Is A New Brace The Answer For Equinus?
- Patrick DeHeer DPM FACFAS
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If you have been reading my recent blogs, you realize I have been writing a significant amount about equinus (see http://bit.ly/pHai03 and http://bit.ly/koOj86 ). I think equinus is underdiagnosed, undertreated and underappreciated by those who treat foot and ankle pathologies. The gastrocnemius recession procedure is a great answer for equinus but I think we have a much better opportunity to treat equinus non-surgically in the near future than we have ever had at our disposal.
First, I would like to discuss night splints and why they are ineffective. I had a personal experience using night splints and realized their flaws firsthand. I developed posterior tibial tendonitis in my right ankle from running and it was not improving with orthoses. I did not want to stop running because it had helped me to lose 40 pounds. I have equinus like most of the population and it was getting worse with running. I started using night splints to help.
One night, I woke up at 3 a.m. to take off the splints and looked down at my legs. I sleep on my side with my knees bent like most adults, especially if I am wearing night splints. I realized the night splints were doing nothing. It is well documented that the gastrocnemius muscle is the muscle that is tight as it crosses the knee, ankle and subtalar joints. My gastrocnemius muscles were not being stretched at all so the splint was a complete waste of time. Additionally, I was not sleeping well due to the night splints and I was ready to burn them. The light bulb went off in my head. You have to have an above-the-knee extension to lock the knee in extension.
A Closer Look At The New Brace
The answer I came up with is the EQ/IQ brace. Patients do not need to sleep in this brace. I recommend using it 30 minutes in the morning and 30 minutes in the evening (15 minutes stretching the gastroc-soleus complex and 15 minutes stretching the soleus).
There are several features of the EQ/IQ brace from proximal to distal, such as an above-the-knee extension with a hinge at the knee. The extension allows the knee to lock into extension to stretch the gastrocnemius muscle. The hinge can release to allow for ease of application and isolated stretching of the soleus. There is also a hinge at the ankle joint, which allows the treating physician to set the exact amount of dorsiflexion desired based on the patient’s biomechanical exam (I see maybe 5 degrees the first month, going up to 10 degrees the second month and, if needed, 15 degrees the third month). The hinge goes from -30 degrees to +30 degrees in 5-degree increments.
We as podiatrists measure everything from X-ray angles to forefoot varus position. Yet we slap on a night splint and tell our patients to pull as tight as they can. This makes no sense to me. We should have more control and precision over the treatment of this condition.
I have made this brace ambulatory with a negative heel rocker sole, which allows ambulation with a fixed, dorsiflexed position. The rocker soles are going to be removable and come in three different soles (5, 10 and 15 degrees) to match the amount of ankle joint dorsiflexion. There is an adjustable wedge that goes under the hallux to engage the windlass mechanism. These wedges come in 35, 50 and 65 degrees and Velcro to the foot bed. I made varying degrees of wedges to allow for those with hallux limitus or rigidus. The femoral and tibial uprights are adjustable for leg and thigh length, and the physician should set this.
Finally, the standard foot beds will fit a small/medium size but one can replace them with an extended version that will fit a large/extra-large size. Please see the attached photos of the brace.
The time period I am recommending is double the recommended time for manual stretching. The recommendation is for patients to do most manual stretching about 30 minutes per day. I think an hour a day is reasonable from an adherence standpoint in comparison to six to eight hours at night while disturbing the patient’s sleep.
The ambulatory component of the brace is also important. I envision the patients, after getting dressed in the morning, putting on the brace and stretching while performing their morning rituals. A similar scenario would play itself out for the evening stretching.
A final consideration is this is not a brace patients will be able to buy at a drugstore or on the Internet. I have had patients complain about the expense of a night splint when they can find the same thing for about 20 percent of the price of the brace. This is a technical device that a physician must set, monitor and adjust. This brace will have a significant positive impact on the practice management component of your practice. Most importantly, it will provide you with a better way to treat the most significant producer of foot and ankle pathologies — the equinus deformity.
Our company, IQ Med, is producing this brace as I speak. It has been a long, interesting journey and we expect to have it on the market by the end of this year. We have other versions patented including a diabetic version, a pediatric version, one with multiaxial hinges and clubfoot braces that will be following our production of the standard brace. I would love to hear any feedback any of you may have. I have been lecturing on this to some focus groups of podiatrist/orthopedic surgeons and I lectured on it at the recent American Podiatric Medical Association (APMA) National Meeting in Boston.
The feedback has been overwhelmingly positive. I am excited to bring something to the market that will better treat patients and help my colleagues financially and clinically.