| Lisa Knox
Before the XTERN: AFO’s of the Past
Author: Kevin B. Rosenbloom, C.Ped, Sports Biomechanist
Curious patients always ask about the newest innovations of the world of podiatry. Occasionally, there will be a question regarding how a specific product began. Though the products of the past were helpful, they were also more intrusive than their modern day counterparts. Understanding the past of the ankle foot orthosis (AFO) is not only enriching to patients, but essential to acknowledging how the industry came to be what it is today.
As far as researchers can determine, the origin of orthopedics began in Egypt 2830 BCE with the making of simple splints and crutches from natural materials and padding, like bamboo and linen (Brakoulias 1990). Other civilizations would use wood and bandage wraps (Classical Greeks), clay (Early Australians) and rawhide (Shoshone Americans) to create splints (Brakoulias 1990, Beckett 1999). The term ‘orthopedic’ was not coined until the 18th century by French physician Nicolas Andry (Andry 1743), but the practice of straightening anatomical structures was being practiced on shoes and boots shortly soon after (Figure 1 & 2.).
Figure 1. Lord Byron’s orthopaedic boot, England, 1781-1810.
Photo Credit: Science Museum, London. Licensed by CC BY 4.0
Figure 2. Foot support, France, 1870-1890.
Photo Credit: Science Museum, London. Licensed by CC BY 4.0
The use of plaster to form a rigid cast for healing injuries was introduced by Dutch army surgeon, Antonius Mathijsen in 1851 (Biemans 1999). Welsh surgeon Hugh Owen Thomas would develop the ‘Thomas Splint’ (Figure 3.) in the mid 19th century and would become most effective in treating patients during the first World War (Le Vay 1956). Thomas’ basic design would soon be elaborated upon with the emergence of modern metallic braces.
Figure 3. Thomas’ splint, fractures.
Photo Credit: Wellcome Collection. Licensed by CC BY 4.0
AFO braces from the beginning of the 20th century
Polio created a demand for new and more advanced orthopedic structures. The new brace structures were upright, hinged systems made of leather and metal materials (primarily aluminum). Leather boots were also attached at the distal end of the brace. Some structures would only extend to the calf and thigh, but others could be designed to attach at the hip or back. All structures would sit above any clothing, making them external. Famous patients were of 32nd U.S. President Franklin D. Roosevelt (Berish 2016), who wore his braces in secret, and fictional character Forrest Gump. This style would serve patients for the majority of the early and mid 20th century.
Figure 4. Woman with KAFO braces in physical therapy.
Photo Credit: jackcast2015, flickr 2016. Licensed by CC BY 2.0
AFO braces in the latter half of the 20th century
As the later half of the 20th century arose, brace technology progressed in a different fashion. With the emergence of thermoform plastic materials, AFO’s became significantly cheaper and quicker to manufacture. The intrinsic traditional AFO became the golden standard and the basis for other designs to come.
Figure 5. Kevin Orthopedic T100 Traditional AFO.
Thicknesses of the polypropylene plastic could vary, offering patients flexibility or rigidity, depending on the planned healing processes. Additional modifications and customizations were now available because the processes were easy to integrate into the plastic itself. If desired, patients with foot drop could also be served with optional plastic flexible hinges and rivets. Carbon fiber material options also became a recent development in the last couple decades.
Figure 6. Kevin Orthopedic T300 Tamararack Dorsi-Assist AFO.
Figure 7. Kevin Orthopedic D100 Dorsiflex Posterior Carbon Fiber AFO with Posterior Cuff and Spenco Top Cover.
Figure 8. Kevin Orthopedic D110 Dorsiflex Anterior Carbon Fiber AFO with Anterior Cuff and Contoured Foot Plate.
Some braces were designed to externally sit and attach on shoe wear, but fashion styles changed frequently, making it difficult for prefabricated fitting. External braces also weren’t seen as effective compared to the highly customizable, intrinsic traditional AFO.
AFO brace innovations today
However, external braces are beginning to be seen in a different light. Today, revolutionary designs like the XTERN are shown to be significantly effective and easy to use. Prefabrication of a few sizes makes it easier to manufacture and its local size adjustment makes it easy to tailor to a variety of shoes. The XTERN’s plastic makes it easy to thermoform, just like any plastic AFO’s available. It has been proved to withstand incredible athletic forces while providing no discomfort or unwanted rubbing.
Figure 8. Kevin Orthopedic XTERN AFO.
The orthopedic industry only grows when innovations are sought after and explored. According to trends from the research, external braces seemed to not fit with modern expectations. The XTERN proves to be challenging that notion. Not only do clinicians and patients benefit from the innovations, but insurance companies will too. The XTERN innovation is proving to be a win for everyone.
References & Works Cited
Andry, N. 1743. “Orthopædia : or, the art of correcting and preventing deformities in children: by such means, as may easily be put in practice by parents themselves, and all such as are employed in educating children. To which is added, a defence of the orthopaedia, by way of supplement, by the author,” Frontispiece Volume I. London: Printed for A. Millar.
Beckett, D. 1999. “From Bonesetters to Orthopaedic Surgeons: A History of the Specialty of Orthopaedics,” The Surgical Technologist. http://www.ast.org/pdf/173.pdf.
Berish, A. 2016. “FDR and Polio,” Franklin D. Roosevelt Presidential Library and Museum. https://fdrlibrary.org/polio.
Biemans, J. 1999. “Antonius Mathijsen: militair geneeskundige en uitvinder gipsverband,” Brabantse biografieën. Levensbeschrijvingen van bekende en onbekende Noordbrabanders Deel. 5. Heeswijk. https://www.brabantserfgoed.nl/personen/m/mathijsen-antonius.
Brakoulias, V. 1990. “The History of Orthopaedics,” A history of orthopaedics: an account of the study and practice of orthopaedics from the earliest times to the modern era. Parthenon: Carnforth, UK.
Le Vay, A. D. 1956. The life of Hugh Owen Thomas. Edinburgh.
Swarup, I. O’Donnell, J. F. 2016. “An Overview of the History of Orthopedic Surgery,” American Journal of Orthopedics 45(7): E434-E438. https://www.amjorthopedics.com/sites/default/files/ajo04511434e.pdf
Valmassy, R. L. 1996. “Chapter 18: Ankle-foot orthoses,” Clinical Biomechanics of the Lower Extremities. Ed. 1 Mosby: St. Louis, USA.
Wroński, S. 2029. “History of the orthotic devices,” Reh4mat.com. Accessed 12 Mar. 2019. https://www.reh4mat.com/en/orc/history-of-the-orthotic-devices/.
Kevin B. Rosenbloom, C.Ped, Sports Biomechanist
Kevin B. Rosenbloom, founder and president of KevinRoot Medical, is a renowned certified pedorthist and sports biomechanist practicing in Santa Monica, CA. With his continuing research on the historical development of foot and ankle pathologies, comparative evolution of lower extremities and the modern environmental impacts on ambulation, he provides advanced biomechanical solutions for his patients and clients.