Continuing on the subject of Ankle Foot Orthoses, we move on to the Gauntlet Brace, or should I say family of braces. The Gauntlet AFO is described as a custom-made brace designed to support and stabilize the foot and ankle, often used to manage conditions that affect mobility, alignment or stability. It typically encases the ankle and part of the foot, resembling a high top shoe or boot, and is made from materials like leather and plastic or carbon fiber. It is generally recommended for patients who require stabilized talocalcaneal, midtarsal & ankle joints.
Indications for the gauntlet brace include adult acquired flatfoot stage III & IV, PTTD (Posterior Tibial Tendon Dysfunction), Talocalcaneal varus or valgus, Tibialis tendonitis (posterior or anterior), Severe pronation or pes planus, ankle arthritis or DJD (Degenerative Joint Disease), Charcot foot, ankle, subtalar, or midtarsal trauma and chronic achilles tendinitis.
The most commonly used model of the gauntlet Brace is the G120 Standard Model. Variations of this brace include short and tall models, articulating and open models as well as the Balance Brace. Options for each brace exist including closure systems (laces versus leather straps with velcro) or combination models. Various colors of leather are available as well as types of medial and lateral flanges and trim lines above the malleoli. Another option is a heel cut out to assist in shoe fitting. Numerous modifications of the foot portion of the AFO are available very similar in nature to standard custom foot orthosis modifications. The order form for the G120 Standard Gauntlet Brace is available here:
Sorting out which model of Gauntlet Brace to utilize can be a difficult decision, however, most cases will do well with the standard model. Considerations include the patient's size and weight, activity level, pain level, amount of additional stability required or if some motion at the ankle is desired. Familiarity with the indications and advantages for each model is advised. My experience has been to utilize a combination closure system with the majority of the closure that will be within the shoe being standard laces, with a leather strap with velcro at the top of the device. The leather straps have a tendency to stretch over time, but they have the advantage of being more easily adjusted by the patient should swelling occur while wearing the brace.
Accurate impression techniques are critical to the ultimate success in achieving the treatment goals of the AFO. Marking bony prominences such as the malleoli, Navicular tuberosity, 5th metatarsal tuberosity and 1st and 5th metatarsal heads is important. Measuring circumference at the level of the midfoot, malleoli and ankle above the malleoli ensure greater accuracy. My experience is to perform the impression with the patient in a semi weight bearing position utilizing a casting sock or plaster, making sure the impression goes high enough up the calf to include the entire braced area. The patient should be seated with the foot gently resting on a cushioned surface. For additional accuracy the weight bearing surface of the inside of the intended shoe or boot should be simulated, usually a 1 or 2 cm heel rise. The patient's knee should be directly above or slightly forward from the patient's ankle which generally involves the patient sliding forward somewhat in the chair. The knee should also be directly above the ankle in the frontal plane unless the patient has a severe valgus or varus deformity. The foot should be positioned as intended to be held within the brace, however many of these patients have fixed deformities that should be captured in the impression.
If you are unfamiliar with utilizing gauntlet braces in your clinic, I would advise practicing the impression technique a few times before using it on a patient. This is most important when using a casting sock which sets up quickly and doesn't allow adjustments to be made once the material has started to set.
The Gauntlet Brace is an invaluable tool in the practice of lower extremity biomechanics. It is a wonderful option in difficult cases and can provide an alternative to surgery in some cases, and also provides the opportunity to prevent further pain, disability and deformity of many foot and ankle conditions.
