Watching a pro football game can be a bit nerve-wracking when one of the players is wearing an AFO that you customized and fitted.
Mike Muratore, CPO, area clinic manager for Hanger Clinic, Bethesda, Maryland, learned that lesson when he saw Alex Smith, quarterback for the Washington Football Team, step onto the field and start playing.
“He was a second-string quarterback at the time,” Muratore says of the day in 2020 when Alex Smith, who has foot drop, walked on the field. “He had to come in very suddenly when the first-string quarterback was injured. I nearly had a panic attack. I was on my knees, rocking back and forth. I was quite nervous.”
He and Alex Smith had been working together for nearly a year trying to perfect that AFO. His foot drop was the result of several surgeries to repair his tibia and a tissue-destroying bacterial infection after breaking his leg in the 2018 season. During multiple debridements, his peroneal nerve was removed.
Muratore and Alex Smith had been through multiple models and more than 16 iterations before eventually deciding on a customized version of the SpryStep Flex, Thuasne USA, Bakersfield, California. Each version, at the patient’s request, had become lighter and more flexible, so much so that the designer at Thuasne said he expected the final version to fold.
Muratore inwardly cringed each time Alex Smith threw the ball or took off running from a 300-pound player. Could any brace take that kind of treatment?
“Have you ever folded a piece of paper a thousand times?” Muratore asks. “That’s what we expected this to do. But it held up.”
Muratore’s nervousness at seeing his device in action is not unique. Other orthotists who have treated professional athletes have had the same reaction when they watched their devices perform under scrutiny while undergoing more stress than most humans put them through.
“When you’re picking your material selection, you have to go by experience more or less, but nobody knows what the forces will be if you have a 250-pound guy running with a 300-pound guy jumping on his back,” says John Held, CO, owner and clinician at Great Steps Orthotics & Prosthetics, headquartered in Sartell, Minnesota. “I haven’t had any break on me yet, but it’s the kind of thing that will keep an orthotist awake at night.”
Not too long ago, orthotists did not have this fear because AFOs weren’t worn in professional games. Foot drop had once been considered a career-ending condition, but that has been changing. Professional athletes like Alex Smith, Green Bay Packers linebacker Jaylon Smith, and Denver Nuggets forward Michael Porter Jr. all had foot drop and were all able to return to their sports with custom AFOs.
Treating these elite athletes is a unique challenge for orthotists who have to find a balance to give players a device that will withstand enormous pressure while simultaneously being flexible enough to allow the athletes to run faster and jump higher than most people in the world.
Know What Is at Stake
A big part of the orthotist’s job when treating professional athletes is to take the process as seriously as the athletes do. For the athletes, Held says, having a device that would cause them to run slower or jump lower is not an option. That is not a concern when designing devices for most patients.
“We’re not typically dealing with someone who will lose their job or their livelihood if what you do doesn’t work,” Held says. “All of these guys have worked hard to get to the top. If they suddenly aren’t as good for a couple of weeks, their entire career is jeopardized.”
These athletes are used to playing through pain, and if a device will limit their mobility, most would rather take the risk and play without a device,
“They won’t be willing to wear something if it slows them down,” Held says.
For foot drop, whether to wear an AFO is not an option. Rather, orthotists are challenged to find the the best device that the patient will agree to use.
“For the athletes I’ve treated, they didn’t have a say in the matter,” says Doug Richie, DPM, owner of Richie technologies, Seal Beach, California, which makes the Richie brace. “It was either you wear the brace, or you don’t perform.”
Even if a brace is working well and giving optimum mobility, it can still be an issue if the athletes believe it might be inhibiting their best performance. Most athletes have a preconceived notion that any brace, no matter how well designed, will slow them down, Richie says. And they are not the only ones.
In many cases, Richie says, it is not just the athlete that the orthotist needs to satisfy. Players are under the care of athletic trainers and physicians, and coaches or other interested parties might also have input.
“The athletes many times direct a lot of the decision-making when it comes to preventive or therapeutic bracing,” Richie says.
Getting athletes and their trainers on board with the brace is necessary for compliance, he says.
“You have to educate them to the benefits of wearing the brace and dispel any preconceived bias the athlete may have about bracing,” Richie says. “You have to get the athlete to buy into the treatment plan. If you don’t, you will fail because they won’t wear it. There are trainers that cave into athletes all of the time even though it’s not in their best interest.”
To help get them on board, Richie says orthotists should set the goals for the treatment. The orthotist should try to find out what ideas the athlete has and dispel anything that is wrong or inaccurate.
“You may need to clarify and lay out reasonable expectations because often you are on two different wavelengths,” he says.
It is crucial to that everyone, including trainers and physicians, agree to a treatment plan and that everyone sticks to the plan, Held says. If the athletes are getting different opinions from different people, they will often choose to listen to the person they are closest to or who says what they want to hear. In many cases, that person is not the orthotist who doesn’t work with them on a day-to-day basis.
“You have more credibility when everyone on the team has the same message,” Held says. “Anytime there’s a difference in messaging, there will be doubt, and there will be issues.”
Also, Richie says, if the condition is not permanent, that should be emphasized. “You always get compliance when the patient knows there is light at the end of the tunnel,” he says.
In the case of Alex Smith, who does not have nerve connection, his foot drop is permanent. Muratore says the two were not even discussing the possibility of return to play at first.
When they first met, Muratore’s goal was to get Alex Smith back to day-to-day activities. Returning to the field was not considered an option.
“Our initial conversation was about whether he would be able to play golf, chase his kids around, or go hiking,” Muratore says.
For the average patient, Muratore would have considered the return to
day-to-day activities as a good outcome. But he soon learned that Smith was not at all average.
Expect to Adapt and Go Through Trial and Error: Quickly
Richie says he wasn’t initially aware that his brace was going to Jaylon Smith, who had developed foot drop after nerve damage, but was drafted by the Dallas Cowboys anyway.
“We made the brace and didn’t realize who or what it was for,” he says. “That’s ok because we do a good job for every brace we make.”
What was different for this case was the pressure the brace was put through.
“It broke about two days later,” Richie says. “We didn’t realize the demand imposed on a brace from a player with this kind of power.”
It took trial and error to make the brace both stronger and more operational. Richie says he used a custom version of the Richie Dynamic Assist brace, which is low profile and does not extend up the leg as far as a traditional AFO.
For Jaylon Smith, Richie says he had to keep increasing the thickness of the plastic to ensure that it was strong enough.
“We went through trial and error to make it stronger and stronger,” Richie says. “After several times we were able to make a brace that was durable and functional. We had started with the standard durometer hinges and increased it to the highest durometer we could. That made it more effective for him because he’s bigger.”
Muratore says he also learned quickly that a traditional AFO would not work for a professional athlete. He initially sent Alex Smith a couple of off-the-shelf carbon braces. Within weeks, he was back and complaining that it was rubbing his foot.
“It was because he was doing 300-pound loaded-sled pulls,” Muratore says. “I kind of started to realize then that this guy was going to push the envelope beyond anything that we had expected.”
Thus started the long process to find the correct brace. At first, he thought they would need a stiffer device to be able to handle the pressure.
“It’s counter-intuitive, but he did better the more flexible it was,” Muratore says. Part of that was because Alex Smith was working so hard to improve that he was going through the rehabilitation process much faster than the average patient.
“Once we realized that stiffness was not what we were looking for, we ended up with something that was minimal and could stay out of his way.”
Muratore says that he and Alex Smith worked closely to find something that would work. They finally decided on the custom, lightweight SpryStep Flex because it allowed him to rotate the way he needed to throw a ball. He says Alex Smith, like most professional athletes, was very in tune with his body.
“Athletes will be able to describe in good detail what they are feeling and what they need to do,” Muratore says. “When we fit them, we also need to be open-minded because the brace you
usually use probably won’t work. You will have to reach into the pantheon of what’s out there.”
Along with finding custom solutions, working with professional athletes means that devices need to be fabricated quickly, the experts say.
“It’s the same process to make the brace, but the difference is that it is much faster and more intense. He needs it by Sunday.”
Held says that his turnaround time on professional and college-level athletes is usually about 24 hours.
“Not every player can wait two to three weeks before they start playing again,” he says. “It’s usually pretty quick when you respond.”
Held says he tells the rest of his team about the assignment and works to get them excited, despite the quick turnaround.
“If they all understand what this means, they will be more receptive to a 24-hour turnaround,” he says. “If they weren’t on board, I know they would still get it done, but they wouldn’t be as happy to work on it.”
Putting the Brace to the Test
Putting an AFO on a professional athlete is the ultimate test of creating a brace that is strong and versatile. The pressure it has to withstand is enormous and the outcomes, whether positive or negative, are public.
Held says that to counter that pressure, he tries to think of the worst possible scenario when creating braces for his player patients.
“Some stress or fatigue is one thing, but you don’t want, if it breaks, to have a sharp piece that can cut somebody,” he says. “You can’t foresee everything, but you want to look at the safety of the product and think about if it can break and question whether it would become dangerous if it did.”
Muratore says he knew he had made the best brace he could, but it was still difficult watching Alex Smith play.
“The brace’s success or failure is on national television,” Muratore says. “They were talking about it on Fox. And there was always the question—if Alex threw an interception, was it the brace’s fault?”
Alex Smith, and the brace, performed well. He led the Washington Football Team to its first playoff berth in five years. Muratore says it was gratifying to see how well Smith could play in his AFO.
“Seeing your work accomplish these goals on a national stage is enormously gratifying,” he says.
At the end of the season, Alex Smith showed Muratore how the brace had held up. It was a mess. It was covered in scratches and was sticky because the athletic trainers had taped the brace to him. He had to use two socks—one that was taped to the AFO and another that covered the AFO.
But despite its ugly appearance, the brace had done its job. Muratore even asked him for it as a souvenir of their time together, but “he wanted to keep it for sentimental reasons,” Muratore says.
Alex Smith has since retired from football, but Muratore says he will always be grateful for the experience of helping a professional athlete come back to the game and put a brace he made through the ultimate test.
“This particular athlete was not only a great athlete but also a great human being,” Muratore says. “He was classy and kind to me and everyone I work with. To help a good guy who is also a great athlete was one of the most gratifying experiences of my life.”
Maria St. Louis-Sanchez can be contacted at