restore alignment.

    This was a real challenge. This is a gentleman with a stage four adult-acquired flat foot. A stage four means they’ve ruptured the deltoid ligament. Look at his medial malleolus almost hitting the ground that occurs when the deep deltoid ruptures and the talus rotates inside the ankle mortise into valgus. We made him a similar arch suspender brace to elevate the talonavicular joint.

    [20:02]

    And again this fellow states that most of his pain is resolved as long as he wears his AFO device. Before and after, pretty powerful.

    The next most gratifying area that we’ve used AFO braces is for drop foot. Podiatric physician see drop foot regularly in their practice because these patients come in with podiatric complaints. They may come in with a pressure induced lesions from the neuropathy of the neurologic condition. These are stroke patients, patients who have had either have Charcot-Marie-Tooth Disease, multiple sclerosis or other injuries. A great opportunity to intervene with a podiatric device to try to restore normal gait.

    But this is a case where you need to act like a physician and take time to evaluate these patients. Watch them walk, measure joint range of motion, measure muscle strength and choose the appropriate device based on their particular needs. You can’t just order the device based on their pathology or the name of their disease.

    One rule we follow is look at their knee when they walk. If they have a stable knee, they can wear a hinged AFO. This would be a hinged AFO for drop foot that has special hinges called tamarack dorsi assist hinges that literally spring the foot back up out of plantar flexion to restore normal gait. This dynamic assist device works beautifully if the patient has a stable knee and has no posterior spasticity or significant equinus. Patients who fit this description are patients who normally have had a stroke. They have a flaccid hemiplegia with a reducible drop foot deformity. And I’m going to quickly go to a video to show you that and then we will – okay.

    So here’s a couple of patients, that’s the guy I showed you earlier. He’s going to be fitted for the dynamic assist brace that has a tamarack hinges and show a remarkable reversal of that drop foot right on the spot the day he’s fitted for the brace.

    This is a 45-year-old gentleman who went to bed healthy and woke up with a drop foot. He’s slept on his leg awkwardly and crushed his common perineal nerve but it didn’t recover. He was fitted for a solid AFO by an orthotist and patient protested because he couldn’t play tennis anymore. And he sought our treatment because he knew we made a flexible dynamic brace and he has a flaccid drop foot so he’s a perfect candidate for the dynamic assist brace. In this case, it restores a perfectly normal gait pattern on the spot and even better for this patient, he’s able to play tennis.

    Here’s a 26-year-old female who went to bed healthy and woke up with a stroke. She has a left side hemiplegia. What she didn’t know is she had lupus and I didn’t know this but lupus has a category of patients who have a hypercoagulability that are at risk for stroke. And this poor woman at age 26 had a stroke because she didn’t know she had lupus because she never went to the doctor. So she got a mild left side hemiplegia. She wants to wear Vans tennis shoes. She’s able to wear her Vans tennis shoes with a low profile dynamic assist podiatric AFO.

    And I’m going to jump ahead, these are other stroke patients and more serious but I want to show you a more exciting application. I’m going to show you a Charcot-Marie-Tooth patient here.

    Charcot-Marie-Tooth normally is a rather spastic and rigid condition of equinus as a patient evolves with this. But this was a good case where this nurse in our hospital with hereditary Charcot-Marie-Tooth remains reducible and flaccid with a severe drop foot on both sides and we fit her for bilateral dynamic assist AFOs that restores a normal gait despite her being moderately intoed. She walks with an extremely stable gait and she’s a clinical nurse on the ward and functions just like everybody else who is healthy, very gratifying applications.

    Finally, degenerative arthritis to the hindfoot or ankle is very challenging conditions for us to treat conservatively. Most of the time our only option here is fusion. In most cases of ankle joint arthritis, it’s been post traumatic and most of these patients have a concomitant subtalar joint arthritis so they have arthritis in both of their hindfoot joints.

    [25:02]

    And these are very difficult to treat with foot orthotics and surgically, there are often faced with a pantalar arthrodesis which for a younger patient can be fairly debilitating.

    This is a fellow who came to me at age 49 with a severely inverted fixed varus position of his ankle from a neglected syndesmotic injury of his ankle, sustained as a sprain at age 25. I put him - this is what he looked like in relax stance, very inverted. I put him in an arch suspender brace fixed position and it restores normal alignment for him and decompresses the ankle joints so he no longer has pain. It restored him to an almost normal lifestyle without having to fuse his ankle. And if you don’t believe it, this is a post card he sent to me from Phoenix, Arizona about 3 years ago. His son graduated from Arizona State University and if any of you have ever been to a Tempe, Arizona, the largest mountain in that area is called Camelback Mountain and many people climb that mountain as he did the morning of his son’s graduation. And he writes, “Because of your brace, I was able to celebrate my son’s college graduation by hiking up Camelback Mountain in Phoenix with him. Oceans of thanks.”

    And here he is, this is the fellow right here, very healthy, a destroyed right ankle that would normally have to be fused but with competent AFO therapy, we can restore mobility here and really change the life of a patient in a way, in my practice, far more positive and far more gratifying than any surgical procedure I have ever done. And I hope that all of you will now look at this option as you enter into your careers, certainly using the surgical skills you have learned but also considering the use of AFO devices before surgery and maybe preventing the need for some of these more debilitating surgeries and also considering using these AFO devices after surgery as a rehabilitation tool to speedily return these patients to an active lifestyle.

    Thank you very much.

    TAPE ENDS - [27:12]