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Program & Orthotics
The Richie Arch Suspender®
The Richie Brace Arch Suspender® is a new invention to provide powerful adjustable control over the midtarsal joint of the human foot. The medial arch suspender stabilizes the talonavicular joint while the lateral arch suspender stabilizes the calcaneal-cuboid joint.
The combined use of the medial and the lateral arch suspender provides an Arch Hammock™ for comprehensive control and stability of the entire rearfoot-ankle complex.
It has recently become recognized and validated that the talonavicular joint is the pivotal, keystone joint of the human foot. Tri-plane movements of the rearfoot complex revolve around the talonavicular joint and fusion of this joint eliminates almost all movements of the remaining joints of the rearfoot subtalar and calcaneal-cuboid joints.
Movement of the talonavicular joint is strongly coupled to subtalar joint movement and tibial rotation. During the normal gait cycle, tibial rotation is directed to the talus and into the talonavicular joint while the calcaneus remains relatively stationary.
Until recently, podiatric philosophy has focused on calcaneal position and movement as being most representative of normal and abnormal foot motion. Accordingly, podiatric treatment strategies utilizing functional foot orthoses to treat biomechanical lower extremity pathologies have been based on the premise that calcaneal (heel) alignment determines overall stability and alignment of the human foot. Balancing forefoot to rearfoot deformities to achieve a perpendicular calcaneus has been the cornerstone of podiatric orthotic design.
With such an emphasis on calcaneal alignment, it is not surprising that studies of podiatric foot orthotic efficacy have failed to demonstrate any change in skeletal alignment achieved by these devices during dynamic gait. The reason for this is the fact that the calcaneus undergoes very little movement during gait, and attempts to control this movement result in negligible change.
Podiatric functional foot orthoses are thought to lock the midtarsal joint and maximize stability of the first ray during mid-stance and terminal stance. Whether these devices achieve such an effect remains controversial and has yet to be validated by sound objective data.
Generally, conformity of the orthotic device to the medial arch of the foot is thought to be desirable to control the midtarsal joint. However, attempts to control a subluxing talonavicular joint with the pressure of a semi-rigid foot plate against this area of the foot usually leads to intolerance by the patient. Hence, podiatric orthotic laboratories commonly have to provide an accommodation, cut-out or “sweet spot” to the talonavicular joint area of the foot orthosis when hypermobility of this joint is anticipated.
Herein is the paradox: The most critical control joint in the human foot, the talonavicular joint, is the very same area of the foot which is least tolerant of the support of an orthotic footplate.
What Does the Richie Brace Arch Suspender® Offer?
Instead of pushing against the talonavicular joint for control of the human foot (as in traditional orthotic therapy), the Arch Suspender™ “pulls up” or “suspends” the talonavicular joint. This is similar to the natural support mechanism already existing within the human foot in the form of the Spring Ligament Complex. This complex provides an acetabular sling for the head of the talus, preventing abnormal plantar and medial migration of the talar head during loading of the foot.
The Arch Suspender™ is oriented similar to the Spring Ligament Complex of the human foot to provide a force directed in a superior-lateral direction to counter the plantar-medial rotation that occurs in the head of the talus during the contact and early stance phase of gait. The Arch Suspender™ is actually oriented perpendicular to the axis of rotation of the entire rearfoot complex to optimize torque on the subtalar and talonavicular joints.
Comfort and Efficacy Through Adjustability
The Arch Suspender™ is fully adjustable. The tension or torque of the device is determined by the patient. The force is not a pressure force of hard plastic against the sensitive navicular area of the foot. Rather, the force is a “lifting” mechanism with an elastic component, similar to the same force exerted by the Spring Ligament complex. The sensation experienced by the patient, is therefore, natural and gratifying as the keystone support area of the foot is lifted and re-positioned into its proper alignment.
A Complement to Richie Brace® Therapy
The Richie Arch Suspender™ is not a replacement, but rather a complement to the traditional podiatric orthotic design of the Richie Brace®. A conforming orthotic footplate that effectively balances forefoot to rearfoot deformities and enhances first ray function is critical to the effectiveness of the Arch Suspender™ device. The Arch Suspender™ is incorporated into the custom balanced orthotic foot plate of the Richie Brace® and provides and enhancement to the talonavicular, calcaneal-cuboid areas or both.
The orthotic footplate of the Richie Brace® is modified to allow conformity of the arch suspender against the foot of the user at either the talonavicular joint, the calcaneal-cuboid joint, or both. The central portion of the orthotic footplate remains intact to contour to the plantar surface of the midfoot and provide resistance to sagittal plane and frontal plane rotations between the forefoot and the rearfoot.
The Arch Suspender™: Fully Reimburseable
The Arch Suspender™ is a true Varus/Valgus control enhancement to the standard AFO design of the Richie Brace® and qualifies for reimbursement under Code L2275. If both a medial and lateral arch suspender are utilized, as with the Arch Hammock™, then two Varus/Valgus control codes are utilized (L2270 x 2). Suggested charge per L2275 code is $115.
The standard AFO orthotic footplate is modified for each suspender with a cut-out accommodation under either the talonavicular joint, the calcaneal cuboid joint, or both. Use Code L3480 for each orthotic plate accommodation. Suggested charge per L3480 code is $45.
Indications for Use of the Arch Suspender Mechanism
The medial Arch Suspender™ should be used on all cases of Adult Acquired Flatfoot secondary to Posterior Tibial Tendon Dysfunction. While the Richie Brace® has demonstrated excellent efficacy in treating this disorder, the opportunity to enhance control over the subluxing talonavicular joint with the Arch Suspender™ should be taken with each prescription for the Richie Brace® when there is a diagnosis of Posterior Tibial Tendon Dysfunction.
Peroneal tendinopathy can be effectively treated with the Richie Brace® combined with the Lateral Arch Suspender™. This support lifts the calcaneal cuboid joint to decrease eccentric load on both the peroneus brevis and longus.
The Lateral Arch Suspender™ is an effective enhancement to the Richie Brace® for treatment of Lateral Ankle Instability. A powerful eversion torque is provided to the Subtalar and Ankle joints with enhanced proprioceptive input to the sensory receptors on the plantar and lateral pedal integument. The benefits of ankle taping are provided with the Lateral Arch Suspender™ without the rapid loss of support that occurs with tape during activity.
The combined medial and lateral Arch Suspender mechanism, known as the Arch Hammock™ may be the most effective enhancement for the Richie Brace® for use in Charcot Arthropathy. The soft, adjustable midfoot support is ideally suited for the neuropathic foot. The focus of support at the midfoot addresses the sagittal and frontal plane subluxation that commonly occurs with diabetic Charcot deformity.
The Arch Hammock™
The Arch Hammock™ also mimics the so-called “Figure of 8” support that is found in many popular ankle braces. The Arch Hammock™, however, does not contact the anterior surface of the ankle, and allows pure unrestricted sagitttal plane movement of the ankle. The Arch Hammock™ therefore is the first truly functional “ Figure of 8” ankle support that will not compromise athletic performance, while providing comprehensive frontal and transverse plane stability to the ankle and subtalar joints.
The Arch Suspender™ and Arch Hammock™ mechanisms represent a significant advance in treatment strategies to control and re-align the midtarsal joint of the human foot. The elastic suspension system is carefully aligned to provide maximum torque on the midtarsal joint axis while allowing forgiveness and adjustability for maximal patient comfort.
Available only on the Richie Brace®, the Arch Suspender™ and the Arch Hammock™ represent a breakthrough in orthotic management of the most challenging lower extremity musculoskeletal pathologies.