Exploring The Role Of Orthoses For Flatfoot Conditions And Equinus
- Volume 24 - Issue 6 - June 2011
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As Dr. D’Amico notes, the presence of equinus influences the secondary, adaptive contracture of the Achilles tendon due to the prolonged, maximally everted position of the calcaneus, which one must identify and address. He says this may involve a night splint to prevent further plantarflexion contracture or serial plaster or fiberglass walking casts to realign the foot and ankle not only in the sagittal plane, but in the transverse and frontal planes as well. For less severe contractures, one may use conventional stretching of the Achilles tendon.
Dr. D’Amico also routinely prescribes peroneal stretching exercises including walking on the lateral border of the affected foot and forcibly attempting to invert the foot while standing. He notes both exercises are more effective if patients perform them in shoes since the sole acts as a lever arm and increases supinatory motion. In the individual with a painful, non-defeatable “spasm,” Dr. D’Amico says a series of intra-articular subtalar joint steroid injections is helpful in restoring motion and reducing pain. He advises accompanying these injections with strapping prior to orthotic dispensing.
After identifying and categorizing the coalition through a computed tomography (CT) scan, Paul Jordan, DPM, suggests looking for the “trigger” mechanism that initiates the inflammatory response and pain. Dr. Jordan subsequently applies a below knee fiberglass walking cast with the foot in neutral. This often leaves the foot in equinus at the ankle but one can accommodate this with heel lifts, according to Dr. Jordan. He has patients wear the cast for four to six weeks with no activity restrictions. Dr. Jordan says one should change the cast in one to two weeks to further reduce ankle equinus.
When casting is completed for the equinus, Dr. Jordan fabricates functional custom orthoses. For the long term, he advises continued stretching and orthosis modifications for skeletal growth. In the past 25 years, he notes that less than 1 percent of his patients with peroneal spastic flatfoot have required surgery.
When do you treat the asymptomatic pediatric flatfoot?
“There is a serious misconception on the part of the public and among a great number of health professionals to equate the problem of ‘flatfoot’ with excessively pronated feet in children,” says Dr. D’Amico. “This is a matter of grave concern since flatness of the arch can be a normal or abnormal finding in foot posture whereas the excessively pronated foot is flattened as a part of a structural malposition.”
Dr. D’Amico also notes that excessively pronated feet may not immediately produce pedal symptomatology but the associated pathomechanics may aggravate the child’s superstructural pathology. At any age, excessive pronation is abnormal, according to Dr. D’Amico, and if one can visualize the excessive pronation, it is excessive.
To identify the excessively pronated flexible pediatric flatfoot, Dr. D’Amico suggests checking for medial talar bulge, lateral concavity, medial convexity, marked calcaneal eversion, the “too many toes” sign, an intact windlass mechanism, medial displacement of the center of force and center of gravity, and associated radiographic changes. After identifying an excessively pronated foot, he stresses the importance of ascertaining the underlying etiology for better conservative management of its accompanying pathomechanics.
Dr. D’Amico says this inherent biomechanical defect of flatfoot is present in “a great majority of children” and is the cause of most lower extremity postural pathology. He cautions that one should not consider excessive pronation of the feet to be a normal finding that children will automatically outgrow.
“Absence of symptomatology in the pediatric foot is an unreliable indicator of foot function,” according to Dr. D’Amico. “The fact that a child does not complain about his or her feet does not mean they are functioning optimally.”