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Hi all
I have recently been referred a patient from my local physio. He is a 14 year old boy who has been suffering from patellofemoral syndrome on inetrmittantly for 2 years. He has been given foot orthoses from other podiatrists( varying shapes, styles and designs). The orthoses have been successful in treating his knee pain however he also has an intoeing gait pattern on both legs. the physio is treating his internal hip position with various physical therapies. However, he has severe medial heel wear on both of his shoes. This is present when he wears orthoses and when he doesn't.
His mother is very concerned about the cost of footwear and also the long term effect of this severe wear on his lower limbs.

He is severly pronated, he has very little external hip rotation, the physio believes this to be of musculature nature. Also of note is that he is very small for his age- he only weighs 28kg. The paediatrician is monitoring this but does not appear to be overly concerned.

My quandry is that this boy appears to require his orthoses as treatment for PFS, but how do I change his orthoses to reduce the amount of intoe and subsequent medial heel wear? I thought if I am to try making an orthoses I might as well not repeat what the other practitioners have already tried.

Has anybody tried gait plates on the previous devices?

No gait plate have been tried. My concern with gait plates is whether they are suitable to be used on an active 14 year old boy?

The gait plate just harasses him into walking straighter, you can grind the excess off in a month or three, whenever the required result has been achieved.
Age shouldn't be a problem unless it becomes symptomatic, in that case just grind it off.
Just put the gait plate as an extension onto the orthotic you decide to make, not a single flat piece as I have seen some people prescribe.
Check with the mother on his sitting position, esp if he has a new PS3 or similar!! He could be sitting in the 'M' position all day long playing shoot-em-ups.
Just don't give up!
Cheers
Mahtay

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Cheers

Mahtay

"Time Wounds all Heels."

cheers mahtay.
That was probably going to be plan with the orthotic, I thought I might see if any other ideas were around though. As for the PS3 that is a high possibility also.

thanks again

Lateral heel wear occurs with an outtoed gait....medial heel wear occurs with intoed gait. The medial heel wear will likely continue as long as he is intoed so you should encourage activities that will externally rotate the hips. Remind the patient and parent that sitting with the feet lateral to the thighs (with the hips internally rotated) is bad and that indian-style sitting (with the hips externally rotated) is good. Also suggest roller blading, roller skating or ice skating to the parent as sports that will help increase external hip rotation.

The more you supinate his pronated feet with an orthosis, the more intoed he will become. You can try a gait plate, but I have never used one successfully in this old of a child. In children such as this I have had some success with a 2-3 mm medial heel skive orthosis balanced slightly inverted (to help medial heel wear) and with a valgus forefoot extension (to help pronate the foot in late midstance to improve angle of gait). Most of the time, a trial and error approach with orthoses is necessary in difficult cases such as this.

__________________
Sincerely,

Kevin

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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
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Useful advice Kevin, thanks.

Robert