Post-Op Orthotics: Can They Have An Impact?
With a compelling case study, this author illustrates how the biomechanical needs of a patient can change postoperatively. Accordingly, he emphasizes the importance of a sound biomechanical assessment and gait analysis after surgery, and how these findings will influence conservative management postoperatively.
Orthotic devices are prescribed for a variety of reasons by many different practitioners. Simply increasing the support for many of our patients’ feet provides relief. However, there is a segment of our patient population that needs even more attention. Ensuring appropriate attention to the details of how the foot functions from heel strike to propulsion is sometimes vital in keeping our patients ambulatory. For those patients who undergo reconstructive procedures, this attention to detail is sometimes as important as the surgery itself.
The foot will heal and the responsibilities of the surgeon may conclude, but if ambulation remains difficult or painful, focus on function is critical. With podiatric surgical expertise increasing steadily, we can not forget the importance of conservative biomechanical care for our patients, our practices and our profession.
Fabricating orthotic devices for our patients is something most of us do routinely. It is often a part of conservative care leading up to a surgical procedure and, in many instances, may even prevent the need for surgery. After surgery, the foot can change, sometimes in structure, sometimes in function, or both. For this reason, the pre-operative needs of our patients are often different than the postoperative needs. If it is a unilateral surgery, then only one foot may change. If it is a reconstructive surgery, there may be additional components such as leg length differences that one needs to assess. For this very reason, podiatrists need to repeat the thorough pre-operative biomechanical examination after the surgery as well. This may result in having to fabricate a new orthotic device for just the operated foot or a new pair if function has caused enough of a change to require something totally different. The following case study illustrates these key points.
When Conservative Care Fails To Resolve Pain In a Patient With Tibialis Posterior Tendonitis
A 56-year-old healthy female was diagnosed with tibialis posterior tendonitis. She had pain for a few months and it was unresponsive to physical therapy, ice, and anti-inflammatory medication. The examination revealed tenderness following the course of the tibialis posterior tendon from its insertion on the navicular proximal to the level of the medial malleolus. She had difficulty performing a single toe raise on this affected left lower extremity. The patient was able to rise up on the toes of both feet but clearly with weakness and pain. Additionally, she had been wearing shoes that were inappropriate in that they offered no support and were slip on shoes.
The X-rays exhibited an abducted forefoot with an increase in the talar declination angle and decrease in the calcaneal inclination angle. She also had a moderate bunion deformity with an intermetatarsal angle of 16 degrees. The appearance of her feet was asymmetric. The symptomatic foot had a lower longitudinal arch and the forefoot was more abducted. She had developed a limp and most days, she had to find time to get off of her feet in order to escape the pain.
Initial treatment consisted of taping for temporary support, footwear recommendations and an over-the-counter support. Her initial response was positive. Therefore, the treating physician prescribed custom orthotic devices. These devices were made from neutral suspension casts of both feet. The orthotics were semi-rigid devices made of polypropylene 5/32" with a deep heel cup for the left foot. Footwear recommendations included a motion control shoe that would accommodate the orthotic devices.