Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Foot Orthotics + ankle/foot brace vs AFO

Discussion in 'Biomechanics, Sports and Foot orthoses' started by bluefish, Sep 28, 2010.

  1. bluefish

    bluefish Member

    Members do not see these Ads. Sign Up.
    Hi Guys, could a foot orthotic + ankle/foot brace be used in place of an AFO to treat stage II to stage III PTTD (I know stage III is usually treated with surgery).

    also what are the best AFO's on the market i have looked at the Arizona , Richie and bracemasters AFO but cant decipher what are the pros and cons of each, I am not a podiatrist yet (starting studies in 2011) so my Knowledge is lacking:confused:

    This question is regarding my own PTTD. i have not talked to my own podiatrist or Physio yet but have booked in to see them but i would like to know what everyone thinks. I know, i know... worst patient ever right, doing research before my consultation.....:eek:
  2. Blue it´s all about reducing load.

    So in all realilty you can use what ever you want the quesion will be comfort and if the things you use are able to reduce the load on the Posterior tendon.

    So a base device with large medial skrive and everything else that can be though off to reduce the loads on the PT will help, as will the ankle brace which will stabilise the medial ankle - it may be a bit bulky to fit your foot into a shoe with all this - which is something to think about which is why the AFO maybe a better option .

  3. bluefish

    bluefish Member

    thanks for your insight Weber
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I disagree. It's all about the staging.

    By late stage II or stage III, the process has moved beyond 'beyond the foot' and into attenutation of the superficial and deep deltoid, hence becoming an 'ankle problem' too.

    If you are at stage III one must consider medial ankle stabilisation via bracing (I prefer a Richie brace). If things progress to stage IV and there is true ankle valgus, then, to put it politely, you're f**ked. Triple arthrodesis +/- ankle fusion awaits you.

    Be aggressive and deal with the frontal plane of the ankle before its too late. Foot orthoses alone are not enough.

  5. bluefish

    bluefish Member

    Thank you very much Luckylis your comments are very clear and concise, it makes it easy for a noob in the podiatry world(Like me) to understand.

    I love your ending comments
    "If things progress to stage IV and there is true ankle valgus, then, to put it politely, you're f**ked. Triple arthrodesis +/- ankle fusion awaits you."

    this sounds brutally true but with a tinge of humor to lighten the daunting possibility of a Triple arthrodesis :eek:
  6. David Smith

    David Smith Well-Known Member


    This article from 'Podiatry Today' that I had on file might be useful

    Selecting Appropriate AFOs: Key Considerations And Modifications
    VOLUME: 16 PUBLICATION DATE: Oct 01 2003
    Issue Number:
    Clinical Editor: Nicholas Sol, DPM
    When weighing the options for ankle foot orthoses (AFOs), you must consider many different factors in order to find the most appropriate device for the patient. Both hinged and non-hinged AFOs work well for patients with certain conditions but not so well for others. In addition, shoe modifications may be necessary in order to help ensure the success of the AFO. With these issues in mind, our expert panelists take a look at the ins and outs of prescribing hinged and non-hinged AFOs.
    Q: What are the three or four most frequent diagnoses for which you prescribe a non-hinged AFO?
    A: Nicholas Sol, DPM, and Doug Richie Jr., DPM, both prescribe non-hinged AFOs for Charcot arthropathy. Dr. Richie also uses non-hinged AFOs to treat Charcot-Marie Tooth Disease, cerebral palsy and dropfoot secondary to CVA. Dr. Sol also prescribes these orthoses for post-CVA patients and those who have post-traumatic stress arthrosis and multiple sclerosis.
    Lawrence Huppin, DPM, says non-hinged AFOs reduce or eliminate motion at the ankle joint and he frequently uses these orthoses to treat DJD of the ankle joint. The reduction or elimination in ankle joint motion can also lead to reduced subtalar joint (STJ) motion, points out Dr. Huppin. He adds this effect makes a fixed hinge AFO appropriate for some cases of STJ DJD and tarsal coalition.
    When confronted with situations in which a dorsiflexion assist hinge would not be appropriate for dropfoot deformities, Dr. Huppin says he will prescribe a non-hinged AFO.
    Dr. Richie says his goal in almost every solid AFO prescription is stopping contracture of the posterior calf heel or musculature cord, stabilizing the knee if the soleus is weak and decreasing plantar pressures of the fore- and midfoot. He notes a solid AFO leads to a loss of plantarflexion of the ankle during the contact phase of gait, causing an “abrupt anterior displacement of the tibia and a somewhat severe flexion moment at the knee.” Adding a rocker sole to the shoe can minimize this problem, according to Dr. Richie.
    Q: Of the three types of non-hinged AFOs (solid ankle, semi-solid ankle and posterior leaf spring), which do you prescribe most often and why?
    A: Primarily, Dr. Huppin prescribes functional AFOs such as the ProLab AFO, Richie Brace, Platinum Brace and other devices. These function by connecting the functionally balanced foot orthotic with medial and lateral ankle/leg uprights. As he notes, “balanced foot orthoses offers superior control over subtalar and midtarsal joint motion while the double uprights prevent internal leg rotation. The hinge can be flexible or fixed.”
    However, Dr. Huppin prescribes the Arizona AFO or another kind of gauntlet-type orthotic if the functional AFO does not provide enough support for a patient.
    The posterior leaf spring is the most common non-hinged AFO choice for Dr. Sol, who notes that its smaller mass facilitates a better shoe fit profile than other orthotics. If he needs increased durability or stiffness, Dr. Sol says he usually reinforces the posterior leaf spring with carbon graphite, which he notes offers many advantages. However, Dr. Richie points out some disadvantages to using posterior leaf springs, arguing they do not provide sufficient knee stability and do not resist equinus contractures well.
    Dr. Richie prefers using a semi-solid AFO design since its trim lines behind the malleoli provide better shoe fit. He emphasizes that he gets good varus and valgus control with the contour of the footplate. He has found solid AFOs do not have such varus/valgus foot control. He has also discovered malleolar irritation and problems with shoe fit in solid AFOs and does not like their trim lines, which are wide and bulky. Dr. Sol says he only orders semi-solid or solid ankle AFOs in extreme cases.
    Q: What are the three or four most frequent diagnoses for which you prescribe a hinged AFO?
    A: Drs. Richie and Huppin each use hinged AFOs for adult acquired flatfoot secondary to posterior tibial tendon dysfunction (PTTD) and lateral ankle instability. Dr. Sol uses them for PTTD, spastic ankle equinus and neuromuscular disease.
    Although adult-acquired flatfoot is “by far the most prevalent” condition for which Dr. Huppin uses a hinged AFO, he also utilizes these devices for subtalar joint DJD. Dr. Richie uses the hinged AFO for peroneal tendinopathy and employs them with dynamic assist hinges for dropfoot if there is no specificity of the calf.
    Q: Which types of hinged AFOs do you most frequently prescribe and why?
    A: Dr. Richie touts his own Richie Brace®. “This short, articulated AFO with a balanced podiatric orthotic footplate can address almost all of the conditions previously treated with long leg hinged AFOs,” he says. “The advantages are comfort, fit, cosmetic appearance, shoe fit and improved frontal and transverse control of the ankle-rearfoot complex.”
    Likewise, Dr. Sol uses the Richie Brace or another freely articulated AFO for PTTD. To brace for spastic ankle equinus, he utilizes a tension reducing ankle foot orthotic (TRAFO), which he describes as “an articulated semi-solid AFO with medial and lateral adjustable limited motion joints.”
    Dr. Sol will usually prescribe either a single or double upright for patients who require spring assisted dorsiflexion or plantarflexion. He says he does this because he has been “disappointed by plastic AFOs with integrated joints that neither provide enough torque nor endurance.”
    Q: What shoe modifications do you most frequently prescribe for use with an AFO?
    A: All three panelists advocate using rocker soles in some instances. Dr. Huppin uses various heel-to-toe rocker soles for those with ankle DJD.
    “Prior to getting the AFO, it is imperative patients understand that they are likely going to need new shoes to fit the device and that modifications to those shoes may be necessary,” maintains Dr. Huppin.
    To that end, he gives his patients a list of stable shoes that work well with the AFOs. For example, when Dr. Huppin treats those who have PTTD, he’ll add a medial buttress and medial flare to shoes for additional control.
    Dr. Sol’s most common modification is a 3/8-inch double rocker sole for those with non-articulated ankle foot orthoses.
    “The rearfoot rocker helps smooth loading response and relieves the knee from excessive shock,” he notes. “The forefoot rocker assists during the propulsive phase of gait and enhances hip extension, thereby reducing the load on the hip flexors.”
    The rocker sole is the only shoe modification that Dr. Richie uses. He says he mainly prescribes this with a solid AFO because the abrupt flexion and extension moments transmitted to the knee during contact and heel rise can be “a great concern” with these AFOs. According to Dr. Richie, research has shown that if you use a solid AFO with shoes that have a rocker sole, you can reduce damaging knee moments.
    Since post-polio patients commonly have a leg length discrepancy, he recommends using an external shoe lift instead of applying a heel lift to the solid AFO.
    Dr. Sol (shown at the right) founded the Walking Clinic, PC and practices in Colorado Springs, Colo. He is a consultant to Tekscan.
    Dr. Huppin is an Adjunct Associate Professor and Assistant Chairman of the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is also the Director of Education at ProLab Orthotics.
    Dr. Richie is a Director of the American Academy of Podiatric Sports Medicine. He is also an Adjunct Clinical Professor of Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College.

    Dave Smith
  7. Not sure how you can disagree without load no or less pain, but I will agree that the stage of the tendon breakdown will effect how you go about reducing load, if an orthotic, AFO or operation the hoped outcome is to reduce load on the stressed tissue.

    so it´s all about load in relation to stage of tendon breakdown.
  8. Guito

    Guito Member

    Hey Bluefish

    I am currently treating a patient in her late 60's with stage II PTTD and have tried high control orthotic, heel raise and figure-eight style donjoy brace. The patient's pain has improved but her pain is not responding as well as I hoped and need's more aggressive control. The next step is a Richie Brace. I was considering a cam walker but I think a Richie Brace is a better long term option. Th pt has sciatic nerve motor compromise and genuvalgus also.

    Knowing that the prognosis of this condition is generally poor past stage II, I agree with LL that you need to treat it aggressively in the early stages to give it the best chance
  9. gaittec

    gaittec Active Member

    From a dispenser's perspective, the Arizona fits more securely, has better control, and very good comfort. The Ritchie, is comfortable, easier to adjust on the fly, and gives reasonable control for most patients.
  10. bluefish

    bluefish Member

    Thanks David that article is really great as it addressees a few questions that i have been wondering about eg; hinged AFOs, appropriate shoes etc.. it does seem that people have many different opinions and methods regarding the treatment of PTTD.
  11. Guito

    Guito Member

    Are there any Australian orthotists making Arizona AFO's or is the best way to have them made in the USA?.
    Does anyone know an approximate cost of a std Arizona AFO?
  12. BAMBLE1976

    BAMBLE1976 Active Member


    I am an orthotist working in the uk and have done quite a bit of work with later stage PTTD. As mentioned previously you have to concentrate on the frontal plane control. Depending on the amount of function you still have at the talo-crural joint and how separated your talo navicular joint is with degree of forefoot abduction present, this should lead to youor orthotic prescription. Certainly in the later stages a rigid afo is indicated over an arizona etc due to the more rigid material and the longer lever arms that can be used in the design to reduce the point loading forces. Also I prefer a rigid afo over a hinged as you can get the medial force of the frontal 3 point force system closer to the medial malleolus for optimum force distribution. My opinion would be dont second guess it and get yourself properly assessed before it progresses!!!!
  13. bluefish

    bluefish Member

    Thank you Bamble.
    all the info people are sharing is great and its nice to hear from an orthotist's point of view.

    I am hoping to get an appointment to see my Physio and Podiatrist this week. i may even show them this thread as im sure they would find it helpful.
  14. efuller

    efuller MVP

    It is very hard to predict what device will work best for each person. On the one hand you have the wants/expectations of the patient. These can vary from they just want something to reduce symptoms a little bit and be able to walk around in "normal shoes" to being able to take long walks. Another variable is the amount of "dysfunction." It would be tough if you were forced to make the choice of only one of the above. It would be great for you to compare them all. For some activities you might choose one device, for other activities you might choose a different device.

    Good Luck,

  15. bluefish

    bluefish Member

    Eric your reply although less clinical than some of the others is useful, and by your statements it sounds as if you are a very caring Pod...:D
  16. 56Furman

    56Furman Member

    In my experience it may difficult to get adequate shoe-orthotic-OTC brace fit. I often had to do a fair amount of spot heating and grinding of the OTC ankle brace to get it to seat well with the orthotic and align with the patient's malleoli. Which is why foot orthotic + OTC ankle brace will be OK for the short term, but for PTTD II a custom AFO is the way to go.

Share This Page