In 1996, after 15 years of sports podiatry practice, Douglas Richie, DPM, was frustrated by the ongoing challenge of fitting sport ankle braces to patients who also wore custom foot orthoses. The two products should have worked naturally together, but, because neither was made with the other in mind, the result was often ungainly and uncomfortable.
“I didn’t really know anything about ankle foot orthoses at the time, but no podiatrists did,” Richie said. “Only about a hundred AFOs were prescribed by DPMs via Medicare that year. We weren’t taught about the devices in school, and when we were in clinical practice we didn’t have relationships with vendors who could supply them.”
The situation has changed, obviously. According to Richie, roughly 40,000 custom AFOs are now prescribed annually. One reason for the increase, of course, is the Richie Brace itself, which he developed and launched in 1996. Today Richie Technologies, Inc., based in Seal Beach, CA, offers a line of nine braces.
The original Richie Brace, which still accounts for 85% of the company’s sales, offers a nonoperative approach to pathologies such as chronic ankle instability and mild to moderate posterior tibial tendon dysfunction (PTTD).
“When doctors initially started saying they wanted to use the brace for PTTD and severe ankle deformities, I was skeptical, because I considered it a sport brace for athletes,” Richie said. “But I kept hearing how effective the brace was for PTTD, so I worked with several people, including certified orthotists, to improve the original design and develop new models for specific pathologies.”
The restricted-hinge variation of the basic brace is designed for patients with degenerative joint disease (DJD, typically osteoarthritis) of the ankle or rearfoot. It’s also used to treat foot drop as long as the patient has a stable knee.
“Patients who’ve had severe ankle fractures often progress to arthritis, for which the only remedy is surgical fusion,” Richie explained. “But for some people, particularly younger patients, that’s not a great option. Some of the best testimonials on our website come from patients with severely arthritic ankles who’ve achieved significant pain relief with our braces.”
Richie offers two other braces for foot drop conditions: the Dynamic Assist (for patients with foot drop without equinus, absent spasticity, with stable knees; as well as those with peroneal nerve injury, poststroke, or postcerebral vascular accident), and the Richie Solid AFO (for those with severe foot drop with spasticity and/or unstable knees).
The Dynamic Assist offers two spring-like hinges, one medial and one lateral, to provide up to 15° of dorsiflexion.
“In all bracing, the goal is to preserve joint motion,” Richie said. “Any orthotist would rather treat foot drop using a device with a dynamic hinge. But if the patient has an unstable knee, you can’t let the ankle move; then you need a solid AFO. You also need a solid device in cases of spasticity or contracture, such as in multiple sclerosis or cerebral palsy.”
Richie offers the Gauntlet and California AFO models for more severe problems such as severe joint disease, Charcot arthropathy, or Stage III and IV PTTD.
There are also two patented models, the Medial Arch Suspender and the Lateral Arch Suspender, that use straps to suspend the arch, medially or laterally.
“The lifting strap can correct severe sagittal plane subluxation of the talonavicular or calcaneal-cuboid joints,” he said. “The idea is to provide the support of a gauntlet while avoiding the usual bulk.”
Richie sees two trends that may significantly affect how his braces, and similar products, are prescribed. The first is the ongoing development of low-cost scanners that could make casting obsolete.
Such devices now cost up to $20,000 if they scan both the foot and the leg, which makes them affordable for central fabricators but prohibitive for podiatry practices. Richie thinks that within a few years they may cost a quarter of that, which would be a game changer.
One problem, however, is that casting offers clinicians an easy way to make corrections before fabricating the AFO, whereas equivalent compensations using a CAD-CAM system are just now becoming available to fabricators.
“Fabricators or labs have been able to correct varus and valgus easily if they have a plaster model,” he said. “When they go to CAD-CAM, they’re scanning a negative cast that the doctor has sent in, which streamlines the process. But those systems are just starting to make varus and valgus corrections possible, and they’re still not ready for use in an office to scan a patient.”
The second trend is likely to be increased scrutiny of insurance and Medicare reimbursement rates for AFOs. In response, Richie may develop a “library system” of off-the-shelf devices. The company already offers two off-the-shelf braces, but a more comprehensive library, such as that offered by some in-shoe orthosis manufacturers, would offer near-custom fits at about a third the price of custom.
Cary Groner is a freelance writer in the San Francisco Bay Area.