Podiatry Arena members do not see these ads

I have a 53 y.o. female patient who weighs 155 lbs and has foot drop after a laminectomy x 2 with complications 20 years ago. She has a strong EHL but very little ant. tib. and does not wear an AFO. I think she is reconsidering the AFO after meeting with me but still wants orthotics for her heel, arch, met head pain. Her arch is chronically swollen, "boggy," and thick to palpation. I don't have the MRI with me now, but I remember it showed no tear of her plantar fascia according to the DPM's note. With overuse of her EHL she clearly is pulling on the medial band of her fascia which I'm sure is part of the arch irritation. Her subtalar joint does not supinate much however with the Hubscher Maneuver, and she has significant navic. drop coming into midstance. She obviously also has a short gastroc which I assume contributes to her pronation.

My concern is controlling her pronation without irritating her arch due to the overuse of her EHL. I'm concerned about asking the lab to make a plantar fascia accommodation due to the difficulty in getting proper placement. Normally I would pour the cast inverted, use a skive, etc. but I don't want the arch height to be a problem. I planned on using a small lift given the short gastroc which I assume will help with control somewhat, but does anyone have any thoughts on controlling her pronation without irritating her arch given how much she uses her EHL without an AFO?

Thank you!

Ann

Mark the plantar fascia on the foot in the area you want the accommodation, when you cast the foot this should be transferred to the negative cast, re-mark this on the negative and it should transfer to the positive. When using this technique, I "pin" this on the positive and then use a felt addition to the cast to create the accommodation in the shell. Alternatively, you could have the lab make the shells up without an accommodation and transfer a marking in vivo and grind out using a bench grinder or even a nail drill. You could use a a thick top cover -say 3mm EVA and cut the accommodation into that. Alternatively if you are using cad/ cam devices have the lab thin the under side of the medial longitudinal arch area of the shell- you can be less specific with the site and increase the flexibility of the shell in this area. Just a few thoughts and a few cat's skinned to achieve a similar goal. Hope this helps.

__________________
Science is the antidote to the poison of enthusiasm and superstition

My location

Good advice.

My approach would be to use a bulkier but softer arch pad. Something like 6mm P92 over 6 or 9mm poron valgus filler with a soft heel wedge / skive (tadpole) can give a great deal of support with considerably more comfort than a rigid casting material in my experiance.

I would also be wondering about getting her in something like an ossur foot up. Its a good comprimise for those uncomfortable with a rigid AFO and can suppliment well in patients with weak, but still present extensor function. Might damp the EHL requirements and solve your problem that way...

Kind regards
Robert

Ann

I would definitely agree with Robert about the use of the Ossur Foot up product. It can either be attached to the shoe or to a 'sock' and patient compliance is very good - just as ling as they can reach their feet to clip the foot/shoe section to the ankle section.
Also I tend to try and reduce plantar flexion moments by 'softening' the heel - grind offs. SACH mods or similar.
Re reducing arch irritation, medial heel skives may be able to reduce the velocity of mtjt collapse/pronation and this can be helped by using a soft arch pad that is positioned posteriorly under the proximal medial aspect of the calcaneus with its peak height at the navicular and then dropped away form the PA.

Cheers

Phil

I would use a ritch brace with dynamic dorsi flex assist tamarac ankle joint. Make the sole polate a regular sagital plane device 3 or 4 deg ff valgus intrinsic with a revers morton's ext and cut out the first ray. No need then for a pl fascial groove.

A dress orthoses would be made the same with no heel stabilizer. I have done this a number of times. Works well clinically and the clients seem to like the feel and their walk is less labourd.

__________________
Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

my appologies, a Ritchie brace

__________________
Graham Curryer

None of us know what we are doing, but some of us know more about what we are not doing than others!::

Clever. Never used one like that. Good concept.

Robert

Why use the word "instead"?

How is an orthotic under the foot going to replace the AFO influence of dealing with foot drop?


I could understand the word 'and', but not 'instead'. Richard Chasen, may be able to give us a definitive answer.



Ron Bateman
Physiotherapist (Masters) & Podiatrist

Ron,

I used the word "instead" because the patient does not want an AFO. She and I are both aware that her foot drop will not be controlled with a foot orthotic.

Thanks for everyone's input so far!

Ann

It is a shame this lady has a defined PNS lesion - these type patients do well with new generation neurostim such as walkaide or similar.
Must be careful medicolegally with these footdrop patients for whom an AFO is not recommended / suggested as they tend to look to blame someone / something when they fall and smash a wrist.