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Dear All,

Have recently seen a nine year old boy who is suffering from Kohler's in the L foot (see attached films).

Some background -
General Health good, nil developmental issues, active child, described as an idiopathic toe walker (yet I did not see any walking as he he is now NWB with crutches). Had been having some issues with mild midfoot pain last year but they seemed to settle suddenly in May of this year "collapsed in a heap" and severe pain. Mother went ot GP who had plain films taken and then referred him to the local hospital orthopaedic section.

Intial Rx - casting and NWB for 4 weeks and follow up films.
Current Rx - NWB with crutches and pressure stocking.

I have seen him the once and was unwilling to be too hands on incase it flared things up as he is now finally pain free. I did detect marked wasting of the muscularture of the L leg which the mother is concerned with.

My current Rx plan are the following -
1. NWB exercises using a theraband of the symptomatic foot and leg to tolerance and to maintain the NWB protocol.

What I would like to hear from others their thoughts on using an ankle or BK airwalking boot with some deflection padding if required, so as to maintain mobility reduced muscle wastage and bone re-absorption.

Regards

Attached Images

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__________________
Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000

Treat the child with gradual increase in weightbearing activities with cam-walker style boot to pain tolerance and to minimize any swelling or gait changes. Cast the patient for foot orthoses while the child is still being treated with the boot so that on boot removal, the child can be transitioned into hiking boots with foot orthoses with medial heel skives, deep heel cups, minimal arch fill and slight forefoot valgus extensions (all which are designed to attain treatment goal of optimizing a decrease in interosseous compression forces on the navicular). He may then be progressed with the orthosis into a low cut shoe with good sole stability. A good foot orthosis can mean the difference between pain or no pain with these patients....by the way, for the sake of the child, don't allow a researcher that thinks that there is "no evidence to justify the use of in-shoe orthoses in the management of flexible excess foot pronation in children" to make these orthoses.

__________________
Sincerely,

Kevin

**************************************************
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
**************************************************

Thanks Kevin,

Is there a time frame for your suggestions? or it simply as the pain resolves?

In your opinion and any others reading the post is there any benefit in the material to be used in the casted orthoses i.e poly prop from 2mm to 5mm or EVA from 120 to 450?

I would most probably use 4mm polyprop with maximum navicular control deep heel cup, medial heel scive of 8 degrees, 1st ray cut out and I like the idea of the Fore Foot Valgus wedge.

Regards

__________________
Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000

No specific time frame. Use palpation of navicular for tenderness, observation of any swelling over navicular, any increase in skin warmth over the navicular, any pain with range of motion (plantarflexion of medial forefoot on the rearfoot) and gait function as guides to clinical healing. Serial radiographs should be performed every four weeks for 4-6 months to assess the shape and density of the navicular.

I would use a 4-5 mm polypropylene plate and rearfoot posts. I would also invert the cast 3-5 degrees, use minimal medial expansion, use a 3-4 mm medial heel skive (at a 15 degree varus angle), not use a first ray cut out, and use a forefoot valgus extension to unload the medial column.

Please let us know how the boy gets along.

__________________
Sincerely,

Kevin

**************************************************
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
**************************************************

Thanks Kevin shall cerainly keep you informed of his progress.

Regards

__________________
Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000

Dear Kevin and other interesed,

Have reviewed this patient recently he is now out of the cam walking boot and in hiking boots and moulded innersoles and pain free. Mother and ptn are very happy.

Latest plain films show bone remodelling

Thanks for the help

__________________
Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000

Its always great when those who ask for help come back and report the outcome, especially to those who take the time to reply. Thanks Mark.

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Mark:

Thanks for the update. It would be interesting and very educational for the hundreds of clinicians that are following along if you could post the follow-up radiographs of this patient so we can all see the changes that occur with healing and maturation of the navicular with your excellent treatment of the patient.

Good job, Mark.

__________________
Sincerely,

Kevin

**************************************************
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
**************************************************

Dear Interested parties I am unable to shrink the size of the jpeg so I can attached the latest xray images of the Kohlers case,

Any ideas how to do this??

__________________
Mark Egan
Absolute Podiatry
331/33 North St
Spring Hill, Qld
4000

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eMedicine has the full text of this on Kohler Disease

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Hi

Im a prosthetics and orthotics student so please forgive my questions as they will seem rather dumb to you but I just cant seem to find the information im looking for to complete my foot orthosis!

Im slightly confused by the orthotic aims for kohler's disease!

Im assuming the aim is to shift weight bearing off the navicular. So this is achieved by supinating the foot (inversion, adduction and plantarflexion).

Im just confused because from the information ive gathered, it seems that patients are shifting their weight to the lateral border to avoid pain. So how is the orthotic any different???

Also, my lecturer asked me am I correcting the pathology or am I accommodating it? My understanding is that accommodating would be more appropriate for older patients, as opposed to children.


So basically, could someone simplify the design of the orthoses that was recommended?

eg. medial heel skive? is that like a rearfoot post where a wedge shape will be thicker at the medial border and run thinner laterally??
minimal medial expansion?
forefoot valgus extension ?


any information would be much appreciated!!!
thanks