as shown in fig1 and 2 , the brace of the present invention is generally indicated as 10 and is specifically designed , as set forth in detail below , to effectively off - weight the plantar surface of a patient suffering from plantar sores and ulcerations while still allowing free and comfortable ambulatory motion for the patient wearing the brace . in short , a significant portion of the downward force is removed from the patient &# 39 ; s plantar surface . the term “ off - weight ” is defined herein to mean the transfer of a patient &# 39 ; s weight from a plantar surface to the shells and adjustable bladders that comprise the brace of the present invention . hence , as noted above , the brace of the current invention differs significantly from the adjustable casts that are currently available . these casts are designed primarily to immobilize an area contiguous to the fracture to prevent the fractured limb from flexing . the device of the current invention , however , functions as a brace rather than a cast . in particular , the brace redistributes or redirects a patient &# 39 ; s weight from the plantar surface to the brace itself . in so doing , the brace effectively off - weights the plantar surface . the brace of the present invention also significantly reduces shearing forces to the plantar surface and minimizes shearing forces at the plantar surface , thereby allowing the ulcerations to heal . the general nature of a preferred embodiment of the instant invention may be readily understood with reference to fig1 and 2 . the brace of present invention comprises a first rigid shell 12 and a second rigid shell 14 which are generally shaped to conform to the shape of the lower leg and foot . thus , the shells 12 , 14 have a generally semi - cylindrical cross - sectional configuration and are essentially in the shape of an “ l .” each of the shells 12 , 14 has two edges that run the entire length of the shell 28 , 29 . the first shell 12 preferably includes a vertical section 16 which extends substantially from the patient &# 39 ; s heel upwardly to a height equal to roughly the calf . the vertical section 16 includes a first section which is shaped to at least partially surround the calf 18 and a second section which is adapted to conform to the rear of the ankle and heel 20 . the vertical section 16 preferably surrounds approximately three - quarters of the circumference of the leg . the first shell 12 also includes a lower horizontal section 22 which extends from the heel outwardly at substantially a right angle from the vertical section 16 . the horizontal section 22 is adapted to at least partially surround the plantar surface and sides of the foot . the horizontal section 22 preferably extends horizontally a sufficient distance from the heel to surround at least a majority of the foot which is received therein and most preferably extends the entire length of the foot . the second shell 14 has a similar configuration . the vertical section 24 of the second shell is adapted to receive the front of the lower leg or shin . a horizontal section 26 of the second shell extends outwardly at roughly a right angle from the vertical section 24 and is shaped to at least partially surround the instep and upper portion of the foot . preferably , the horizontal section 26 of the second shell extends outwardly from the vertical section 24 a distance which covers at least a majority of the upper foot and most preferably extends to cover the entire length of the upper foot such that , together with the horizontal section 22 of the first shell , the entire foot is enclosed by the shells . at least one bladder is disposed within the interior space of each of the first and second shells . the bladders are bags formed from plastic sheets which have been sealed along the outside edges . the bladders contain a filler . at least some of the bladders are adjustable and include an injection valve through which filler can be added or removed . thus , the term adjustable refers to the fact that the size or volume of the bladder can be readily adjusted by either adding or removing filler from the bladder . this is a particularly important feature in that it allows the interior space of the brace to be varied in accordance with variations in the leg sizes of different patients as well as with changes in an individual patient &# 39 ; s leg so as to maintain a constant pressure between the bladder and the leg . preferably , the bladder placed within the first shell is adjustable , whereas the bladder in the second shell need not be adjustable . as best seen in fig2 and 5 , the first shell 12 has concentrically disposed therein a first adjustable bladder 60 which generally conforms to the interior curvature of the shell but which may extend beyond the width of the shell on either side to surround a greater portion of both sides of the leg than the shell itself . the first bladder 60 typically extends essentially the entire length of the vertical section 16 of the first shell , thereby encompassing the calf and ankle regions of the leg , l . this first bladder 60 preferably is formed by a radiofrequency welding process such that a thin weld 62 extends vertically downward the length of the bladder , thereby dividing the bladder into two sections ( see fig7 a ). each section preferably has an inlet valve 100 molded or welded into an upper portion of the bladder through which additional filler material can be added or removed in accordance with changes in leg size . referring again to fig2 a second bladder 70 is concentrically disposed within the second shell 14 and generally conforms to the interior curvature of the second shell . whereas the first bladder 60 may extend beyond the width of the first shell 12 , the second bladder 70 generally covers the entire interior surface of the second shell 14 but does not extend beyond the longitudinal edges 29 thereof . unlike the first bladder 60 placed in the first shell 12 , the second bladder 70 typically is not divided into subsections and need not be adjustable . in those cases when the second bladder is not adjustable , the second bladder 70 is completely sealed and contains a fixed volume of a relatively non - compressible material and thus acts as a pillow or cushion for the front part of the leg . the combination of the first and second bladder 60 , 70 preferably substantially surround the patient &# 39 ; s leg . referring now to fig5 - 7 b , in a particularly preferred embodiment , a third adjustable bladder 80 is positioned within the first shell 12 and extends vertically from about the mid - heel area of the ankle region 20 approximately midway up the vertical section 16 of the first shell , i . e ., to about mid - calf height . preferably , this third bladder 80 has a central region 82 and wings 84 on either side thereof ( see particularly fig7 b ). viewing the brace from the front as it stands vertically upright ( fig7 ), the central region of the third bladder 82 is centered within the interior portion of the first shell 12 . the wings 84 of the third bladder when fully extended ( prior to placing a leg within the shell ) extend outwardly beyond both edges 28 of the first shell . hence , once a foot is inserted into the first shell 12 , the center part 82 of the third bladder 80 surrounds the achilles heel region and the wings 84 of the third bladder can be wrapped at least partially around the sides of the patient &# 39 ; s ankle . the third bladder 80 is also preferably positioned between the first shell 12 and the first bladder 60 . this arrangement allows the inlet valve 100 welded onto the third bladder 80 to be conveniently extended through a lower portion of the first shell 12 , thus allowing the facile addition or removal of filler material from this bladder ( see fig5 ). the welds in the first and third bladders 60 , 80 are preferably positioned so that the welds of one bladder overlap with a non - welded region in the other bladder so as to avoid the creation of pressure points against the leg . as described in additional detail below , the third bladder 80 can act to securely immobilize the ankle within the brace , thereby preventing the foot from moving up and down relative to the footbed 52 . this helps to eliminate contact between the footbed and the metatarsal region which is an area where foot ulcers are particularly prevalent . as illustrated in fig6 in some instances it may be desirable to extend the third bladder 80 into the heel region 81 of the footbed 52 to elevate the heel to further reduce the likelihood of contact between the metatarsal region of the patient &# 39 ; s foot and the footbed . the third bladder 80 can be extended even further yet to include the midfoot region 83 of the footbed to reduce further the possibility of contact . the material used to fill the various adjustable bladders can vary . in general , the filler material selected should be one that undergoes only minimal expansion or contraction with changes in altitude or as the temperature within the brace fluctuates . this type of filler is important in avoiding pistoning of the leg within the brace . such movement , of course , could result in the plantar surface making direct contact with the footbed , thereby further aggravating the ulcerations and delaying the time for healing . examples of such fillers include non - compressible silicone , injectible polyurethane foam , silicone and wax liquid composites and compressible silicone liquid . the use of non - compressible silicone has been shown to give particularly good results and to effectively negate pistoning of the leg in the brace even with the temperature changes which commonly occur within a patient &# 39 ; s brace . existing adjustable casts are designed primarily for fracture care and have typically utilized inflatable bladders that are filled with air . use of air inflated bladders for the treatment of plantar ulcerations , however , is not preferred , because of the tendency for air to expand or contract with temperature fluctuations within the brace . the fillers listed above all expand and contract less in response to temperature and altitude changes than air . expansion can create painful pressure against the leg and can aggravate the circulation problem diabetic patients already experience . contraction of the filler material , as just noted , results in harmful pistoning of the leg within the brace . the inlet valve 100 through which filler is added or removed is preferably made of a tubular piece of plastic that has two ends . as shown in fig4 a , one end 102 is molded or welded into one of the bladder sheets 104 . the end of the injection port which is not connected to the bladder preferably includes a flexible cap 108 . the inlet valve 100 extends through an aperture 106 in the shell to facilitate the addition or removal of material from the exterior of the brace . the cap 108 is sufficiently flexible so that it can be forced through the aperture 106 in the shell . however , the cap 108 is larger than the aperture 106 so that once the cap has been forced through the aperture it expands along the exterior of the brace and assists in holding the bladder in the proper location . however , the inlet valve can be made of alternate materials , have a different structure and be located at other positions as would be appreciated by those skilled in the art . the two shells of the brace 12 , 14 are joined by first placing the shells in abutting relationship with respect to one another . the second shell 14 preferably has flared longitudinal edges 30 as indicated in fig2 and 4 so that the flared edges of the second shell slightly overlap those of the first shell 12 . the two shells 12 , 14 are then fixedly connected or immobilized with respect to one another by the use of a fastening system . the fastening system can include belts manufactured of a hoop and pile material ( most commonly sold under the trademark velcro ). with reference to fig1 and 9 , one possible arrangement includes a plurality of belts 32 each of which contain separate sections of both hoop and pile material . one end of the belt 32 is connected by rivets 34 to one exterior side of the first shell 12 ; a metal loop 36 is attached by anchor rivets 34 to the opposite exterior side of the first shell . the belt 32 is then extended over the second shell 14 , passed through the metal loop 36 and returned back over the second shell . the hook and pile sections of the belt 32 which overlap are then connected to create a secure attachment between the two shells 12 , 14 . a more preferred fastening system is illustrated in fig8 and includes a plurality of straps 38 and a cam - type buckle unit 42 . the strap 38 is connected by rivets 34 to one side of the exterior of the first shell 12 and contains a plurality of ridges 40 , but preferably contains only two ridges . the cam - type buckle unit 42 is attached on the exterior of the opposing side of the first shell . the cam - type buckle unit 42 includes a hoop 44 that can engage the ridge 40 on strap 38 . when a lever 41 of the cam - type buckle unit 42 is pushed into the closed position , the strap 38 is held securely in place . a variety of other fastening systems could also be used provided the system securely holds the two shells together to form a unified brace structure . as shown in fig8 and 9 , the fastening system preferably includes three straps or belts . two straps or belts are positioned on the vertical section of the first shell . in general , one strap or belt is positioned near the top of the vertical section and another strap or belt is positioned near the mid - point of the vertical section of the first shell , i . e ., about mid - calf level . the third strap or belt is preferably located at approximately the instep of the foot . the fastening system preferably also includes a locking means which prevents the patient or unauthorized personnel from opening the brace ; alternatively , the locking means may be designed so that the patient can unlock the fastening system but not without the unlocking being obvious to the attending physician . examples of potential systems include a pin and hole system or a wire and clamp system . in these cases , the pin cannot be removed or the wire cannot be cut without such action being obvious to the physician . this is an important feature of the brace design to ensure patient compliance with the treatment regime prescribed by the attending physician . a sole walker or rocker 50 is attached to the underside of the horizontal section 22 of the first shell as shown in fig1 and 2 . the sole walker 50 can be made of a variety of non - slip materials . examples of such materials include crape rubber , hard rubber , a vibram sole or other alternative rubber based materials . the sole walker 50 can also have a tread design molded therein to further reduce the likelihood of a patient slipping while walking with the brace . the sole walker 50 preferably extends essentially the entire distance of underside of the horizontal section 22 of the first shell . in a preferred embodiment , the sole walker 50 has convex curvature as shown in fig5 . the current inventors have found that sole walkers 50 that are curved , particularly those in which the rockers have a greater radius in - line with the patient &# 39 ; s tibia , result in the patient spending more time on the heel and less time on the forefoot . this design helps eliminate the propulsive phase of gait and is important in minimizing the shearing forces on the metatarsal region where ulcers are more prevalent . this particular combination of elements yields a brace which is effective in treating plantar ulcers , including those on the feet of patients suffering from neuropathy . in particular , the adjustable bladder ( s ) in combination with the cushioned bladder located in the second shell provide a uniform pressure around the entire leg and ankle region . this uniform pressure means that a patient &# 39 ; s weight can be effectively transferred from the plantar surface and redistributed to the shells of the brace , thereby eliminating or significantly reducing the direct downward pressure or force exerted on the plantar surface , especially the metatarsal region which is particularly susceptible to plantar ulcerations . furthermore , the combination of the wings of the third bladder 84 which wrap alongside the side of the ankle and the additional support provided from the first bladder are important features in preventing the foot from plantar flexing ( i . e ., preventing the foot from flexing at the ankle , thereby keeping the foot in a primarily horizontal orientation during ambulation ). for patients suffering from plantar foot ulcerations , the fact that the first and third bladders cooperate to effectively restrict foot motion is particularly critical , as this keeps the foot from flexing downward and contacting the footbed located in the first shell . if the foot were allowed to plantar flex , the shearing forces generated as the plantar surface rubbed against the footbed would further aggravate any sores or ulcerations and hinder the healing process . thus , unlike the casts developed to date , the positioning of adjustable bladders in the brace of the current invention effectively prevent plantar flexing , off - weight the foot and reduce shearing forces to the plantar surface — a combination of results which is required for effective treatment and timely healing of plantar ulcerations . these combination of results make the cast especially beneficial in treating plantar ulcers for patient &# 39 ; s suffering from diabetic neuropathy . this contrasts with certain existing air inflatable casts which contain warnings that the casts should not be used by patients incapable of communicating physical discomfort . variations of this general design can be utilized to further enhance the effectiveness , convenience and comfort of the brace . for instance , preferably , the inner diameter of the first and second shell members are tapered inward near the ankle region and tapered outward near the upper leg region to more closely match the physical dimensions of an average human leg . if desired , hinges 57 such as those shown in fig3 may also be attached near the edges of the first and second shells 12 , 14 to facilitate the joining of the two shells once a patient &# 39 ; s leg has been placed between the shells . in order to enhance patient comfort , a narrow foam cuff 58 is preferably adhered to the upper edges of the vertical sections of the first and second shell which are in contact with the calf and shin , respectively ( see fig1 and 2 ). although the volume of the adjustable bladders can be varied to accommodate a variety of leg sizes as described above , the effectiveness of the brace can be optimized by the use of various sized braces . typically , three sizes — small , medium and large — are sufficient to accommodate nearly all patient leg sizes . in fact , braces according to the present design have been effectively used to treat patients in which the smallest part of the calf size ranged from 19 to 26 inches in circumference and in which the largest part of the calf ranged from 23 . 5 to 49 . 5 inches in circumference . a variety of plastic materials can be utilized in the construction of the brace , provided the materials establish a rigid shell structure . polypropylene and rigid polyurethane are examples of preferred plastic materials . the thickness of the shells is preferably between 0 . 125 and 0 . 156 inches thick and most preferably is 0 . 156 inches thick . the desired shape and taper can be achieved using standard thermoforming processes . the material selected for the interior of the horizontal section of the first shell , i . e ., the footbed 52 ( see fig2 and 7 ), should have minimal resistance to shearing forces . examples of materials satisfying this criterion include silicone , low density foam materials such as polyolefin - based compressible foam , polyurethane foam rubber and open - cell polyurethane and polyethylene in the 1 . 5 lb to 3 . 0 lb per cubic foot density range . the material making up the footbed 52 generally is cut to cover the entire width and sides of the horizontal section of the first shell as illustrated in fig2 . the material can be die cut or thermoformed to the proper size and shape . adhesive or double - backed adhesive tape can be used to securely fasten the material to the footbed . typically , the bladders are manufactured of a urethane material , although other plastic materials could also be utilized . such materials , however , do not allow body heat generated between the leg and the bladder to easily escape . hence , as illustrated in fig4 an absorbent layer 54 is preferably attached to the surfaces of the bladders which abut the surface of the leg . this arrangement places an absorbent layer 54 which can absorb perspiration between the bladder and the leg surface . the absorbent cloth can also reduce the incidence of allergic reactions to the bladder material . examples of materials that can be used for the absorbent layer include , but are not limited to , felt cloth and cotton materials . pressure transducers or sensors 56 can also be sandwiched between a shell wall and a bladder to monitor the pressure of the bladders against the patient &# 39 ; s legs ( see fig5 and 6 ). this is important in ensuring that a constant pressure is maintained throughout the treatment period and to protect against unduly high pressues which might cause discomfort to the patient and hinder circulation through the leg . alternatively , pressure at the leg can be determined from the back pressure at the inlet valve using known correlations between back pressure at the valve and pressure at the leg . with this description of the brace itself , the method of using the brace of the present invention to treat patient &# 39 ; s having plantar ulcerations can be readily understood , particularly with reference to fig2 . the two shells 12 , 14 are initially separated . if hinges are used to join the shells 12 , 14 , than one of the shells is swung open to provide access to the interior regions of the shells . the patients leg , l , is then positioned within the first shell 12 and the first bladder 60 positioned to surround the calf region 18 and achilles &# 39 ; heel region 20 of the patient . if the third bladder 80 is used , it is also arranged in the ankle region and the opposing wings can be positioned alongside the sides of the patient &# 39 ; s ankle . the second shell 14 including the second bladder 70 is then placed over the shin and top of the patient &# 39 ; s foot to enclose the patient &# 39 ; s leg , being careful to ensure that the various bladders essentially completely surround the patient &# 39 ; s leg ( as shown in fig4 ). in joining the second shell 14 , the flared edges 30 of the second shell are placed over the edges of the first shell 28 . the two shells 12 , 14 are then fixedly joined using the straps or belts 38 attached to the first shell , after first passing the straps or belts over the second shell , to form a unified brace . a locking means connected to the fastening system can be employed to keep the patient from removing the brace , thereby assuring patient compliance with the physician &# 39 ; s treatment instructions . of course , the order in which the shells are applied to the leg could be reversed . the desired pressure in the shells is achieved by injecting the appropriate amount of filler into the adjustable bladders . as noted above , a preferred filler is non - compressible silicon , although injectible polyurethane foam , silicone and liquid wax composites , and compressible silicone liquid can also be used . the filler material can be injected into the adjustable bladders through the injection ports welded into each bladder using a device which is very similar to a caulking gun . a hand trigger is used to pump the silicone out of silicone tubes that are typically 6 to 8 inches in length . preferably , the inlet valve contains an internal valve which is opened when the nozzle of the gun is inserted therein and then closes when the nozzle is withdrawn . the filler could also be injected by various manual or automatic pumping systems . as noted earlier , the desired pressure can be monitored using sensors located between the interior shell wall and the adjustable bladder or from correlations between back pressure at the inlet valve and pressures on the leg . the volume of filler in the bladders is adjusted to provide the uniform pressure necessary to ensure that the plantar surface of the patient &# 39 ; s foot is effectively off - weighted and plantar flexing minimized . as the volume of the patient &# 39 ; s leg changes due to edema or atrophy , proper pressure can be restored by adding or withdrawing filler as appropriate . since the bladders are adjustable , they can also be reused simply by adding or withdrawing filler as necessary . while the present invention has been described with respect to several preferred embodiments , and while changes and modifications have been discussed , it should be understood that various other changes and modifications could be made to the brace of the present invention without departing from the broad scope of the current invention . for example , other fillers besides those listed herein could be used so long as the fillers satisfy the general requirement of expanding or contracting less than air in response to temperature or altitude changes . the type of fastening system could also vary from the velcro and buckle and cam systems described herein . similarly , a number of different locking schemes could be utilized .
the present invention provides methods and an apparatus for treating patients having ulcerations of the lower foot , including patients suffering from diabetic neuropathy . the brace generally includes a pair of rigid shells , a fastening system for joining the shells together to form a unified brace and a combination of bladders which engage the patient &# 39 ; s leg and ankle to off - weight the plantar surface , prevent plantar flexing and minimize shearing forces to the plantar surface . the volume of the bladders may be adjusted by the addition or removal of a filler in order to maintain a uniform pressure between the bladders and the patient &# 39 ; s leg . the filler contained in the bladders preferably does not undergo significant expansion or contraction in response to temperature or altitude changes . the brace also preferably includes a series of full - length bladders and a specially designed adjustable bladder located within the ankle and heel region of the brace to maximize off - weighting and to prevent the foot from moving downward toward the footbed of the brace . in addition to providing an effective means for off - weighting the plantar surface of a patient , the brace is reuseable , easy to apply and fully adjustable to accommodate changes in a patient &# 39 ; s leg size .