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Hello All,
I have a female px, 50 year old, history of surgery to L3/ L4/ L5. She presented with bilateral pronation of the midfoot and ankle, weak dorsiflexion and inversion, worse on the left. I have supplied custom orthoses which have corrected the right foot well, and the left slightly. A medial heel wedge on the Left foot under the orthoses made minimal difference. The left ankle is tending to evert over medial the side of the shoe.
I have not yet tried a rigid polyprop type ankle brace that limits inversion/ eversion, has anyone else used these & have they been succesful?
She does not really need an AFO, the dorsiflexion is adequate, but there is no foot inversion against resistance of the left.
I have advised strengthening exercises for the inversion/ dorsiflexion weakness & will investigate trigger points in the relevant muscles & antagonists next visit.
Further suggestions most welcome.
I am in Aus, do Occupational Therapists make custom braces of this type?
Cheers,
Kara.

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Kara,

An Orthotist is the best person to make a custom brace as you have described.
Check their professions website for a local

http://www.aopa.org.au/

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Stephen Tucker
Calvary Health Care

My location

Hi Kara,

The range of bracing available is enormous for this type of problem and is a comprimise/balance between functional loss/cosmesis and weight. A good orthotist should be able to run through all the potential options with both you and the patient

Just a point of note(and I realise that I am probably stating the obvious here) - medially wedging the heel will not, in itself, improve inversion (nor dorsiflexion) in swing phase. That being said, mechanically advantaging the tib ant muscle by increasing the distance from the sub talar joint axis to the insertion of the tibialis anterior tendon may improve it's strength in the swing phase. Will it be enough? Only trial and error will tell you that and it depends on the terrain/footwear and activity level of the patient.

I use everything from foot orthosis to control frontal and transverse plane problems in addition to a foot up style brace http://www.ossur.com/?PageID=13530 as a very lightweight option to rigid AFOs for maximum control right up to SAFOs http://www.dorset-ortho.com/orthotic...products/safo/ to give a cosmetic solution that can be worn barefoot or with a sandal/thong. If necessary, it can be used in conjunction with an anti pronation sandal http://www.schollorthaheel.com.au/sa...gs/womens/tide or http://www.aetrex.com/categories/Wom...rt-Collection/ (the aetrex sandals are excellent as the footbeds are very customisable although I have had little requirement for customisation as the generic shape is usualy sufficient.

As I said, a good orthotist is probably your best route but these are just some suggestions

Good luck

Robin

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Why not try the less expensive and more "customer friendly"approach of a good quality ankle boot(lace up) first?

Here is a link, http://www.bilbyshoes.com/page5.html go down to the product "Commander" a solid lace up boot with a full length zip on the inside and a 4mm removable foot bed to allow your orthosis to fit into.

There are other products around, but this is a good example of what l am talking about, they may feel better in a hiking type boot?

Maybe a small medial flare could be added later if need be

__________________
David Sutton
C.Ped.CM.Au
Facebook
My location
www.bilbyshoes.com

Hi Kara,

Have you seen the range of Richie braces? These are podiatric AFOs which are far superior to most traditional AFOs. Check out richiebrace.com or qol4feet.com.au (the Australian manufacturer) for a treatment guide. If you patient doesn't have drop foot, perhaps a standard Richie brace would be suitable. If there is some flacid drop foot, a dynamic assist would be suitable. You can cast for this type of AFO in your clinic (it's really similar to how you would cast for a standard foot orthotic) and fit it into normal shoes.

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Cheers,
Kent

Performance Podiatry & Physiotherapy

My location

Interesting statement. How so?

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I see you girls checkin' out my trunks
I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps

Hi Robin,

The Richie brace is a custom AFO produced from non-weightbearing suspension cast of the foot and ankle. It has an articulated footplate with medial and lateral leg uprights. It preserves what we know works with podiatric foot orthoses (casting, balancing FF deformities, locking the MTJ, reducing supinatus, maximising 1st ray function etc.) and combines it with a bracing element. You can also incorporate modifications such as medial heel skives.

I find patient acceptance to be much greater as it is more comfortable (e.g. less irritation problems) and it's a lower profile. I would estimate that about half of the patients I've put into a Richie brace have been previously wearing a traditional posterior leaf AFO and all of these patients are more comfortable in the Richie brace.

__________________
Cheers,
Kent

Performance Podiatry & Physiotherapy

My location

Now I'm confused. Are we distinguishing between "podiatric" AFOS and "traditional " AFOs? I was quite enjoying this discussion for a while..........
Surely it doesn't matter who fits the AFO, an orthotist or a podiatrist, as long as the prescriber has the relevant experience and training. In the UK, this is most likely to be an orthotist, I would imagine, but saying that I have seen bad AFOs from orthotists, physios and podiatrists alike.

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