Exploring The Role Of Orthoses For Flatfoot Conditions And Equinus

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Author(s): 
Guest Clinical Editor: Joseph D'Amico, DPM

   Dr. Valmassy emphasizes that if one can control a pronated foot in a patient with a congenital equinus, the individual will develop compensation at another level. Therefore, he suggests assessing the patient for potential genu recurvatum at every visit when there is a suspected congenital equinus. If genu recurvatum develops in a patient with equinus during the course of treatment with a functional foot orthosis, Dr. Valmassy advises clinicians to immediately stop the orthotic treatment and consider surgical intervention.

   Dr. Volpe notes that if one does not recognize the equinus influence in the clinical exam and incorporate management of the equinus into the treatment plan, there will be a higher complication rate with orthoses. If the tension remains on the heel cord and there is semi-rigid control under the midtarsal joint, he notes a great likelihood that the patient will pronate into the shell at this joint, which will cause discomfort.

   Dr. Jordan emphasizes the importance of assessing full lower extremity equinus contractures, not just the ankle joint. When there is significant equinus, he says one cannot adequately address excessive midtarsal joint pronation without first correcting the equinus.

   All panelists note the importance of heel lifts. Dr. Volpe will combine heel raises on orthoses to reduce the need for midfoot compensation. If the total equinus is mild to moderate, Dr. Jordan says it is feasible to use heel lifts as temporary accommodation and one should plan on reducing the heel lift height as the child’s equinus influence reduces. Similarly, for patients with a significant equinus in whom surgery is not an appropriate choice, Dr. Valmassy often utilizes a ¼-inch heel lift beneath the orthotic. He says this allows the patient to better tolerate the correction and to put some slack in the posterior muscle group. Both Drs. Volpe and Jordan suggest stretching exercises.

   If one wishes to reduce midtarsal joint compensation, Dr. Jordan suggests using orthoses with a good plantar-lateral inclination angle as well as a sneaker or shoe with a heel for enhanced orthosis control.

    “If the equinus cannot be corrected or accommodated, attempted management of the foot with orthoses will result in pain or unwanted compensation elsewhere,” Dr. Jordan cautions.

   Dr. D’Amico is a Professor and Past Chairman in the Division of Orthopedics at the New York College of Podiatric Medicine. He is a Diplomate of the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, and a Fellow of the American Academy of Foot and Ankle Pediatrics. Dr. D’Amico is in private practice in New York City.

   Dr. Jordan is in private practice in East Northport, N.Y.

   Dr. Valmassy is a Past Professor and Past Chairman of the Department of Podiatric Biomechanics at the California College of Podiatric Medicine. He is a staff podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco.

   Dr. Volpe is a Professor in the Department of Orthopedics and Pediatrics at the New York College of Podiatric Medicine in New York City. He is in private practice in New York City and Farmingdale, N.Y.

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