Douglas Richie, DPM discusses cases treated successfully with ankle-foot orthosis (AFO). Dr Richie outlines the indications for use and discusses examination and diagnoses of specific conditions, emphasizing the condition most commonly treated with AFO— Adult Acquired Flat Foot.
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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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TAPE STARTS – [00:00]
Bob: We had just a minor switch in our program. We’re going to have our five – our lecture on AFO bracing first, now. If there is somebody who’s dedicated his career to biomechanics management of lower extremity, gait disorders, biomechanical disorders, it’s Dr. Doug Richie who has been doing this for – what? Over three decades. The developer of the Richie brace which many of you are well aware of, another biomechanical innovation.
So Dr. Richie is going to be speaking about a new approach to – excuse me, the wrong one. I'm sorry, the treatment of complex ankle and hind foot deformities with AFO bracing.
Now, we use a lot of AFOs and I think this is really a very timely and a very, very important project because I can tell you myself I don’t know much about AFOs but we really prescribe them quite frequently. So let’s welcome Dr. Doug Richie.
Doug Richie: Well, thank you, Bob. Appreciate you guys let me switch and we’re going to get started here. How do I advance?
So as Bob pointed out, I do own a company that manufactures prefabricated and custom AFO braces. What I hoped to do in this relatively brief lecture is kind of introduce to you certain conditions which you may not think about that are applicable to AFO bracing.
I'm going to show you some examination techniques that help us choose the proper brace for the proper condition and this goes back even more than three decades when Bob and I were in school.
This is a classic table that came out of root, weed and orients seminal text on lower extremity biomechanics and when we were students back in the 70s, we were really taught how to evaluate every aspect of lower extremity movement. We would watch patients walk and we would always start at the hip and go down to the foot, and within the foot itself.
And we had a pretty good knowledge of every aberration in the lower extremity that could present in our office relative to all these different segments of the lower extremity. But when it came to treating those disorders, this was pretty much it. It was foot orthotic therapy.
And not to down play that, foot orthotic therapy was, and continues to be very effective in treating a lot of these disorders. But one – early on in my practice, patients came in wearing one of these plastic things and they assumed that I knew what it was they all – many of them ask me to replace it or adjust it and I didn’t even know what that was.
The term AFO was never brought up in any of my training. And yet as a lower extremity specialist, my patients thought I should know about this and be able to work with them with this device.
If a patient came in my office says this fellow did about 10 years, he’s a 26-year-old military officer who was struck by an automobile in Tokyo, Japan. And he suffered a traumatic knee injury where he’s tore ACL and medial qulateral ligament but he also traumatized the common perineal nerve and it left him with a foot drop.
If this patient came in my office early in my career, I would’ve referred him out to our friendly orthoptist because I had nothing in my armamentarium to treat him. But today we can intervene with a very dynamic ankle foot orthosis with dorsiflexes devices on the hinges and restore pretty much a normal gait.
Now, it’s interesting earlier this year we had a football player for the Dallas Cowboys referred to one of our practitioners had that exact same injury. This is not an uncommon injury in football where with a severe ACL derangement, they will traumatize the common perineal nerve and the athlete that we were directed to – his name Jaylon Smith and he had won the Butkus award two years ago while playing for Notre Dame and he had a horrible knee derangement in the festival against Ohio State and while he recovered from the surgery to repair the ACL, he was left with a drop foot exactly like the fellow – can you back up one slide for me?
Back up to the previous slide. Go ahead and start it.
Jaylon Smith walks like this. And we made him that exact same brace and he starts at middle linebacker for the Cowboys. If you watch any of their games the rest of the season, the commentators always refer to the miracle that he’s playing at this level and that he wears an AFO brace.
So we’re going to talk about just a couple clinical indications of when we use AFO bracing. And just to make it simple the first thing we can use the brace to do, is off load a specific soft tissue structure.
And in the podiatric profession, the number one indication for AFO bracing is pathology of the posterior tibial tendon, so called PTTD or adult acquired flat foot.
We all see this in almost epidemic proportion today and it is one of the most challenging biomechanical situations we face as podiatric physicians.
The deformity is now staged at four levels, one, two, three and four. And I will tell you basically AFOs are indicated from stage 2 onward. Only a stage 1 deformity seems to be manageable with typical foot orthotic therapy.
Many students, residents, and even practitioners have a hard time understanding the difference between a stage 2, a stage 3 and a stage 4. And to make it very simple, the only difference between a stage 2 and a stage 3 reducibility of deformity, meaning you put the patient in relax stance, and if you can correct their hindfoot to neutral, so to speak, that is a stage 2 deformity. If you cannot reduce the hindfoot, it is fixed, it’s rigid, it’s a stage 3 deformity. And a stage 4 deformity is not only rigid and fixed but on radiographic exam has a valgus deformity in the tail or curl joint from a rupture of the deep deltoid ligament.
If I were to pick one test I do to differentiate when to use an AFO for adult acquired flat fort versus a foot orthotic, it’s this test, the single foot heel rise. This test in a healthy subject, they can lift their foot in single leg stance off the ground and the hind foot will supinate their in-heel rise. This means the gastrocsoleus is a supinator of the hindfoot as it is in a healthy subject.
The heel arise test is made possible if the midfoot is stable. If the mid tarsal joint is stable and the ligaments across the midfoot are functional. If the posterior tibial tendon ruptures, they can still do a single foot heel rise. But if the posterior tibial tendon ruptures and the ligaments of the midfoot, most notably the spring ligament ruptures, they cannot do a heel rise. If you watch them from the side and they try to do a heel rise, you’ll see the midfoot break down across talonavicular joint, a clear indication that they’ve ruptured the spring ligament. They are a candidate for an AFO, not a traditional foot orthotic.
So you watch these patients attempt a heel rise and the only motion you see is the tibia and the talus plantarflexing across the midfoot. Instead of the ankle plantarflexing, the tibia and the talus plantarflex across the midfoot. That happens because they’ve ruptured the spring ligament.
Not all flat feet break down across the midfoot. Here’s an extremely flat foot but I asked the patient to do a heel rise, no difficulty at all. This is a functional flat foot with no ligament instability. That foot is controlled with a foot orthotic.
The next thing I look for in relax stance is what we call forefoot supinatus. We correct the rearfoot and if the first ray rises off the ground, they have a supination deformity which is acquired. That’s not a forefoot varus deformity, that’s a soft tissue adaptation to a rearfoot valgus alignment during gait and during stance. It is important to recognize that because you must correct that when you cast for the AFO.
If you simply cast them like Mert Root taught us where you just lift the fourth and fifth toes, you’re going to miss the boat. You will get a poorly conforming device and a poorly functional device. If you simply push down on the first ray, you reduce the supinatus, you get a much better conforming device, whether it’s a foot orthotic or an AFO.
This is a picture of the STS casting sock, which has made AFO therapy much easier for us, and it’s a great innovation by two podiatrists. Who would that be, Bob? Richard Stess and Peter Graf, two excellent podiatric physicians who ran a great residency program at VA Palo Alto or VA San Francisco and they came up with this device. It’s now sold worldwide. And Richard Stess and Peter Graf are retired now. Okay? A couple of VA guys who made it good, made it big.
Okay. When we treat the symptomatic flat foot, I tell patients my goal is to eliminate your pain and to restore mobility. That’s our goal, not to make their foot look better, not to reverse the deformity. I want to get rid of pain and restore mobility. And finally, I want to keep this condition from getting worse. If I do those three, I’ve succeeded.
So here’s a patient with a stage 2 reducible adult acquired flat foot and when I treat her, I use a functional AFO that reconnects the foot to the leg and it controls tibial rotation. If we control tibial rotation, we control motion across the talonavicular joint. We combine it with a contoured functional foot orthosis so we get to employ everything that Mert Root taught us about foot control but now we connect the foot orthotic to the leg. Very simple concept but very powerful.
We want to control the tibia, we want to control medial displacement of the talus, and we want to control abduction of the forefoot. We want to push against the medial malleolus and prevent adduction of the rearfoot, which drives the talus medially and pronates the midtarsal joint.
We cast these patients off weight bearing, we lock the midtarsal joint and we use all the magic of podiatric biomechanics that most of our orthotist colleagues never were taught, never employ, we know how to do that and that’s why we can do it better.
This is a patient typical who presents with a unilateral symptomatic flatfoot but both feet look pathologic. We treat the symptomatic side with an AFO and asymptomatic side with a custom foot orthotic and we almost always prescribed running shoes with this disorder because they take brace beautifully and they have medial post in to control pronation. One of my favorite shoes is the Brooks Aerial for women where the Brooks Beast for men.
We do use a gauntlet type AFO for this, the stage 4 adult acquired flatfoot. The diagnosis of this stage 4 deformity is made radiographically. Look at the valgus tilt of the talus that occurs because the deep deltoid ligament is ruptured and this is a complete ankle and foot deformity. You treat it like you will a pantalar arthrodesis, you use a gauntlet. Very popular devices, very successful for advanced stage adult acquired flat foot.
We tried to control abduction of the fore foot with a flange. We use a lateral flange to prevent abduction. That surprises a lot of practitioners who always think of using lateral flanges for cavus, it’s really the opposite. We want to put a wall on this right footed AFO brace to prevent abduction of her right foot, put the wall up along the lateral column and you prevent abduction.
In severe cases of abduction like this stage 4 deformity, we will add up forefoot strap and combine it with a lateral wall to control forefoot abduction.
The shoe is critical to control abduction of the forefoot while this patient looks abducted on their AFO brace. You put him in a proper shoe, that’s a strong component of the system. The system will fail without proper footwear. So this just kind of summarizes everything I said.
Most of important thing when treating an adult acquired flatfoot is the casting technique. Here’re a couple patient videos. This is a gentleman in his 60’s. He works at Disney Land near in my office. He drives the train in Disney Land around the park. And if you visit Disney Land, go up and see him. He’s always wearing his AFO brace to work. He’s got a unilateral left side stage 2 adult acquired flatfoot. He wears it in his work boot. People are asking, “You wear this brace in a boot?” No problem at all. It doesn’t interfere with the boot. The boot actually not really necessary when you wear a brace, but in his case, it’s a safety boot.
Here’s a before. Here’s an after, before and after. Look at the position of the tibia as it changes with the brace on. That’s really a profound comparison there.
There’s an interesting guy that came in. I have a practice near the beach in Seal Beach, California. And he came in again with a unilateral left side stage 2 adult acquired flatfoot. And he told me he wanted to wear the brace and sandals because he lives by the beach. And I said, “You can’t wear those brace and sandals. You’re not supposed to be wearing sandals anyway.” When he came back for his first recheck and he’s wearing that sandals. Now this is a sports sandal, it’s a Teva sandal, and this taught me very valuable lesson about bracing. While you cannot wear a foot orthotic in a sandal very easily because it moves around in the sandal, because the brace attached to the leg, the foot plate doesn’t go anywhere and that it actually functions pretty darn well in a sandal. And so we have commonly told our female patients and male patients they can war the brace in a sandal as long as there’s a forefoot strap, such as SAS, Echo, Mephisto, et cetera.
This is one of my most gratifying cases of a woman who has combined drop foot and adult acquired flatfoot. She underwent a lumbar laminectomy and woke up after the surgery with a severed portion of here sciatic nerve, unfortunately a surgeon error, which left here with a complete dysfunctional posterior tibial musculature and anterior musculature of her lower leg. She has been given appropriately a surgical recommendation for a pantalar arthrodesis to control the ankle and the hind foot. But she’s otherwise extremely fit, active and healthy, she doesn’t want have pantalar arthrodesis.
We have a brace where we have an additional supportive device under talonavicular joint, we call it the arch suspender. And this what I fitted for to control that massively collapsing flat foot. And here’s a video of her walking down the hall in the device controlling the flatfoot and controlling the severe valgus collapse of the ankle. What’s really special about this video is you can see the outfit she’s wearing. I took this video of her right after she completed her 5-mile walk in the vicinity of my office which she does every morning in Seal Beach, quite a remarkable story for someone who would otherwise be really disabled, so here’s a before and there’s the after. You can see the multiplanar correction here of the tibia and the forefoot that’s achievable with proper bracing.
Here is one of my more challenging patients with a severe adult acquired flatfoot stage 4. The heel is about 45 degrees in valgus, the medial mallealus is almost touching the floor. And this is an interesting case because he had already been fitted for a gauntlet brace and he didn’t like the gauntlet because he couldn’t drive a car, that’s one downside to rigid, solid AFOs on the right foot, they can’t drive a car safely and so I said, “Well, I’ll make you one of our more flexible hinge braces, but I don’t know if I can control this deformity.”
But lo and behold we did. This guy did really well with that same type of brace with the arch suspender. And while his heel is not totally out of valgus, it won’t be because he has a rigid non-reducible deformity. But what’s critical is he does no pain and he’s mobile. In if he’s mobile and has no pain, I call that a success. So, here’s before and after.
And he can drive the car. So just to finish up, it’s kind of interesting to look at this from a practice management stand point.
Let’s look at this fellow here with the stage 2 adult acquired flatfoot. I’m still on private practice, so I have a pretty large surgical volume from my practice and I’m well-trained in hind foot and ankle surgery and I do these surgeries, but I tell you right now I would much rather brace these people because I get paid better for the bracing than I do the surgery. The reimbursement for that brace that I made this guy here, the average reimbursement for the Medicare is $954.
Now the typical surgical approach to a flexible stage 2 adult acquired flatfoot would be a medial displacement cancaneal osteotomy usually combined with a flexor digitorum longus tendon transfer. The total reimbursement from Medicare from that is about $40 less. But keep in my mind that after you do that surgery, for 90 days, you’re working for free on that patient every follow up visit for free for 90 days and they come in a lot after that kind of surgery because they need a lot of tender loving care
This patient, I mentioned that she probably needed pantalar arthrodesis. That brace, because it has multiple components, reimburses average on this country about $1,100. A pantalar arthrodesis which is an ambitious procedure will be reimbursed slightly more than that but what a headache and what an undertaking, and what potential for complication. And of course, I’ve never heard of podiatric practitioner being sued from an AFO brace, never heard of one. Okay, so that’s something to keep in mind.
I hope I’ve somehow opened up your mind or peaked your interest about the potential for using devices like this. If you ever have questions about it feel free to contact me, everybody gave their email address, but you can contact me through our website. I love doing patient consults with my fellow practitioners. I love talking to practitioners on the phone or via email, feel free to reach out to me. Thank you very much.
TAPE ENDS - [22:27]