A recent new client to the clinician, but not to the service recently required a revised prescription; complications with several rigid AFOs, one Ritchie styled, custom and OTS were a constant irritation. The client could see the benefits in gait, but this was outweighed by the irritation and discomfort felt for several years. A changing and worsening clinical picture meant that the client felt she required a new device; therefore reached out to the clinic for an opinion. A pragmatic approach with a fresh set of eyes, and the excellent new dynamic Step-On 100 AFO in the lateral hinge solved a chronic problem.
A bit of background to the client: Polio, Female, 72, Active; recently felt although undiagnosed that the increased weakness in unilateral dorsiflexion previously oxford 3, now at 2; was down to post-polio syndrome, alongside a 6mm LLD, and good UL dexterity. It appeared, rather deceptively easy to treat; a saggital swing phase safety issue, reasonable control of tibial progression, with typical circumduction / steppage compensations; which were becoming harder to make due to new proximal increases in weakness, and no long term dependency on a device as intervention was absent until later life. An easy fix, or so it seemed.
Diving into the assessment, with incomplete notes, taking history from the client it appeared in her mid-50s that a Talonavicular fusion was undertaken due to Posterior tibialis tendon overstrain. I presumed the surgeon considered a triple arthrodesis to have increased risk of complications. The calcaneus was in valgus with some correction, but therefore midtarsal unstable, and PTT under strain even with the fusion. An extremely prominent medial malleoli, medial STJ axis, low talo-crural angle where found, and indicative of factors of irritation of previous enclosed M-L custom AFOs, and sited by the client for reasons for decreased compliance, understandably so, history of subcutaneous bursa, and sores. The client was unsuitable for a revision surgery, so a medial calcaneal displacement osteotomy etc was out of the question; and if it was an option the client was too active to risk a period of non-WB and post op weakness; we had to work with this presentation.
Step-On® 100 LH Innovative ankle-foot-orthosis – Lateral Hinge
A decision was made to treat the sagittal swing phase issue with the Step-On 100, the hinge provides 22° dorsiflexion and 11° plantar flexion with adjustable dorsiflexion assist to allow precise tuning of the dorsi assistance based on the weakness encountered, and the plantar flexion useful as it will self-adapt to the varying different shoe pitches, the client found this highly practical as a lady, and a complete revelation to her.
The dorsiflexion ROM was especially useful due to the newly encountered proximal weakness in swing, and further helped by the 290g weight to reduce a pendulum effect on swing. The lateral strut allowed no containment of the problematic prominent medial malleoli, but the patient still presented with symptomatic PTT. The Step-On 100 has a lower tibial strap which anchors to the lateral strut to reduce the valgus heel tendency, this was used for 4/52 to assess if tolerated and it was, the client had her sagittal problem resolved with no pressure issues, the client although safe and more functional still had PTT strain rated at 7/10 from 9/10.
This progress was built upon by next manufacturing a semi corrective FFO in order to help reduce the kinetic strain on the tissue. The flat Step-On ¾ footplate with neutral profile is ideal for adding an FFO to the stable base, this was key to the successful treatment. We have found that alternating between the Step-On AFO with the corrective ankle strap solely and adding in the FFO for several hours through the week in conjunction with the Step-On to have an optimum effect of finally bringing this patient to a pain score of 2/10.
The Step-On again illustrated just how versatile its reach is across another pathology.
For more information about the Step-On 100 or to arrange a demo please contact the customer services team on 0191 258 8944 or email sales@braceorthopaedic.co.uk
