10 minute read
Transformations
by AOPA
Mike Muratore, CPO, works with Alex Smith outside the Hanger Clinic facility outside the Hanger Clinic facility
Against the Odds
Mike Muratore, CPO, helped NFL quarterback Alex Smith return to the field after a devastating injury, 17 surgeries, and 12 orthotic interventions
New for 2023, O&P Almanac debuts the Transformations column. Each month, you will meet an O&P clinician who will share the success story of one inspiring or challenging patient. We start off this month with the story of Mike Muratore, CPO, who treated NFL quarterback Alex Smith when he required a unique orthotic solution.
It was Oct. 11, 2020, and Hanger Clinic prosthetist/orthotist Mike Muratore, CPO, was anxiously focused on his TV. This was no ordinary Sunday of relaxing and watching professional football. It was the second quarter, and the thenWashington Redskins were playing the Los Angeles Rams when starting quarterback Kyle Allen went down with an injury. The Redskins would have to put in their backup.
When the backup QB took the field, “I wondered: What if I didn’t find the right device, and that kept him from being able to play in the NFL?” Muratore says, recalling the stress he felt that day. After all, treating a patient in the national spotlight, “your success and failure will be presented before the world,” he explains.
When Muratore got the call from the Redskins training staff in 2019, he was already familiar with the background of his new patient. Quarterback Alex Smith had made national headlines when he was injured in a game against the Houston Texans in 2018, suffering a compound fracture that broke both the tibia and fibula in his right leg. His rehabilitation was complicated when he developed a flesh-eating bacterial infection following his initial surgery; Smith endured 17 operations before he could fully start the recovery process and, in his own words, was “very much lucky to be alive.”
Once Smith had recovered to the point that he was ready to begin walking, the Redskins (now Commanders) contacted Muratore for his assistance in finding an
orthotic solution. During their initial meeting, Muratore recalls that Smith was using crutches and wearing a Sarmiento orthosis. Muratore could see his wounds were still deep and his skin graft very recent.
“I did what all of us would do,” says Muratore. “I started manual muscle testing. I knew that he had an injury; I knew the nerve was compromised. I knew that he had lost some muscle.” Then, Muratore discovered the entire anterior lateral compartment of Smith’s leg was debrided down to the bone. “Basically, what I was feeling on his leg was his vastus lateralis from his contralateral thigh. That’s where we started.”
Moving the Goalposts
Because his leg was so badly damaged by the infections and surgeries—comparable to service members who suffer blast injuries—Smith had sustained footdrop. “We started with simple goals,” he recalls. “When I met him, he had no tibial nail, and was non-weight-bearing. So, his goals were to return to weight bearing, return to walking, return to playing with kids, and perhaps return to being athletic”—but Muratore was not sure if Smith would play football again.
Smith had not “put foot to ground” in months, and “I wasn’t sure how much support he would need,” says Muratore. Because “the volume of his leg was in a state of flux, given an impending [medical procedure], and time was of the essence,” he began by fitting Smith with an off-the-shelf SpryStep and a Fillauer Dynamic Walk, “which allowed me to quickly supply options that would offer Alex immediate aid.”
Smith had his tibial nail implanted and tested the initial braces. “He came back three weeks later into my office and said, ‘When I do loaded sled pulls, this brace pulls a little bit.’” Muratore was shocked to learn Smith was already pulling 200 pounds; the athlete had defied expectations and was progressing much faster than most individuals in similar circumstances. “That showed me that our goal-setting process would have to go deeper,” to meet Smith’s elevated definition of “returning to being athletic.” Muratore and Smith set new, targeted goals of returning to high-impact activity, returning to football conditioning, and returning to professional-level athletics.
To reach those goals, Smith would need a brace that could handle punishing athletic movement. Muratore and Smith worked together and tested out a Richie-style ankle-foot orthosis (AFO) with dorsi-assist joints. Their progress was interrupted when the COVID-19 pandemic began. “Alex went to Hawaii and quarantined there. He sent me a video of him running in the Richie-style brace.” The treadmill was turned off—Smith was powering it with his legs alone, so weight bearing was no longer an issue. At that point, “his only pain was tibial plateau pain, where the tibial nail was driven in. Distally, he was fine,” although he still wanted to protect his skin graft.
“As he progressed through his goals, we needed a more dynamic functional solution,” says Muratore. Once Smith returned to the practice field and began to test his athletic abilities, it was clear he needed a different orthotic solution. Smith saw a televised NBA game showing the Denver Nuggets’ Michael Porter Jr., who had footdrop and was competing wearing a SpryStep Flex AFO from Thuasne; the brace is made of a
Muratore says Smith learned medical terminology to communicate exactly how his ankle and foot were functioning.
flexible material blend, fits into shoes, and offers posterior-lateral strut.
Muratore contacted Fraser Allen, product manager at Thuasne. They discussed composition and materials, and recognized that Porter’s brace was too short for Smith. They considered Smith’s functional goals and brainstormed on how to custom-build an orthosis similar to Porter’s that would meet the quarterback’s unique needs. “He needed a more dynamic solution that would allow him to put his foot on the ground and drive off of it,” Muratore explains. “It had to rotate, it had to have torsion, and he had to be able to plantarflex off of it. But it had to give him enough upward motion of his toe that he cleared the ground.”
Muratore worked collaboratively with Smith to design an orthosis that would allow him to play football professionally once again.
They decided to adapt a SpryStep Flex. “We took a cast” to customize a brace that could fit into a football cleat. “Of that mold, we made three models.” Smith tried all three options and chose the most flexible option. Once Smith tested it at practice, he called Muratore and said, “This is the one!”
“That was surprising for us,” says Muratore, who expected Smith to prefer a stiffer brace. The orthosis offered plantarflexion but also allowed him to cut and twist, and move laterally on the field. Using this solution, Smith was able to fully rehab, and was cleared by the team for football activities. Muratore and Allen helped adjust and tweak the design, particularly in the footplate. “The first feedback he gave was that when he started to run, he was still scraping the grass. So, we increased the dorsiflexion angle 5 degrees. And to give him less third-rocker back pressure, we angled the toeplate up slightly more, and we feathered the carbon out so it was more flexible,” Muratore says. “We wanted the brace to ‘get out of his way,’ so he could pull his foot up— and literally nothing else.” Once they finalized the design, they built him two backups.
Returning to the Field
Smith earned a spot on the roster of the Washington Football Team on Sept. 5, 2020, as a backup quarterback. He altered the way he played compared to pre-injury: “His first step was not as quick,” but he was able to adapt in other ways. He quickly determined the best way to wear the orthosis during play: one sock, then the brace, then a game sock, then a shoe, then tape on the shoe.
Wearing his newly designed orthosis, Smith returned to field 693 days after his initial injury, and during that Oct. 11 game against the Texans, he completed his first pass.
A few minutes later, Aaron Donald, defensive end for the Texans, jumped on Smith’s back and brought him to the ground in the first of six sacks Smith endured. Muratore was watching closely on his television. “I was rocking back and forth worrying from home,” Muratore recalls. He wasn’t sure how durable the orthosis would be under such intense and unique circumstances. “We thought it might de-laminate [and crumble, like folded-up paper], but it actually worked more like a rubber band,” says Muratore.
Smith went on to play in several more games that season, including a memorable performance in December in leading his team to beat the undefeated Pittsburgh Steelers. In an almost-unanimous vote, he earned NFL Comeback Player of the Year honors.
Smith ultimately retired from professional football after that season, but he “ended his career on his own terms,” thanks to orthotic intervention. Today, he works as an NFL analyst for ESPN and spends his spare time with his wife and three children, playing golf, and engaging in other activities. He continues to wear the adapted SpryStep Flex, which he says gives him confidence to participate in rigorous and demanding activities. He also has an off-the-shelf out-of-shoe AFO that just provides enough dorsiflexion to enable a normal walking gait, for everyday activities.
Carrying the Ball
Muratore is grateful for both the benefits and challenges he experienced when treating a high-profile athlete. He worked collaboratively with Smith, who taught himself medical terminology to communicate exactly how his ankle and foot were functioning. “Professional athletes are so in tune with their body and know what they’re feeling, and they’re very good at describing it,” says Muratore. “He knew his muscles, his nerves, internal rotation, external rotation— he could explain how he felt and what he needed from his device in words I understand,” says Muratore, which allowed him to tune the brace quickly.
Treating Smith required extra time and expertise to ensure the right solution to a complicated presentation. He spent many hours traveling to and from the training facility. Other challenges included ensuring his patient’s privacy. “I kept Hanger Clinic’s involvement under wraps—for HIPAA purposes, plus it’s his story to tell.” At one point—after word got out that Smith was being treated at Hanger Clinic—news crews showed up at the facility, but Muratore asked them to leave. “We wanted to protect him and not let him feel ambushed.”
Overall, working with Smith—who is “a genuine individual—kind and courteous, with no celebrity aura”—was an overwhelmingly positive experience. And Muratore learned to take a slightly different approach with dropfoot patients—and some other orthosis users: “Now I don’t take away motion unless I have to,” Muratore says. “The more flexibility you can leave, the more comfortable the user feels.”
He attributes the success of the patientcare experience to a team approach. “The success that we had was based on good communication, being clear and openminded about goals and solutions, and employing all the resources available to us,” he says. In addition to collaborating with Smith and Allen, he also worked with Smith’s physical therapists, trainers, and orthopedic surgeon throughout the process.
“I’m humbled to have been a part of it,” says Muratore. “It was the perfect outcome for a great guy.”
DO YOU HAVE A TRANSFORMATIVE PATIENT-CARE EXPERIENCE YOU’D LIKE TO SHARE WITH O&P ALMANAC
READERS? Contact Editor Josephine Rossi, jrossi@contentcommunicators.com, with your story to be considered for an upcoming profile.
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