Treating complex neuromuscular conditions can be challenging. There are many factors to consider
which aren’t necessarily always examined in great detail if you were prescribing a foot orthotic.
However in my clinical practice, treating these patient are consistently the most rewarding patients.
In my experience, there are a number of patients who are wearing traditional AFOs who are not
happy with them. The dissatisfaction can stem from discomfort (rubbing etc), aesthetics and
material failure. However, if you’re armed with the right information, you can resolve these
problems and have a truly rewarding experience by allowing the patient to perform simple daily
activities that many people take for granted.
The first consideration when assessing a dropfoot patient for an AFO is knee stability. In terms of
knee stability, we look at the ability of the quadriceps, hamstrings and triceps surae muscles to
control the knee in the sagittal plane through stance. Most Richie brace models will not control
anterior migration of the tibia which accompanies knee flexion deformities. Genu recurvatum is
easier to treat with heel lifts or by placing the footplate of the brace into plantarflexion.
The second consideration is ankle range of motion. If the patient has passive ankle ROM beyond
90°, they may be suitable for a dynamic assist brace. However if the patient is unable to achieve at
least 90° of dorsiflexion (e.g. due to posterior spasm), the dynamic hinges may not be able to
overpower this force, leading to a loss of ground clearance in swing phase. The dynamic assist Richie
brace will achieve heel strike for dropfoot conditions if the patient has at least 90° of ankle
dorsiflexion. Remember an AFO can no correct a fixed equinus deformity.
Thirdly, calf strength is important. The dynamic assist Richie brace will achieve a normal gait pattern
as long as the posterior calf musculature is strong. You can check this by asking the patient to
perform a single leg calf raise. If the calf is weak, consider a restricted hinge Richie brace.
The fourth and final consideration is frontal plane deformity (varus or valgus alignment of the
rearfoot during gait). The dynamic assist Richie brace is the preferred brace for all dropfoot
conditions, but is less effective to correct severe varus or valgus deformities of the hindfoot. The
flexible hinges will give way, particularly in tall or obese patients. The restricted hinge Richie brace is
preferred when a severe varus or valgus deformity is present.
The dynamic assist Richie brace is the preferred brace for dropfoot conditions where there is good
stability of the knee, good ankle range of motion and lack of severe deformity of the hindfoot. Most
stroke patients and common peroneal trauma patients meet this criteria. Most patients find this
brace to be very comfortable and allow for normal daily activities such as walking up and down
The restricted hinge Richie brace is preferred over the dyanimc assist Richie brace when the patient
has severe varus or valgus deformities, has ankle equinus, calf contracture or some instances of knee
instability. An example might be a Charcot-Marie-Tooth patient with an acquired cavo-adducto-
varus deformity of the foot.
By examining these simple criteria, you will be armed with the right tools to confidently prescribe a
Richie brace for your dropfoot patient and you should achieve an excellent clinical outcome.