Condition Description and Patient Evaluation
Degenerative joint disease (DJD) is a form of arthritis. Patients with DJD suffer from pain due to inflammation in their joint cartilage. Many times, the cartilage can be worn down completely and then lost. The Richie Brace® can relieve symptoms of DJD, particularly in the ankle and subtalar joint. Some of the most positive and life-changing experiences with the Richie Brace® have resulted from treating DJD of the ankle where no other viable treatment options have been available to the patient. The goals of brace intervention:

• Limit motion
• Decompress a joint surface

Choosing the Richie Brace® Standard

• The Richie Brace® Standard (with flat rearfoot post) is recommended for patients with subtalar arthritis.
• If the patient also has significant varus or valgus alignment of the calcaneus, add medial heel skive (valgus deformity) or lateral heel skive (varus deformity) to decompress the affected side of the subtalar joint.

Choosing the Restricted Hinge

• The Richie Brace® Restricted Hinge is recommended for patients with ankle arthritisPATIENT EVALUATION NOTE: Check for fixed equinus and adjust theangle of footplate accordingly. If the ankle mortise is compressed in varus/valgus direction, add a medial heel skive to decompress valgusdeformity or add a lateral heel skive to decompress a varus deformity. Posting of the brace in rearfoot, forefoot, or both can also be utilized todecompress frontal plane deformity of the ankle.

Choosing the Gauntlet or the California AFO
The Richie Brace® Gauntlet or the Richie Brace® California AFO are recommended when there is global DJD of the ankle, subtalar joint, and midfoot and where there is severe deformity.
NOTE: In most cases, the Richie Brace® Restricted Hinge will work just as well and offers far better shoe fit and ease of wearing.

Condition Description and Patient Evaluation
Patients have difficulty lifting the front part of the foot and the toes tend to drag across the ground when walking. Depending on the patient’s evaluation, practitioners should choose one of the following Richie Braces® for Dropfoot:

• Dynamic Assist
• Solid AFO
• Restricted Hinge
• AeroSpring Dropfoot Stability System.

Choosing the Richie Brace® Standard

• The Richie Brace® Standard (with flat rearfoot post) is recommended for patients with subtalar arthritis.
• If the patient also has significant varus or valgus alignment of the calcaneus, add medial heel skive (valgus deformity) or lateral heel skive (varus deformity) to decompress the affected side of the subtalar joint.

Choosing the Dynamic Assist
The Richie Brace® Dynamic Assist will achieve a heel strike and a normal gait pattern for patients with dropfoot if the following patient conditions are present:

• Range of motion in the ankle joint is able to reach 90° (foot to leg)
• Posterior calf musculature is strong
• Good knee stability
• Lack of hindfoot deformity
  NOTE: Stroke patients, as well as patients with common peroneal nerve injuries, meet this criteria.

Choosing the Solid AFO
The Richie Brace® Dynamic Assist is preferred for all dropfoot conditions but will fail if the following patient conditions are present:

• Knee instability
• Fixed equinus
• Spasticity
• Weak calf (consider Solid AFO or Restricted Hinge)

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Choosing the Restricted Hinge
The Richie Brace® Dynamic Assist is preferred for all dropfoot conditions but will fail if the following patient conditions are present:

• Severe varus
• Severe valgus
• Weak calf (consider Richie Brace® Solid AFO or Richie Brace® Restricted Hinge)

In these cases, the most appropriate Richie Brace® is the Restricted Hinge.

Choosing the Restricted Hinge – Dropfoot with Severe Varus or Valgus Deformity
In Charcot-Marie-Tooth Disease or other common peroneal nerve injuries, there is often an acquired cavo-adducto-varus deformity of the foot.

The varus condition combined with dropfoot requires the following prescription modifications:

• Measure tibial varum and ask the lab to bend uprights when tibial varum exceeds 10°
• Add 6mm lateral heel skive
• Add 4° valgus sulcus wedge (extended forefoot post)
• Add 4° valgus rearfoot post for extreme cases

Severe varus conditions that arise from neuromuscular pathologies often require footwear modifications such as a valgus midsole wedge.

Choosing the Restricted Hinge – Dropfoot with Equinus
When equinus is present, this condition is better controlled with the Richie Brace® Restricted Hinge.

The brace must hold the foot in the maximum dorsiflexion position that is allowed to each specific patient. This requires that the footplate be aligned at the ankle in a plantarflexed position.

This position must be measured and designated by the prescribing doctor based upon measurements of maximum range of ankle dorsiflexion available to that patient.

This requires the laboratory to make some modifications based upon the deformity captured in the impression cast. However, the STS mid-leg casting sock must be used!

Additionally, this allows accurate measurement of fixed equinus but requires the practitioner to:

• Cast the patient in a non-weight bearing position with the knee flexed to at least 45°.
• Dorsiflex the ankle to end range during the casting process.
• When this brace is fixed in equinus, a heel lift should be applied to bring the limb uprights to perpendicular. The heel lift will also aid in achieving a heel strike when equinus deformity is present.
• Remember to apply a heel lift to the contralateral shoe!

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Choosing the AeroSpring Dropfoot Stability System
In cases of dropfoot caused by stroke or nerve injury where there is no spasticity and the knee is stable, the Richie Brace® Dynamic Assist would be recommended. However, when there are neurologic conditions resulting in some degree of posterior leg weakness or contracture as seen in Charcot Marie Tooth disease, the Richie AeroSpring Dropfoot Stability System can provide additional support and improved gait efficiency.

Mechanism
Traditional solid shell plastic AFOs designed to treat dropfoot provide support primarily during the swing phase. A carbon fiber AFO (like the AeroSpring) with latearal strut can add the additional benefit of dynamic recoil during the third rocker to aid in push-off propulsion.

• Carbon fiber AFO – controls ankle joint dorsiflexion and load on Achilles tendon
• Custom functional orthotic – controls rearfoot pronantion and patented “Richie Wedge” lateral offloads the medial-central band of the plantar fascia
• Carbon fiber footplate with toe rocker – diminishes dorsiflexion of the MTPs and engagement of the windlass

The lightweight dynamic features of the Richie AeroSpring Dropfoot Stability System allows the otherwise healthy patient to engage in walking or running for exercise. Dynamic carbon fiber AFO devices have shown to improve push-off while optimizing energy expenditure during walking. The possibility for participation in sports or exercise would not be possible with most bulky solid shell AFO devices but is now feasible with a carbon fiber brace system.

Contraindications

• Severe instability of the knee; mild-to-moderate instability in the sagittal plane can be controlled with the Richie AeroSpring Bracing System.
• Severe ankle joint contracture with equinus; the Richie AeroSpring Bracing System incorporates a carbon fiber brace with a footplate aligned at 90°. Some compensation can be achieved by incorporating a heel wedge to balance equinus.

Condition Description
Lateral ankle instability is a condition which causes a patient’s ankle to “give way”. Lateral ankle instability is prevalent during activities such as running, walking, and sometimes even just standing.

Brace Recommendation
Richie Brace® Standard

Key Points of Patient Evaluation
Hindfoot Varus

• If there is NO significant varus alignment of the hindfoot, no need for any additional modifications
• If there IS significant varus alignment of the hindfoot, the following modifications are recommended:
  • 6mm lateral heel skive
  • 2–4 degree valgus sulcus wedge
  • Medial flange

Condition Description
Lisfranc (midfoot) injuries are present when the tarsometatarsal (TMT) joints tear. If misdiagnosed (as it often is), the injury will worsen and become harder to heal in a much longer amount of time. The disability can sometimes become permanent.

Treatment of the sprain, where the midfoot joints are stable with no evidence of diastasis, usually requires immobilization in a walking boot for a minimum of 8 weeks. When open reduction and internal fixation is required, the post-operative course requires up to 12 weeks of boot immobilization.

Walking boots address several deforming forces on the TMT joints but do not provide proper arch support to prevent sagittal plane collapse across the midfoot joints. The bulk and the limb length discrepancy imposed by walking boots discourages long-term use and can lead to decreased patient compliance with poor clinical outcomes.

Brace Recommendation
We recommend the Richie AeroSpring Midfoot Offloading System when patients are showing little to no positive response to traditional treatment options. This new alternative to walking boots is available for patients facing long-term immobilization after a midfoot sprain. The lightweight carbon fiber brace allows ease of ambulation while the thin composite footplate will not disrupt leg length. The brace can be loosened at the proximal attachment to allow full mobility of the ankle while driving an automobile.

• Carbon fiber ankle foot orthosis – controls ankle joint dorsiflexion and load on the Achilles tendon
• Custom functional foot orthosis – controls rearfoot pronation
• Carbon fiber footplate with toe rocker – diminishes dorsiflexion of the MTPs and engagement of the windlass
• Graduated heel wedges (10mm) – lateral offloads the medial-central band of the plantar fascia

Mechanism
The Richie Aerospring Midfoot Offloading System is designed to improve the protection of the midfoot joints provided by walking boots. While walking boots reduce load on the midfoot from the Achilles and provide a rigid rocker sole, there is no arch contour which is critical to support the TMT joints.

The new AeroSpring provides a brace to limit Achilles loading, a rigid carbon footplate to reduce bending movement across the midfoot joints, and a custom contoured foot orthosis to prevent sagittal plane collapse of the TMT joints. A graduated heel lift system further offloads the Achilles and the midfoot joints.

Severe Recalcitrant Plantar Heel Pain Syndrome

Condition Description
Plantar fasciitis is the most common cause for heel pain in adults. Additionally, this condition is CHRONIC. More than half of patients who suffer from plantar fasciitis will experience heel pain for a period lasting more than two years.

Brace Recommendation
We recommend the AeroSpring Plantar Fascia Offloading System when patients are showing little to no positive response to traditional treatment options.

Mechanism
During standing and walking, the plantar fascia is subjected to elongation strain by:

• Achilles tendon located immediately proximal
• Tie rod” component of the truss mechanism of the arch
• Tension created by the windlass mechanism at the first metatarsophalangeal joint

With severe recalcitrant cases of chronic plantar heel pain, clinicians often prescribe walking boots which address some, but not all, of these damaging mechanisms. Walking boots have numerous disadvantages which lead to poor patient compliance:

• Limb length discrepancy causing hip and back pain
• Bulky and heavy causing knee pain
• Need for removal when driving an automobile

The Richie AeroSpring Bracing System® has been developed to simultaneously address all three of three loading mechanisms of the plantar fascia. The result is a three-prong approach to minimize the mechanical strain on the plantar fascia during standing and walking.

Superior to walking boots, the Richie AeroSpring Plantar Fascia Offloading System addresses the biomechanics of foot function to reduce strain on the plantar fascia. A custom balanced orthotic footbed contours to the medial and lateral longitudinal arches. Heel wedges combined with the shank contour of the foot orthoses have been documented to offload the central band of the plantar fascia. The patented Richie ArchLock™ offloads the medial-central band of the plantar fascia.

Compared to walking boots, this dynamic brace system does not create a limb length discrepancy and can easily be disengaged for driving an automobile.