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Ankle and Foot

Clubfoot

What is it: Clubfoot (talipes equinovarus) is a congenital osseous deformity that includes varus deformity of both rearfoot and forefoot, rearfoot equinus, and an inverted and adducted forefoot.

Treatment: The initial treatment of clubfoot, regardless of severity, is nonsurgical. The majority of clubfeet can be corrected in infancy in about six to eight weeks with the proper gentle manipulations and plaster casts. Treatment for the newborn with clubfoot is by manipulation to correct the condition and then casting to maintain the correction. Casting begun at a later age may be more difficult due to the worsening ligamentous contracture and joint deformity. Long-leg plaster casts are used to maintain the corrections obtained through manipulations. Casts are changed at weekly intervals, and most deformities are corrected in two months to three months. Despite successful initial treatment, clubfeet have a natural tendency to recur. Bracing is necessary for several years to prevent relapses.

Orthosis: There are several different braces that are commonly prescribed. All braces consist of a bar (the length of which is the distance between the child’s shoulders) with either shoes, sandals, or custom-made orthoses attached at the ends of the bar in about 70 degrees of external rotation. The bar can be either solid (both legs move together) or dynamic (each leg can move independently). Chen et al (2007) found that the dynamic brace has a higher compliance and lower complication rate than the traditional solid brace.The brace is worn 23 hours a day for three months and then at nighttime for three to four years. In children with only one clubfoot, the shoe for the normal foot is fixed on the bar in 40 degrees of external rotation. Bracing is critical in maintaining the correction of the clubfeet. If the brace is not worn as prescribed there is a near 100 percent recurrence rate.

Babies might get fussy for the first few days after receiving a brace, and will require time to adjust. It is important to check the child’s feet several times a day after initiating the bracing to ensure no blisters are developing on the heel.

Sources: http://orthoinfo.aaos.org/topic.cfm?topic=A00296#Nonsurgical Treatment Benefits and Limits,

Lusardi & Nielsen. Orthotic and Prosthetics in Rehabilitation, 2nd Edition.

Chen R, Gordon J, Luhmann S, Shoenecker P, and Dobbs M. A new dynamic foot abduction orthosis for clubfoot treatment. Journal of Pediatric Orthopaedics. 2007Jul-Aug; 27(5):522-B.

Severs Disease

What is it:  Severs Disease, also known as Calcaneal Apophysitis, is a painful foot condition that usually affects children between 9 and 15 years of age. Active children may often suffer from Severs Disease when they experience sharp, aching pain in their feet, particularly in their heels, which may cause them to change their gait.

Severs Disease affects growing, pre-pubescent children. As the growth plate of the calcaneous grows, sometimes the muscles and tendons in the foot grow at a slower rate, causing severe pain when walking or running. Because the calcaneous is growing faster than the muscles and tendons in the foot they become stressed, and as the child runs or plays sports the tension in the muscles can become extremely painful.

Treatment: Initial treatment for Severs Disease should begin with limiting physical activity. Maintaining intense exercise will only cause the pain to worsen and make the condition more severe. Anti-inflammatory medications may also be helpful to some degree to reduce pain. Wearing supportive shoes is also important in order to help keep as much stress off the heel as possible. However supportive shoes alone will not usually be effective in curing the condition.

Orthosis:  Orthotic shoe inserts are a good way to treat the symptoms, as well as help eliminate Severs Disease completely.

Resource: http://www.heel-that-pain.com/severs_disease/index.php

Another orthosis used to treat Severs is the pediatric UFO. This unique lower-limb orthosis positions the foot and ankle in optimal alignment for placing stretch on the soleus while the patient is sleeping. When used in conjunction with a knee immobilizer, this orthosis can also stretch the two-joint gastrocnemius group.

Resource: http://orthomerica.com/products/pediatric/ped_ufo.htm

Ankle fracture

Orthosis: The Air/Gel Ankle Stirrup provides uniform ankle compression and support for sprains, fractures, chronic instability and athletic protection. The pneumatic bladder helps eliminate swelling and edema, and can be used for acute injuries. The removable bladder can be placed in a freezer, providing up to 20 minutes of cold therapy. Fits into most athletic shoes and is universal left or right.

Resource: http://www.cascade-usa.com/products/pediatrics/pediatric%20orthotics/pediatric%20lower%20extremity%20orthoses/ankle%20supports/pediatric%20air-gel%20ankle%20stirrup.aspx

Claw toe

What is it: Claw Toe deformity features hyperflexion of the PIP and DIP joints, although the MTP joint can by hyperextended or hyperflexed. This causes localized pressure at the tips of the distal phalanges, at the dorsum of the toes, or under the metatarsal heads. In weight-bearing, this deformity decreases loading under the toes while increasing loading under the metatarsal heads. It is a rare condition, but usually occurs in conjunction with a cavus foot, present in neuromuscular diseases like Charcot-Marie-Tooth disease or myelomeningocele.

Orthosis: Orthotic options for claw toes

Resources: Orthoseek, Lusardi & Nielsen. Orthotic and Prosthetics in Rehabilitation, 2nd Edition

Gout 

What is it: Gout is related to an increased level of uric acid in the blood (hyperuricemia). Uric acid is a byproduct of purine digestion. Gout mostly affects the joints of foot especially the big toe.

Treatment: The treatment objectives are similar to those for patients with arthritis – preventing or limiting motion of painful or inflamed joints, accommodating foot deformities, and cushioning the impact of loading on the involved joints. A reinforced counter to limit subtalar motion or a high-top design to limit overall ankle motion should be considered. An extra-depth shoe of thermoldable leather is best able to accommodate deformities without creating pain and discomfort over sensitive joints. A rocker bottom can be applied to assist push-off, prevent pedal joint movement, and reduce ankle motion required for push-off. Shock absorbing accommodative orthoses and cushion heels provide even more comfort and protection of inflamed joints during gait

Resources and Orthosishttp://www.docpods.com/Default.aspx?PageID=2710094&A=SearchResult&SearchID=2105614&ObjectID=2710094&ObjectType=1, Lusardi & Nielsen. Orthotic and Prosthetics in Rehabilitation, 2nd Edition

Hallux Rigidus

What is it: DJD of the first MTP joint causing pain, loss of mobility, and eventually fusion of the joint. Osteophyte formation on the dorsal aspects of the metatarsal head and base of the proximal phalanx can be quite painful and result in loss of extension.

Treatment: The goals are to limit motion of the hallux and first MTP joint and to reduce pressure on the dorsal and plantar surfaces.

Custom-Made Orthotics: are considered to be the “Gold-Standard” of medical treatment, especially in the prevention and early stages of Hallux Limitus/Rigidus. A message from OurHealthNetwork.com on how their orthotics work:

Stabilize the foot by using uniquely placed medial wedges, deep heel cups, and “posts”
(stabilizers). When the foot is stabilized, it is brought back to a neutral or normal alignment.
When the foot is in its normal alignment, pronation is reduced or completely corrected, and, the
big toe is no longer forced to bear excessive body weight. This prevents abnormal wear and tear
on the big toe cartilage, and helps to stop or prevent Hallux Limitus/Rigidus from occurring.
Provide the specific amount of arch support. Custom-made orthotics
support not only the arch as a whole, but each individual bone and joint that forms the arch.
When the arch is properly supported, it is allowed to function  in providing optimal shock
absorption for the foot, especially to the big toe joint.  This will reduce the wear and tear on
the joint cartilage.

Stabilize the big toe and limit its movement during the gait cycle. This is accomplished through
the use of a uniquely placed “”stabilizer”” called a Morton’s Extension. It is embedded in our
custom-made orthotics, and placed under the 1st metatarso-phalangeal joint and big toe. It is a
semi-rigid platform, which is covered by a padded material to ensure comfort. This extension limits
the motion of the big toe joint, thus reducing or eliminating pain.  It works in two ways:
o  It reduces/or prevents the big toe from bending and pushing us forward as we walk or run.
o  Its shape allows for a slight tilting of the forefoot that “”off-loads”” the weight from
the big toe to the remaining structures of the forefoot and  toes. When this occurs, the
big toe is allowed to “”rest,”” while the orthotic itself, and the other foot structures take
over the job of the big toe.

Sourceshttp://www.ourhealthnetwork.com/conditions/FootandAnkle/HalluxRigidusandHalluxLimitus.asp(Lusardi & Nielsen. Orthotic and Prosthetics in Rehabilitation, 2nd Edition).

Hallux valgus

What is it: This is a common deformity, where the great toe is deviated laterally to overlap the 2nd toe, and the first metatarsal bone is deviated medially, causing a prominence to form on the medial aspect of the metatarso-phalangeal joint (MTP joint). A bursa forms over the area as a result of the constant irritation and inflammation, forming a painful bunion. There may be some degree of foot pronation (flat feet) associated with the condition. Many factors come into play to cause the problem, including foot structure which may or may not be hereditary, and use of narrow stylized shoes that crimp the toes. Most cases are mild and asymptomatic, and do not need treatment. These patients should be counseled in wearing shoes with lots of toe room and no heels.

Treatment: Hallux valgus is most often the consequence of rearfoot valgus, leading to varus of the first metatarsal. The conservative approaches to treating this condition in children are orthoses and comfortable shoes, with a good heel counter to maintain the heel in subtalar neutral

Orthosis: A custom orthotic can take the weight of your body and dispense it more evenly throughout the foot.  Keeping the foot in a neutral position helps reduce or eliminate most common foot problems. By adding a metatarsal pad and other modifications to a custom orthotic we can manipulate the foot and help with common aches and pains associated with Hallux Valgus. It may also help slow down the progression of Hallux Valgus.  http://archfitters.com/Default.aspx?tabid=63

Sources:  http://www.orthoseek.com/articles/toedeform.html#hallux, Lusardi & Nielsen. Orthotic and Prosthetics in Rehabilitation, 2nd Edition

Other ankle and foot orthoses

 

Hydrogel Toe Cushion Loop

What it does: It is used for toe support and alignment

Indicated for: Hammer toe, Claw toe, Mallet toe

Shoe Insert

What it does: Shoe inserts can evenly distribute the body’s weight throughout the foot and provide arch support

Indicated for: pronation (varying severity), hypotonia

UCBL (University of California Biomechanical Laboratories)

What it does: Fits below the ankle and is used for plantar fasciitis, excessive pronation, metatarsus adductus

SMO (Super Malleolar Orthosis)

What it does: Indicated for excessive pronation or supination

Indicated for: Low tone pronation, high tone pronation or supination

AFO (Ankle-Foot Orthosis):

What it does:  Helps to either prevent drop foot, knee hyperextension, or provide ankle stability

  • DAFO (Dynamic Ankle-Foot Orthosis):  “Is custom molded to intimately fit an individual while providing specific biomechanical help.  This is achieved by way of dynamic assistance, controlled restraint, or both.  A range of styles provide various levels of flexibility in different areas of the brace.”16
    • Indicated for: hypotonia, hypertonia, pronation, supination, swing phase inconsistency, knee hyperextension, crouching gait, positioning
  • Semi-Rigid: intended for patients with dorsal or anterior nerve injuries, Charcot, or Drop Foot
    • Indicated for: Drop foot, Charcot, crouching gait
  • Rigid: intended for maximal motion restriction
    • Indicated for: excessive plantarflexion
  • Hinged:  Can be made with full ROM in the ankle, free ankle with DF assist, and DF assist with PF stop
    • Indicated for: hypertonia supination, swing phase inconsistency, excessive plantarflexion, knee hyperextension
  • Hybrid: Designed with plastic and metal for adjustability, strength, and intimate fit
  • Patellar Tendon Bearing:  Designed to off-load the foot and/or ankle when there is a weight-bearing restriction

Custom Made Orthotics

  • Any orthotic that is individualized for a specific client’s needs

Test Your Knowledge:


 

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