Pertinent Roundtable Pearls On Orthotic Management
Appropriate surgical management of the equinus deformity is the ideal solution, according to Dr. Harris. However, he cautions that both the child and the parents may be very resistant to this form of therapy.
Dr. Dananberg cites the efficacy of manipulating the ankle as a very effective method of care for such patients, noting that ankle manipulation has demonstrated “extremely positive” changes in motion.1 He says one of the most important features of manipulation is the neurologic effect on muscle strength, an effect one cannot attain simply by lengthening the Achilles tendons. He adds that aside from the neurologic change, the effect of manipulation is instantaneous in comparison to the months of recuperation and risk of excessive long-term weakness with tendon lengthening surgery.
If the problem is an uncompensated equinus, Dr. Spencer says the main concern is the absence of heel contact during the gait cycle. In pediatric patients, he has found this is usually the result of congenital or spastic causes. He notes that age is an important factor along with the underlying cause of the uncompensated equinus. If the child is young enough, Dr. Spencer says one may employ serial casting or bracing, and make incremental adjustments to attempt to stretch the tendo-Achilles. For older kids, one can attempt stretching but in patients who have failed all conservative methods, he will refer them for surgical correction of the equinus.
If the problem is apophysitis secondary to traction from the equinus deformity, Dr. Spencer uses a combination of stretching and functional foot orthotic devices. He has found that the orthosis’ decreasing plantar foot tension coupled with the stretching of the Achilles tendon results in rapid resolution of the condition due to the decreasing of traction forces pulling on the calcaneal apophysis.
Q: What is your conservative orthotic approach in the treatment of posterior tibial tendon dysfunction (PTTD)? In patients who have undergone previous surgery, how do you control the foot postoperatively?
A: Dr. Spencer conservatively manages the posterior tibialis dysfunction patient with either a functional foot orthotic device or a Richie style brace, depending on the severity of the condition. For patients with mild to moderate PTTD, he will use a functional foot orthotic device with a medial heel skive, wide width and somewhat deeper heel cup, close to a UCBL style device. In the more severe PTTD patient, he says a Richie style brace will permit the patient to function with the deformity.
For patients who have undergone surgery for PTTD, Dr. Spencer will use a functional foot orthotic device that may incorporate a medial heel skive. He attempts to conform the arch of the orthotic device closely to the arch of the patient’s foot postoperatively and will initially order the orthotic in a wide width, which one can narrow as needed.
For patients with PTTD, Dr. Dananberg says foot control should include some amount of inversion of the cast prior to the orthotic shell being pressed. He says this aids in the positioning and permits improved control of the foot. Dr. Dananberg emphasizes that manipulation is a very valuable technique that is underutilized for management of PTTD. For PTTD patients, he says it is the posterior tibial muscle that is inhibited as related to ankle equinus, and mobilizing it can be a very positive adjunct to care.
Dr. Dananberg advises against over-posting of the orthotic as internal hip joint rotation is limited by rearfoot posting and orthotic inversion. He cites the necessity of balancing the patient’s needs with being mindful of more proximal function.
Dr. Harris says that tibialis posterior dysfunction, as one would see in adult orthopedic medicine, implies inflammatory change in the tibialis posterior tendon. This change leads to varying degrees of degeneration and rupture, resulting in painful rigid or flexible acquired flatfoot. However, as a pediatric specialist, Dr. Harris say this pattern “is so seldom seen in the child that it may not even exist, except in children with seronegative or seropositive arthritis.” Some adolescents have pain from unstable accessory naviculars and Dr. Harris says one can best manage them by excising the accessory navicular alone if indicated or in combination with other flatfoot reconstruction procedures.