Patients with special needs experience higher rates of certain foot and ankle conditions. In order to address the unique needs of this population, the panelists discuss specialized interpersonal approaches to these cases, along with common pathology, orthotic modifications, materials and shoe compatibility.
In your experience, what conditions warranting orthotics do you most commonly encounter in a patient population with special needs?
“Many of the biomechanical and structural conditions that we commonly encounter in the special needs population are very similar to those we see in everyday practice,” shares Timothy Dutra, DPM, FACPM.
Dr. Dutra cites common injuries and pathology such as plantar fasciitis, medial tibial stress syndrome, patellofemoral pain syndrome, posterior tibial tendonitis and hallux limitus/rigidus in these patients.
Dianne Mitchell-Pray, DPM adds that the most common conditions she sees in her special needs patients are flexible flatfoot, either in isolation or in combination with hallux valgus, hallux varus or posterior tibial tendonitis.
Specifying that his experience is primarily in those with intellectual disabilities (ID) such as Down syndrome and Fragile X syndrome, David Jenkins, DPM, FACFAS cites hyperflexibility as a root cause of much of the pathology that may require orthotic management.
“I say ‘may’ as so many of our Special Olympics athletes present with severe pes planus, hallux valgus, etc. but fully function as athletes with no discomfort or performance limitations,” explains Dr. Jenkins.
Citing his personal research, he includes pes planus, brachymetatarsia with resultant metatarsalgia, capsulitis, keratomas and/or ulceration as common in those with intellectual disabilities. In patients with cerebral palsy, one might see the opposite issue with contractures or severe cavus feet.1
Are there any unique aspects to the biomechanical examination that one should focus on when evaluating a patient with special needs for orthotics? What is the biggest challenge with gait analysis and when prescribing orthotics for these patients, such as Special Olympics athletes?
Karen Langone, DPM, DABPM feels that working with these athletes requires the clinician to be more intuitive to the patients’ needs.
“I tend to be very animated when I am with patients but I have found that being calm and more soft spoken is often received better by the special needs athlete,” explains Dr. Langone.
Dr. Langone also cites gentle reassurance, demonstration of what will occur in an examination, slow examination and verbal support to all be helpful in her experience as these measures give these athletes a sense of confidence during the visit. She also relates that making the examination fun, creative and engaging is crucial.
During the biomechanical exam for patients in the special needs population, Dr. Jenkins states the clinician will immediately note significant hyperflexibility when it is present and recommends relating this to the patient history to see if it is causing symptoms or performance issues. He also points out that significant contractures in some athletes pose difficulties as do cases when the patient may not understand instructions. In these situations, Dr. Jenkins recommends the clinician or the coach (if present) hold the patient’s hand while walking.
“Some athletes think it is a good time to show off and be silly! (They) may run, skip or otherwise not walk in their typical gait,” relates Dr. Jenkins.
Dr. Jenkins adds that a number of athletes will have early heel-off and significant abduction while others may be severely adducted and have issues with tripping.
In her experience, Dr. Mitchell-Pray relates no significant differences in her approach in this part of the evaluation.
“I do a complete biomechanical exam and provide a lot of education to the patients and family, caregivers and coaches,” maintains Dr. Mitchell-Pray. “I also provide a lot of shoe education but nothing more than I would for any other patient and family.”
However, she does agree with Dr. Jenkins that patients may decide to be silly in that moment, making gait analysis a bit more challenging. She advises the clinician to be patient and have fun with it, perhaps joining in the fun and then redoing that part of the exam.
Are there any particular orthotic-prescribing or modifying pearls you can share for this patient population?
Most of the panelists cite proper shoes as being extremely important to the success of any orthotic prescription for this population. Dr. Mitchell points out that cost can be an issue for both shoe gear and the orthotics. However, the clinician should consider the shoe gear when determining the right orthotic for the patient.
Dr. Mitchell-Pray shares that she often orders wide orthotics with deep heel cups and minimal arch fill. She may also consider a medial flange and possibly a navicular ‘sweet spot’ to increase surface area contact between the orthotic and the foot for better proprioception and control.
In regard to modifications, Dr. Mitchell-Pray says it is important to ask patients what they think the problem is and listen.
Dr. Langone favors semi-flexible devices for patient comfort and will often use an antimicrobial top cover to help prevent tinea. She additionally asks the patient what color top cover they might like in order to engage him or her in the plan.
If the clinician determines the patient could experience pain relief and/or improve performance with an orthotic, Dr. Jenkins advocates for addressing any severe pronation or calcaneal eversion with a more aggressive device with a deeper heel cup, possibly incorporating a Blake inversion or Kirby skive modification.
Dr. Dutra often focuses on the fit of the orthotic in the shoe itself. If the athlete participates in multiple activities, he notes that additional orthotics may be required for different shoe gear. Dr. Dutra cites a Cobra-type of orthotic as one he frequently uses in spikes and narrower shoes. While this orthotic fits well in these shoes, Dr. Dutra says one may be sacrificing some biomechanical control due to the low profile.
He also relates generally making his orthotics more flexible and adding a cushioned topcover in older athletes along with waiting out the break-in period before making any modifications.
“I think the biggest recommendation is to approach your orthotic prescription and recommendations (for special needs patients) like you would for your (typically developed) athletic and sports medicine populations,” states Dr. Dutra.
Does a patient’s sensory processing status play a role in materials selection?
Dr. Dutra shares that in his experience, the topcover and forefoot extensions of orthotics can play an integral role in proprioceptive feedback. He adds that the type of athletic sock is a consideration as is the shoe itself, including the outer sole.
Pointing out that diabetes is more prevalent in patients with intellectual disabilities, Dr. Jenkins relates he is reconsidering how he evaluates sensory status, including possible loss of protective sensation (LOPS), in these patients. He relates that some studies on this very topic are in progress.
Dr. Langone states she aims to provide a device that the athlete will find comfortable and be willing to wear. Some patient-specific accommodation on materials may be necessary to achieve this adherence, according to Dr. Langone.
Dr. Dutra is an Assistant Professor of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Past President and Fellow of the American Academy of Podiatric Medicine, and a Fellow of the American College of Sports Medicine. He is the Vice Chair of the Joint Commission on Sports Medicine and Science, as well as a podiatric consultant for Intercollegiate Athletics at University of California, Berkeley.
Dr. Jenkins is a Professor at the Arizona School of Podiatric Medicine at Midwestern University in Glendale, Az. He is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is also the Global Clinical Advisor for the Special Olympics Fit Feet Program.
Dr. Langone is a Diplomate of the American Board of Podiatric Medicine, and Co-Vice President of the American Association for Women Podiatrists. She is a Fellow and Past President of the American Academy of Podiatric Sports Medicine. She is in private practice in Southampton, NY.
Dr. Mitchell-Pray is a Fellow of the American Academy of Podiatric Sports Medicine and is board certified by the American Board of Podiatric Medicine. She is in private practice with Mercy Medical Group, Inc. in Sacramento, Calif.
1. Jenkins DW, Cooper K, O’Connor R, Watanbe L, Wills C. Prevalence of podiatric conditions seen in Special Olympics athletes: structural, biomechanical and dermatological findings. Foot (Edinb). 2011;21(1):15-25.