The MOSI Archies

Transcript:

Hi everyone craig payne here i just want to talk to you about a little trick that i’ve developed with these things. These are the Archie’s thongs. Now we call these thongs in Australia, jandals in new zealand and flip-flops in the rest of the world, but these come with an arch support built into them and we sell them like hot cakes in the clinic pretty much everyone who tries them on likes them. The problem is with any arch support or any or even in these or in the orthotic. If that arch support pushes right where the subtalar joint axis happens to be that they can actually be uncomfortable or even worse, if the subtotal joint axis is very medial, the actual arch support area is on the lateral side of that joint axis and there’s actually a Pronatory moment at the subtalar joint, so that’s not exactly a desirable thing.

So what i want to show you? What i do is what i’ve done with some of these now this is my daughter steffy who who’s volunteered to be a participant in this little demonstration. Now i’ve made no secret of my of being a bit of a fan of the MOSI, the medial obliques of subtalar inclination, um, foot, orthotic or design feature in foot orthotics and combined with that. The importance of the subtalar joint axis and prescribing foot orthotics because, as you’ll see in this foot here it’s actually quite the access is quite medial. So what i want to try and do is incorporate a MOSI design feature into these Archies to try and um one make them more comfortable and probably perhaps more effective.

So the first thing i’m going to do is work out where the subpaler joint axis again. This is not a lesson on how to find the subtitle to a nexus, there’s plenty of information available elsewhere on that. This is also not a lecture on the MOSI design feature um, there’s plenty of information on that elsewhere. I have a whole lesson in my online clinical biomechanics boot camp sort of on this mozzie design feature. But if i was to try and palpate steffi’s subtotal joint axis, it’s here um, you know you can see that.

So this is the area where we want the design to work and if you even just look at the, even though i promise this isn’t a lesson on mozzies, you can see this whole area here of the arch is on the lateral side of the axis. So i’m going to mark this quite sort of with this felt, pin there’s a little ticklish and we’re going to put there put the arches on the foot and then what i’ve done. You can see i’ve just transferred that sub taylor joint axis of hers onto the device. So let me just stop the video here i’ll go and do something and then come back and then show you what i’ve done. Okay, so you can see what i’ve done here.

The first thing i’ve done is just i’ve used. I’Ve used a gray, eva and i’ve. It’S a about five six mil thick and i’ve glued it on on the medial side of that line. Now don’t forget that line that i drew is going to be different in everyone’s foot. It’S going to be in a different place, so you you’d move it around now i did have to heat up the eva to get it to fit into the curvature.

So what i’m going to do now and i’ll go ahead, and do this and come back is just better shape it and finish it so that we’ve got more load on the medial side of the subtalar joint axis now, combined with a bit of arch support that Come in these arches combined together are going to give a much more comfortable and a much better control of stiffy’s foot. Okay, so you can see what i’ve done here now. I’Ve done it in grey um, because i want you to be able to see it now. If i was doing this for a patient, i’d use, a white, eva arches come in a whole range of different colors, so we have a lot of different eva that will we’ll shape. So you can see how you know: i’ve ground that edge, smooth we’ve smoothed off that edge so stiffy wearing this.

We just put it on um. You can’t actually see from behind, but you can see what’s happening. Is we’ve got an extra force or or low on the medial side of that subtable joint axis? So can we just look so hopefully you find that as a useful design, design feature that you can add on to products like these that actually helps those ones that are not comfortable, because the arch area pushes right on the joint axis, and i think we just Know from experience with foot orthoses that, if there’s just too much force right where that subcover joint axis is it’s just uncomfortable um or as in steffy’s case. The arch here is actually on the lateral side of the sub-television axis.

You can buy the Archies online here and see them here at a stockist in Melbourne.

PodChatLive Episode 92 with Doug Richie [The Richie Brace]

Uh welcome everyone and uh. Thank you for joining us if you’re joining us live or what you’re listening after the fact, um we’re here on 29th of april 2021, recording episode, 92 of podca live and we’re super excited that uh dr doug richie, has joined us thanks for joining us, doug uh. He is tonight’s topic of conversation, is the eponymous richie brace, which you may well be already prescribing. You may well be very familiar with. You may have heard of it uh, but you’ve never really dipped your toes in those waters uh or you may have never heard of it before so we’re gon na sort of start at the beginning and give people the whole the whole package of of information.

If you are watching and you’ve got any questions for doug or comments, uh, please fire away and craig will bring them in at the appropriate time. So, by way of looking rather prepared, which is rare for me, i know a few facts about the richie grace before we asked doug to to give us some of his his insight on it. Um it is its 25th uh anniversary. It was first prescribed by one lab in the u.s in illinois in 1996, and i believe at that time there were fewer than 500 afos per year being prescribed in in the u.

fast-forward 10 years on from there, and by 2006, there were 30 000 afos being Prescribed per year now, of course, not all of those were richie braces, but i think we shouldn’t sleep on what a catalyst and what a part of that that that surge, um, the richie grace probably was – and it’s now available in in seven countries, including the uk And including australia, so the first question we should probably start with doug is just how enormous is your house? No, no i’m joking could do. Would you uh? Would you be kind enough to take us back to the years just prior to 1996?

Because, obviously, if that’s when it was first prescribed, we all know that there would have been many years of of heartache and thought process and prototype that you were going through, probably early 90s up into mid 90s.

Do you mind just giving us an insight into where your head was at, with with this in general, with what you were trying to achieve? Was it? Was it a a sort of uh general unhappiness with the way afos at the time were what sort of led you to this invention? Yes, um at that time, uh i was in private practice. My practice in california focused heavily on sports medicine, and so, as a result, i was treating a lot of ankle, sprains and ankle injuries and i would often use the popular uh air cast or air stirrup, brace as a remedy uh or an immobilization for these patients.

That would come in either with an acute ankle, sprain or even with tendinopathy around their ankle, and the air stirrup was an effective device because it was easy to put on and off. But i found often that these patients were also wearing foot orthoses and when they would put, i would fit them for their air cast and then they would put it inside their shoe. Suddenly there was a conflict with the existing foot orthotic and they would say to me i guess i’ll have to take my orthotic out of the shoe and, i would say yeah, that’s probably necessary. But what a shame i don’t know how we’re going to make this work, and i, like many practitioners, had this vision. What if we could connect an air cast stirrup to their foot orthotic, but i never took it any further until one day, and this is really one of those great accidents that happens in life.

But a sales representative came to my office with a articulated sport, brace that was a flat foot plate, but it articulated to stirrups that looked like an air cast – and i said boy, that’s an interesting design. Is it possible to make that foot plate more custom contoured to the foot and he said well, i don’t think there’s any benefit to doing that. Why would you want to do that and i said well, maybe i should talk to the owner of your company and i that company was owned by a small. It was a small company located in southern california, and i was able to partner with that company initially with some of the design and prototype testing, and we actually shared the technology together and shared the licensing rights to it. When we took it to pal, which was a large podiatric lab to really carry forward the product development and the testing, the key was integrating the benefits of a custom.

Semi-Rigid foot orthosis with this ankle support and it actually wasn’t as easy as as we thought it would be, because you have to do expansions and modifications of the positive cast up and around the malayalam in a way that none of us had ever done before and Going that high above the normal heel cup of an orthosis, so there was a lot of trial and error until we finally felt confident enough to launch the product. But it wasn’t. I would say it was a two-year process, ian and uh. It definitely was born out of a necessity that i saw early in my career, but actually quite by accident. The actual idea came forward for me in a real life situation.

Yeah. I love it when those accidents uh just completely change your entire career. It hasn’t happened to me yet, but i’m still, i’m still waiting for my moment for people that haven’t um, perhaps seen the brace. I think craig’s got a picture, he can pull up and we should probably mention at this point when we talk about the richie brace we’re not just talking about one brace. So could you just speak to some of the different and we’re going to come on to talk about uh sort of certain pathologies that they’re useful for in due course, but at the moment, could you just speak to some of the different models that are available and I guess the key differences between them for those that aren’t familiar sure.

Well, you know when i introduced quote d: richie brace it was the model you see on the left hand, side of that screen, it was, and it now is known as the standard brace it was really designed for that patient. I described earlier an athlete with chronic ankle instability who wanted to wear a functional brace day to day or specifically during sport. That would contain the foot arthrosis, but also fit properly in a shoe and not be real restrictive of their movement, particularly in the sagittal plane, and that’s how we introduced it. It was a sports phrase. Um.

It was not long into the product launch. The podiatrist came to me, they said hey, i put it on a patient of mine with a posterior tibial, tendon rupture and it was phenomenal the way it controlled the foot and leg, and i i actually told them. I thought they were crazy. I said: that’s not what it was designed for, and they said well you’d be surprised how well it works and we started going back and looking at it and realizing. Why not and we actually started incorporating enhancements in it like a medial heel, skive uh, flanges, uh, actual posting in the rear foot uh extended four-foot sulcus wedging to really try to control that severe pronatory force through the adult, acquired flat foot and and that’s when it Really took off, and today uh, i would say, 80 percent of our prescriptions are for posterior tibial tendon dysfunction, ie adult acquired flat flatfoot about six years into it.

An orthotist came to me and said: have you thought about putting tamarack hinges on your brace to use for drop foot conditions? I said: what’s a tamarack atkins i’d never heard of that. He showed me – and i said well, let’s figure out how to do that, and that was a little bit more of an engineering process to mold it onto the brace with cavities and things. And lo and behold we had a drop foot, brace that was far more preferable to patients because of its low profile and again its ease for fitting in a shoe. And so, as the years went on, we kind of responded to our input from our clinicians.

And we came out with an enhanced version for posterior tip dysfunction, which we call the arch suspender, and then we also came out with our own version of a gauntlet style, brace which are very popular here in the states. The the prototype is known as the arizona afo, and these are a solid afo with a leather enclosure which, with laces, to secure the foot and ankle into this brace and provide a much more rigid control for more advanced stages of adult acquired flat foot and for Severe arthritic conditions of the foot and ankle, and so we kind of responded to what the industry was offering and also what our clinicians were asking us to do. So i think today we have about eight different afo braces uh, some that are very similar to solid afos with some modification and then some that are simple modifications of the original standard, ritchie brace yeah, and we will put a link to your your site with so People can go there and spend more time. The one thing i’ve always enjoyed about your site is how much detail there is and how much guidance it gives people with regard to when perhaps to choose between the braces, depending on the the patient or the context in front of you in clinics. So we’ll make sure we link uh to that.

I love the story about you being sort of reticent or resistant to people using this for to post pathology when, like you’re saying, certainly my interpretation is that’s, that’s the lion’s share of it or the key number. One thing we tend to give it for now and i love the fact that uk brought this to market saying this. Is my sports brace, you know almost disco. Would you go as far to you? You were discouraging people from from using it for that pathology?

Oh yeah, i love that you mean for posterior tip yeah yeah, oh yeah. I was for a lot of reasons. I i was worried about how well an elderly patient would ambulate with a more restrictive device like this. Even though orthotists were prescribing much more bulky solid afos already, but to me it had we hadn’t gone into this uh territory and an elderly patient wearing a respective ankle, brace uh was a little bit uh daunting to me in my mind. Until we tested it, we actually chose a few offices with practitioners that we trusted and we had them do kind of a pilot study.

And lo and behold we didn’t have problems and we actually had extraordinary outcome. Uh. To give me a complete about face on that perception, so let’s talk um pathologies, the richie brace may be something that a clinician would or should consider um, and certainly the the mount rushmore of pathologies for the ritchie brace for me are posterior. Tibial tendon dysfunction. Foot drop the two you’ve already mentioned: uh rear foot, midfoot, osteoarthritis, degenerative change and then uh, i guess chronic ankle instability.

Would they mirror your big four? We missed any glaring pathologies. We should be thinking about this brace, for you know um. I would say 15 years ago you would be spot on with that, but i would say, with the emergence of tendinopathy conditions, almost being an epidemic proportion we’re seeing practitioners using it for perineal tendinopathy, tibialis, anterior uh, even achilles, which i’m not so sure the brace is That specific for, but i would say tendinopathy conditions, seem to be more popular than chronic ankle instability that there’s a big misperception that patients with chronic ankle instability need greater mobility, more range of motion, more proprioceptive and balanced training, which i agree. But it doesn’t mean you can’t apply functional bracing to them at the same time, you’re going through these rehab protocols, because i think functional bracing, only augments, all that it doesn’t inhibit.

Unfortunately, many practitioners, particularly physios, don’t see it that way interesting, so people are prescribing the brace uh over a very short period of time for the first sort of tendinopathic uh issues versus perhaps a more longer standing issue. You know if you, if someone with a foot drop, comes in or you’re, probably setting expectation that this may be a part of their life for the foreseeable future, if not, if not all of it. But what sort of timeline are people prescribing richie braces on for tendinopathies? Yeah? That’S a great question, so you hope that the tendinopathy resolves three to six months, maybe sooner um.

I think it’s worth the investment for the brace uh. The brace is not cheap uh. In the united states it sells for upwards of seven eight hundred dollars uh. So to justify that you’re, you probably are looking at a condition that requires three to six months of treatment. I would say if you think this is an early stage tendinopathy, you might manage it with the more traditional methods, even a walking boot or a taping or other more temporary immobilization.

I will point out that uh, what we’ve learned and what has been borne out by other researches tibialis posterior dysfunction, uh adult acquired flat foot, can become more asymptomatic with long-term treatment, with a ritchie brace such that those patients also move out of their base and are Controlled with traditional or more aggressive foot orthotic therapy, perhaps after one year of daily use in my experience in my own clinical experience, 50 of my patients would discard their richie braids, but they would be obligated to wear appropriate footwear and more aggressive. You know inverted orthoses um, you know all the other tricks and bells and whistles we would employ for traditional orthotic therapy for posterior, tib dysfunction, yeah and that’s a lovely sort of linking so what we, the three of us, were really briefly just talking about before we Went live, which is uh. We should say it now for anyone listening that that clinical decision um process that we all go through, and perhaps you could give us some insight as to how you your reasoning when we’re we’re trying to decide. Let’S say in the case of a posterior, tibial tendon dysfunction at what point should we be thinking about the brace versus when we’re thinking, okay, get into a stiff, walking boot with with a varus posted device with a big, medial heel skype? What’S the tipping point at what point do you decide if this person just needs good footwear and foot orthoses versus this person would probably be a really good candidate for the brace great question?

First of all, um we see we see posterity dysfunction in two clinical presentations. The first is the patient, who has already been to several practitioners and is bouncing around because often this is a challenging condition and for whatever reason, they’re not getting better and oftentimes. They already have a foot orthosis that is not adequately treating it. That’S kind of a no-brainer, because now you can go to the ritchie brace, that’s the next step, but on the other hand, the patient, who is being diagnosed for the first time in your clinic, who presents with a very painful swollen ankle all the clinical signs of A collapsing progressive, adult acquired flat foot therein becomes a challenge into how do i start and which patient is going to fail with the foot orthosis and which patient should really appropriately go right to a ritchie brace. I would say first of all, there’s no harm in trying a foot orthosis first, because there are some cases where i was surprised.

The patient actually responded very well and didn’t need to go to the ritchie brace, even if they fail with the foot orthosis. That device could be useful, nine months to 12 months down the line when they okay, they’re, moved to a ritchie brace, but hopefully they’re going to go back to the foot orthosis later i would say, though, to cut to the chase. I think it’s very difficult to know on the first clinical visit that which patient is going to require an afo, because often their acute symptoms conclude your ability as a clinician, to really grade the severity of the condition to stage it appropriately in stage one through three And i often will just temporarily mobilize them with a strapping procedure, sometimes with a walking boot and sometimes with a even a short leg, cast calm these symptoms down and then go through an evaluation process to see what stage they’re in and, if they’re, in stage two Deformity, meaning there’s asymmetry, one foot has visibly collapsed more than the other and they cannot do an independent toe raise on the affected foot. In my experience, they do much better going right to a ritchie bridge if they cannot perform an independent toe, raise, usually a standard foot. Orthotic therapy is going to fail.

So if i were to say that’s the one, the deciding factor that would be it great craig. Any questions on uh facebook before i press no, no, no nothing to bring up at this stage. Okay, i’m just putting myself i’m trying to put myself in the in the position of someone who’s, uh, really unfamiliar with the brace and just trying to walk them through sort of uh the journey. So in clinic we might see, we see a patient. We may make a decision about whether we need the brace.

Let’S talk about uh, an assumption that we’ve made where we’ve got a patient in front of us. We are deciding okay, we’re going to try richie brace for the first time, um a couple of things when i’ve spoken to students that have shadowed me or you know, undergrads – that they get really really nervous about um and the first is well. I don’t know how to cast for it. Now. I’Ve heard you speak about this uh several times before doug and one of the things i i really enjoyed hearing you say once was like.

If you can cast for football fosees, you can cast for a ritchie, brace and obviously there’s subtle differences. But i’m asking you a sort of two-part question. The first is: could you just explain to someone who uses plaster of paris um who regularly casts the football photos? What they would have to do to cast for a ritchie, brace and the second part of that is, i know many of our colleagues have moved away from plaster of paris into more sort of uh. App-Based scanning based models of negative impression capture.

Is that something that leads itself to which you break prescription as well? Yeah great question cast you’re, absolutely right. If you can cast for foot orthosis or scan for foot orthosis, you can do the same for ritchie breaks. If you choose to use plaster. The pictures craig is showing there on the upper line of pictures you’re simply going to apply a trip, a standard slipper cast with plaster, but in the case of the ritchie brace you’re, going to use one extra strip of plaster and go above the top rim.

Of that slipper cast and capture the anatomy of the lower uh leg and ankle more specifically capture the malayalam, and so with one additional uh, four inch strip of plaster. You can go above the typical slipper cast capture the malayalam eye, and now we can fabricate the brace from that cast. If you don’t capture the entire shape of the malayalam eye, we can’t make the brace, but what’s really critical here, is that we follow the casting process that has worked well for us for 50 years, and that is a off-weight bearing suspension cast. If ever that technique is critical, it’s for poster tip dysfunction and for some of these other deformities of the foot and ankle where we really want to capture accurately, though, the three-dimensional contour of the plantar surface of the foot, the heel cup uh, the shapes of the Medial, lateral, lateral, longitudinal arches, because with that we’re going to get a better clinical outcome and so what’s different between a ritchie brace and a standard afo that most orthotists make the orthotists go right to weight-bearing cats. And they do that because they don’t apparently have much appreciation for the footplate of the afo.

The footplate of most orthotists fabricated afros looks like a flat box. It looks like a rectangular shoe box, whereas we that that or that foot plate of origin base looks like a custom, functional foot orthosis with a very deep heel cup. It has a 35 millimeter heel cup, but the arch contours and the shape of the calcaneal fat pad and all those other nuances that are so critical for control and foot are captured in our foot plate, and we can’t do that if we do a weight-bearing cast. We have to cast them off weight-bearing now, with the advent of scanning. What i have seen in both in australia and in the united states is the practitioner seems to think that positioning of the foot is no longer necessary.

That all you need to do is take this scan or literally a picture of the foot with a ipad, a structure, sensor scanner and the lab can make a perfectly fitting foot, orthosis or efo uh. Far, be it from the truth. The the position of the foot must be uh, captured in a proper alignment to the leg, either with the positioning device which qol has patented in australia. It’S called the scan, mate or the practitioner can hold the foot in the proper position and uh correct the four-foot supernatus deformity, which dominates an adult, acquired flat foot and can position the rear foot where they want and then take the scan. You can’t take the scan with the foot just hanging off the end of the exam table.

You got to position, it correct the forefoot supination and we find it’s better to have the patient lay in a prone position. So the scan can capture that critical anatomy on the posterior aspect of the ankle and the malayalam difficult to capture that with a scan when the patient is supine because the uh practitioner has to literally get on their hands and knees and get under to capture that Calcaneus, i think that’s true for foot orthosis, true uh too. I think that we’re far better off scanning the anatomy with the patients lying in chrome, yeah doug – i i agree totally regarding the supernatural and i would plaster always reach across and push down. But given the age group we’re talking about it’s not necessarily possible or even always desirable to perhaps cast it out as much as you would probably like someone a bit younger. So i wanted you to comment on that.

Yeah. That’S a really good point! I mean i. I have a video on my website that shows a patient where she’s like she’s in a prone position and her first metatarsal or the medial column is completely dorsiflexed. Probably 30 millimeters she’s got literally a 30 degree forefoot varus deformity.

But when i push down on her first metatarsal, it reduces to zero. She has an absolutely perpendicular forefoot to rear foot, and so the question is, am i really comfortable reducing that and i will tell you in my experience: yes, i’ve never um i’ve, never over uh corrected that forefoot supination deformity as long as i’m not forcing it. It’S just a very passive general plantar flexion to a very gentle end range of motion capture that scan in that position. I’Ve never had it end up making a device that was either uncomfortable and conforming to the foot or, more importantly, not functioning properly when they walk. The question is: what do you do when the patient has a stage three and stage four deformity that is so fixed?

They have, they actually now have a fixed, forefoot varus of 20 to 30 degrees, no matter how you cast it out, what’s the lab going to do, should they balance that forth with your rear foot, and i would say most of these labs – i know qol are Reluctant to balance anything greater than 10 degrees, he gets a patient. That device is so inverted. The patient just seems to slide off it. You know they pronate off of it. So that’s a challenge when you have that type of patient, but in every place you want to pronate that forefoot on the rear foot as much as you can in the screening process.

In my opinion, sure now i don’t. I don’t do this stuck, but i know others do what about dorsiflexing the helix during the casting process? Yeah that that that’s another way to uh. I don’t, i think, that’s helpful when there’s a minor forefoot supernatus deformity, but i don’t think it’s adequate in these a lot like the patient. That’S on my video.

I also find that if you dorsiflex the hallux, it does both spring the plaster a little bit off of the plantar surface of the flip. So you lose a little bit of that contour of your plaster or fiberglass through that critical, medial, arch area. You know, because you get a bow stringing from the windlass activation now, whether that’s really that critical – i don’t know, but from a theoretical standpoint. I i would rather just push down on the first metatarsal dorsal and not mess around with the hallux. That’S what i’ve always done just reach across with my fingers and push down that’s i’ve got to be honest.

I tend to do that just for normal foot authorities nowadays, yeah because of the lab. I use you know, and you know fire. You know, martin at firefly. Well, doug, and just something that the conversation he and i had maybe 15 years ago, and i’ve just done it ever since, and it’s one of the reasons i’ve been a bit reticent to move to scanning technology. I just i just just because i’m an old man really but um.

I just like the control of being able to reach around and push down. I’Ve always wondered where the third hand might come from. If i had started to use um a scanner. Can we, let’s go back to our um, our sort of uh inexperienced clinician with respect to the ritchie brace we’ve talked about sort of when they may decide to use one. We talked about sort of okay, first worry or hurdle for them is the casting the next one.

In my discussions with people is often the prescription form, and this is true, i think, when you grab a load of undergrads for the first time and you’re. Just talking about you know, cut normal custom made foot orthosis. They just get terrified by the looking at the form and saying how do i know what to write? How do i know you know whether to write four degrees or six degrees? How do i know whether to do forefoot or rear foot intrinsic or extrinsic?

Could you put people’s minds at rest with regard to, if they’re diving into this, for the first time they kind of go? Okay, i’m happy to cast now i’m going to sit there in front of the form. What sort of learning curve are they going to find themselves on um when writing prescriptions regularly for for richie braces what we’ll keep the context as our posterior tibial tendon dysfunction? I think yeah um. A couple points here is by all means for the new, the the novice practitioner, who’s, never used or inexperienced practitioner and accustomed to using the ritchie brace.

Please start with a patient with posterior tib dysfunction, start with a patient with sharp deformity or post-traumatic arthritis of the foot and ankle to start with the easiest, which is really posterioritive dysfunction, believe it or not, number two. We actually tried to simplify this in a way that, if you prescribe the standard, richie brace on the prescription form, that’s all you have to do. I mean you uh. We already have the package built in. We have a 35 millimeter heel cup uh.

We have a flat rear foot post on the back uh, we don’t do any forefoot posting and it works most of the time. There’S nothing wrong with just checking the box and that’s what believe it or not. Most of our prescriptions that come in don’t have anything more than check in the box standard, ritchie, brace for more experienced practitioners who know a medial heel sky always helps, i i say, go big or go home six millimeters or even more works really well on the Ritchie, brace or a lateral sky for chronic inflammability or severe varus deformities, nothing wrong with going with that. I think when you start adding flanges and things it gets a little more risky with irritation to the foot and keep in mind when you have a 35 millimeter foot orthosis in the heel cup 35 millimeter heel cuff, you already naturally have flanges built in because it’s A wider device and comes around the foot to meet that parameter of the 35 millimeter heel cup. So you know, there’s not a lot of need to add things where we get a lot of our inquiries from clinicians is on neuromuscular conditions, uh drop foot and for sure on the acquired, various deformities.

We see it behind foot and ankle, such as charcoal marie tooth disease post stroke patients, because when you put a brace on a patient with already a various deformity of the hind foot or ankle, it’s challenging. It’S really challenging with foot orthoses. But when you do it with bracing, you have you run the risk of compromising they’re already in place compensation for that various deformity. I mean. We all know this from prescribing foot orthotics and the patient walks with worse varus afterward, because inadvertently you’ve taken away their own inside compensation for that problem.

So i do a lot of consultations with doctors on how to approach patients who have dropped, foot weakness of the perineals loss of the perineals with an acquired varus deformity, because there we bring a lot of stuff into play. Lateral heel, skive uh, definitely put an extended forefoot valve sulcus wedge. I mean we’re just trying to pronate that foot out to end range of motion and then some and keep it there with the brace, and so that can be a little challenging. But these labs, like firefly in the uk, uh qol in australia, uh, are pretty seasoned now with this and they provide excellent clinical support for their clients and – and i do as well they’ll reach out to me – i i do uh consults via email for practitioners in Australia and in the uk fairly frequently are you i thought you were saying: you’d retired. This doesn’t sound that much of a retirement to me doug.

You know i retired from clinical practice, so i could spend more time doing this because it’s it’s truly uh rewarding to work with a colleague on a patient and see a positive outcome and and see everybody benefit from that so uh. This is kind of a new stage in my career that i’m really enjoying yeah. I got a question so sorry and we we just we just talked about you know when you pull the trigger and move from a inverted device into a rishi brace at what stage would you not? Has it gone too fast for for the braces? Is there a, is there a point with it and now that i’m it’s that this is a surgical case, you know, is there a trigger there as well, or are you still willing to give the brace a go?

Well, you know um, i’m a trained foot and ankle surgeon, and i i did a lot of reconstructive surgery in my career and uh like it or not. I i failed with with the ritchie brace on a certain percentage of my posterior tip patients, and i learned that if that patient wasn’t improving the first six weeks after they got the brace they probably weren’t going to improve, i mean you usually know this right out Of the first visit almost or the first visit back, these patients come in either with a big smile on their face, or they say you know, i really don’t feel a lot better. Fortunately, that’s not as common, but it happens, and if they’re not better after three months, they usually end up going to surgery which is disappointing, but that just seemed to be the way it is. On the other hand, the majority were better and continue to get better, and i found that the earliest it was worth the risk of cleaning them out of the brace was six months, and usually it was nine months. I i would have a patient totally asymptomatic, no swelling around the poster.

Tibial tendon, no sinus, tar side pain, ambulating perfectly in the brace, and i would say why don’t you start going without the brace for a couple hours each day but make sure you wear your foot orthotic, which they either already had or i made for them and If it was less than six months into this treatment, they would relapse very quickly, but after eight months nine months a percentage of them did really well with their foot orthotic and after a year a lot of them did well, but we wouldn’t do it cold turkey. We would do a few hours each day and then back to the brace a few more hours back to the brace and it’s it’s hit or miss uh. I wasn’t always that good at figuring out who was going to succeed and who wouldn’t. But it was worth a try yeah on that, just oh god, sorry, craig, oh, it’s dicko dicko’s got a question just back back tracking to the just backtracking to the previous topic. Before we came to that question.

Simon’S just asked this question about this. You know how you want to really want to pronate the riff, the forefoot in these people um. So i’m just going to be careful with terminology here that simon’s asked, but he’s really asking are lateral, forefoot wedges more effective than a like a lateral, forefoot skive to sort of say, pronate that foot or reduce that supinating foot in a ritchie brace. So i i i think, yeah i think i’ve got the terminology right, yeah um, you know i’ve had that question come up and i uh – and this is actually outlined in a lot of detail in my book, which i know we’re going to talk about in a Minute but when you pronate the forefoot on the rear foot in the casting process or scanning process, it induces a three-dimensional change of the entire architecture of that foot that you want to preserve in your foot arthrosis and your breaks that three-dimensional rotational change in the curvatures. That are assumed, after that change cannot be duplicated by simply putting a lateral wedge on the orthotic to theoretically pronate the forefoot on the rear foot.

That’S not to say lateral. Wedging of the forefoot can’t be a nice enhancement to do later, especially when you’re not getting the results you’re. Looking for i find it can be a nice adjunct to try later after the brace has been dispensed, but i don’t think it’s an adequate substitute for the critical positioning of the foot twisting the foot plate, as we say in the optimal position during this casting process. Yeah, i think also i i know simon well, i suspect what he’s getting at is the theoretical uh sense that you’ve got a longer lever arm to exert pronation moments at the forefoot than you have at the rear foot. Is that do you think that’s what he was saying craig?

Is that he’s a force it might have been yeah um, i was gon na say actually just just just while, while i’m in this train of thought, um, we’ve we’ve, hopefully given people some some ability to have confidence in saying: oh okay! Well now i i you know if i see a tid post problem, uh it comes in and they bring a bag full of foot. Orthos and they’ve not got any success. What can i do? That’S different?

Well, maybe the answer is the richie brace, maybe you’re, confident to say i can i can cast for this now that isn’t going to be a big drama. I think you’ve very much put people’s minds at rest that writing a prescription for richie brace in many ways. I hope i’m not crudely simplifying it, but it sounds almost more simple than writing a prescription for a foot orthosis. I guess the last thing i’d love people to to to have information was to gel it all together are there must be certain times or certain scenarios where a ritchie, brace’s contra indicated where we should be thinking. Oh, this won’t be a good idea.

Um. Could you talk us through when perhaps you know we talk about how we should select this thing? When should we not be thinking about the richie brace? What are the key, contraindications yeah great question, the first contraindication, and this came up early when we launched the brace? Is everybody wanted to try it on charcoal deformity on neuropathic foot conditions, and to this day i tell practitioners not to do that.

I i don’t think the braces uh i never designed the brace for that um. I i get really nervous when we’re putting semi-rigid devices in the shoes of patients that are completely neuropathic and have other balance issues and proprioceptive issues um. I i think charcoal can be very well managed, with appropriate footwear and total contact in shoe orthosis. Having said that, we have practitioners who have used the brace on uh variations of charcoal where a patient also has unfortunately had a ruptured, posterior, tip, tendon or other things, but in general i would caution against using it on neuropathic feet, particularly on charcoal or arthropathy number. Two are the neuromuscular conditions that, beyond a simple flaccid drop foot ritchie dynamic, assist brace works very well on when you start moving into patients with severe spasticity contracture toe walkers like, for example, a patient with cerebral palsy, some more extreme cases of muscular dystrophy patients who Have had brain injury that are extremely i none of our braces are adequate to address that, because in most cases these patients have proximal weakness and other issues that immortal uh traditional long leg, afo to control that tibia is really critical and so um.

I get real nervous when a practitioner starts describing patients with multi-levels of impairment of their lower extremity, wanting to use a really simple, ritchie, brace the ritchie brace is great for sagittal the drop foot brace for just sagittal plane, passive hemiplegia, but when you’re getting into multiple Conditions or influences above the knee uh, i tend to tell the patient or the practitioner to refer that patient out to a more qualified orthotist with a wider array of afo interventions to implement yeah. Are there any um just questions that suddenly come to my mind? Are there any objective measures that may be a good predictor of whether someone will do well? So i know we don’t have many of these for many things. We do to be honest, so um, i think i probably know the answer, but certainly i know some people that will always look for a certain amount of ankle flexibility or or car flexibility or ankle range before they’ll make certain considerations for prescribing.

Are there any objective measures that your experience over the years has led you to realize? Okay, people that exhibit these findings tend to do better, yeah well for sure. With drop foot, we mandate that the practitioner measure ankle joint range of motion and and assure that that patient’s capable of getting to neutral to a 90 degree foot and ankle position, because if they passively can’t get to 90, the brace can’t get them there either. The brace is only capable of moving the foot and ankle within the range of motion available of that specific patient. So we would have doctors, prescribe a drop, foot brace and not recognize.

The patient had a fixed aquinas already in their ankle and then the brace gets dispensed and the doctor sends it back and says: hey it’s not controlling the drop side, they’re still landing on the forefoot and the heel isn’t coming down to the ground and we would Say well, what’s their available ankle joint range of motion and they would say: well i never measured it which is kind of frustrating, but that happens in terms of posterior tib dysfunction. I can’t really think of an objective measure that is required, but i’ll tell you an interesting test and i learned this from practitioners. They would say you know i had a patient come in. I made them foot orthosis for coastal tip dysfunction. They just weren’t getting better.

So what i did is i strapped their ankle with a high die strapping up above and when they walked down the up and down in the clinic. They said. Oh, my god. I feel so much better. That to me said.

Maybe i need to go to a ritchie, brace and i would say: wow – that’s a great diagnostic test, yeah and more often than not, they did better in the brace. So you know connecting that foot to the leg and using that leg control is the obvious advantage of the brace over a standard foot orthotic, and you can simulate that with just temporary strapping and what i love about. That is it sort of mirrors the way you sort of invented this brace in the first place. With the the you know, the the marriage of an orthosis and, like you say, uh an aircast a60 like ankle, brace so that kind of works well, um, craig anything else, uh. Anyone any any burning questions from any anyone watching.

No, no, no more questions, but i sort of got one. I know doug and i have talked about this before it’s really a terminology issue. Is it a delta quite flat foot? Is it posterior, tibial, tendon dysfunction or that that new term that i’ve seen creep in the last 12 months progressive collapsing foot deformity? What really should we be calling this yeah?

You know i i’ve seen that uh progressive collapsing, but i that term really disappoints me because it’s a little vague, um and non-descriptive. But i i don’t know i really respect that panel. That came up with all the clinical recommendations that primarily were surgical by the way. But that was a good group of researchers who came forward with that. As you know, there was a great review paper uh, i believe, from your australian colleagues looking at this uh uh, who was the lead author on that i i megan ross, yeah um yeah exactly and uh, they said um yeah, the the literature at that time has Either adult acquired, flatwood or posterior tip dysfunction.

But really, if you look at the descriptions of the two they’re different uh ulcerative dysfunction, attributes the entire pathology to a rupture of the posterior tibial tendon. Whereas a dull acquired flat foot can actually be a condition that develops with an intact posterior tibial tendon, you can have an isolated rupture of the spring ligament there’s certain a charcoal deformity is really an adult acquired flat foot. In the absence of a ruptured, posterior tibial tendon, so there are shortcomings to the both i’ve learned this and no matter what you try to teach clinicians today, still love using the word pttd i mean everybody knows what that is. Everybody has an idea of what that is, and – and i i instead of trying to push back the tide i just give into it say, go ahead and call it pttd, even though it has its limitations yeah. I think that it’s, i think the only issue i have with pttd is that it puts the pathology on the posted tendon and there’s a hell of a lot more going on.

You know you mentioned the spring ligament, you know like it’s it’s and i’m i’m sure. You’Ve seen the arguments where people have tried to suggest that the spring ligament is the primary pathology sure, and it’s just about what is the pathology we’re dealing with, and i agree with you the new this progressive uh collapsing foot deformity again is just as vague as Adult acquired flat foot yeah, not to mention a touch, no cbic, but we won’t go there this evening, yeah well, yeah, let’s uh! If we haven’t got any more questions about about the richie brace, it would be a miss of us not to not to pump up the tires a bit on on doug’s latest uh publication. Uh he’s published many things over his years, but this is his new book that we’re referring to, which is refer, which is called patho mechanics of common foot disorders, um available uh as a hard copy available as an ebook. Don’T think you’re narrating it on audible, just yeah are you doug, but um people can get it, and here it is um.

Now i know you mentioned uh just before we came online, that you’d retired, but for anyone that’s ever tried to publish a paper in a journal and knows what an absolute saga that is. Could you just give us an insight into just what a drama publishing a book is and what on earth made you realize just this close to retirement? You know what i’m gon na. Do i’m gon na i’m gon na pull together a book because that that’s some task, isn’t it uh? It was a um, a task, as you said far more challenging than i even envisioned, and i about a third of the way through.

I asked myself why i even got it uh as as retirement approach, um colleagues of mine, who had retired uh, all uh advised me ahead of time you’re in for a bit of a shock, and you should really have some things planned to keep. You active and uh keep your mind busy and, and i said well, i’ve already decided i’m going to write a book and that’s that sounded great in it. Obviously i figured that’s going to fill my time nicely, but it was. It was far more time than i envisioned and i made a deal with my wife. I said i’ll tell you what i want to write this book and i promise you i’ll spend at the most two hours a day uh on the book and the rest of the time is ours to go out and do whatever we do well, it ended up Being six to eight hours a day through the books so um it was a daunting task and instead of taking a year it took a year and a half and i’ll be honest with you.

I ended uh the book with plantar heel pain. I really wanted to get into achilles tendinopathy and aquinas, and i just said i just can’t do anymore and i, in the back of my mind, i said i’ll, just save that for volume two, but not a good idea. I hope your wife’s not listening, because i’m certain she isn’t aware of volume, 2’s plans yeah and this stuff, this you know when you’re retired writing a book is no good for your golf handicap either. You know this right now. Could you give people?

Could you give people a bit of an idea of the kind of thing i mean? Obviously craig and i both got a copy and we scanned the contents um. Could you give people a bit of an idea of what they can expect from this book and then the kind of stuff that that’s within it uh if they’re considering a purchase yeah the book really uh? The idea for the book came from uh. Many of my colleagues after i gave lectures i it’s interesting in my career.

I really, as i said, i was very involved with our sports medicine academy and um uh, going to sports medicine conferences and my original papers that i published were all in the sports medicine realm, but the lat because of the ritchie brace. I got invited to a lot of surgical conferences and the last 15 years of my career. I gave many more lectures and surgeons, uh, podiatric surgeons and orthopedic surgeons than i did to sports podiatrists and the lectures i gave primarily focused on patho mechanics, because it was an area that i felt comfortable in an area that i knew they did not understand fully And, as i gave lectures on the patho mechanics of these common conditions, they were doing surgery on they would come up afterward and say: where can i find more of that or have you ever written all that out or is it available? Is it published anywhere and i would tell them no, it’s a compilation of other people’s work uh and it’s only in this lecture. They would ask me, for my lecture hand, but ask me how come you haven’t written this up as a compendium of everything that you’ve put together, and i said well, maybe i’ll do that when i retire.

So that’s really what how the book came about when i set out to do the book, i made a commitment that i would try to commit to evidence-based research. I wanted no matter what i said in this book. I wanted to have it validated by fairly solid evidence. So that’s why the book took so long to write, because i had to back check everything. I said as much as i could and, as you know, that’s that’s challenging because it everything changes uh, it’s funny.

The first chapter uh i wrote uh – was on uh, alex valgus and a year and a half later, the volume of papers that were published on alex valgus had almost doubled uh, particularly in the patho mechanics area, which was really cool but um. The bottom line is i, i chose the most common pathologies that we treat as foot and ankle specialists as podiatrists, and i explored the patho mechanics how they got there and as i did that, and as i developed my lectures, i found myself going back to the Patho anatomy first and realized – if you don’t understand the anatomy here, you can’t understand the pathomechanics, because most of these conditions are a failure of key anatomic structures that most of us really didn’t, learn well in school. We kind of skipped over it because it was boring. But let me tell you that came back to me and i relearned it in a new way and learned from these anatomists in such a way that i devoted the entire first chapter of the book to anatomy and comparative anatomy. That really became the foundation of the book and the foundation of each of the chapters that dealt with the specific mythologies lovely.

So if you’re, a student watching think about sending uh sending an order doug’s way for his book uh if you’re a clinician watching who doesn’t prescribe the richie brace, you know next time someone comes in with a with a pttd uh and i have a bag of Failed authors think about you know, think about the richie brace um and, like i say here in the uk uh, we got great support, uh from the lab that distributes them, firefly and and the big cheese there. Martin’S, a lovely guy and super knowledgeable on the richie brace in australia. Qol as as often i’ve been referred to, i’m sure are the same yeah and – and it seems like doug is i mean he’s got a great website which we’ll link to below loads of resources. On the website, but um by all means pump his inbox, you know the more he can um he’s, not you know, he’s retired now, so just firing with emails and he’ll be absolutely right. Actually i’ll just get a plug-in for it.

For canada, i think it’s paris, orthodox and precision orthotics in canada, doug, yes, yeah, i’m great! I’M glad you did that paul paris and paris. Orthotics were really my first international lab to manufacture the brace and they’ve been a fantastic partner for over 20 years. What are the seven i you know the set. This is where i show that i did a tiny bit of research, but i didn’t go that deep.

The seven countries i referred to. We obviously got canada, us australia, the uk. What what the other three that we’re missing? Well, i believe or not. I have a lab in spain that manufacture the braves and they distribute it in both spain and in portugal and um.

My australian lab has now begun distributing the brains in singapore, so we’ve moved into those countries in terms of actually fabricating the brace uh. We have four laps, but we’re in seven countries got you awesome perfect. So i think that’s everything um yeah. Well, i’ve got one one. I’Ve got one one comment to finish on from zoe excellent guys.

Thank you. I use the richie brayson clinic more and more and love it. It’S a game changer. So i think that’s a that’s a good note to finish on nice. Um.

Thanks very much doug for those that have joined late and i’ve noticed a few australians start to come on towards the end of this. The video will be up like well. You come back in 10, 15 minutes the whole. The whole video will be here on youtube. Give us a few hours it’ll be up on um, sorry i’ll, be on facebook in a few hours, it’ll be up on youtube and we’ll have it on our podcast um sources soon too.

So thanks a lot doug and ian thanks doug my pleasure. Thank you.