Responses to Unlaoding the Talus

Responses to Unlaoding the Talus

Don McGovern

Here is my original post. Please accept my apologies as some replies were
inadvertently deleted.
> Dear List,
>
> I am working with E.S. E. S. is a fifty year old, Caucasian woman with
> lupus. She presents walking with care and the right L. E. in ext. rot. due
> to pain. Her hx includes a fall on the ice one year ago sustaining
fractures
> of the tib-fib. and talus. The recent MRI reveals several nonattached
> fragments on the ant. medial aspect of the talus. The area corresponds to a
> clinically observable localized swollen, warm area on her ankle. She has
> cavus feet. Plantarflexion and eversion are painfree. Dorsiflexion and
> inversion are limited and painful. She does not tie her shoes all the way
up
> since any compression on the proximal dorsum is intolerable. E. S. reports
> she wears high top shoes to bed to immobilize the foot and ankles. At
present
> she is limited to short distances of ambulation.
>
> It is my assumption her pain is from the talus accepting an increasing load
in
> stance as DF proceeds. She is limited to neutral before the pain occurs.
Therefore, I have
> recommended an orthosis to stop DF at the point of pain, or earlier. I
> discussed a lt. wt, carbon graphite type of low profile AFO with free PF and
> DF stop. The biomechanics of the pain and of the orthotic intervention has
> been explained and understood by E. S.
>
> Understandably, E. S. was not prepared for intervention of this extent.
She
> had expected a small little whatever. She has tried ankle wraps but her
> dorsum is too painful.
>
> The only other type of intervention I thought may help and be minimal was
> rocker bottom soles.
>
> My question is there something other than my ideas to satisfy the persons
> requirements.
>
> Thank you for your time and effort.
>
> Don McGovern CPO


Thank you all for your responses, here they are:

1-
Hi Don,
Sounds like you have your hands full. You might want to consider a well
molded ucbl full foot length(for rigidity upon df) but well padded with a puff
liner ~1/8. A stablizing heel flare/post on the orthosis would be in order as
well. Stiffening the sole of the shoe with a rocker would probably be
beneficial as you already suggested.
I havent had a pt like your sbut do alot with ucb's for pt's with foot pain
2-
Hi Don,
Sorry...but just had another thought...Couple actually...
Any chance of a surgical intervention to take care of the roughened areas of
the talus?
Second, any chance that a substance such as Synvisc might help...it's nasty
stuff but can be helpful in a case such as this.
Not much else I can think of Biomechanically...even that suggestion of
higher heel in the shoe I don't think will help....more likely to cause OA
of the hip because of leg length discrep.
 ....here I asked this Biomechanist (?) for more info on the above....
Hi Don,
Sinvisc is a synovial lubricant, injected into the joint by a surgeon...can
be helpful in the case of small spurs or joint mice...I think that was what
you were describing, right? Or am I reading into this further than what was
described?
Heel lifts won't cause OA, but a unilateral heel lift (don't laugh...I've
seen it! <grin>) can cause significantly increased load bearing through the
raised hip during heelstrike through to toe-off.
3-
Dear Don
Since your client finds dorsiflexion painful, how about getting her a shoe
with a
higher heel? That way the anterior part of the talar head won't be
articulating with
the ankle mortice. However, this is a more unstable position for the ankle
joint and
may be undesirable because it shifts too much weight onto her metatarsal
heads.
4-
I would lean toward the above suggestion. In your original post you do not
tell at what point in dorsiflexion the patient begins to feel pain. If it is
close to neutral, a total contact foot orthosis with between 1/8 inch to 1/4
inch heel lift may provide adequate planter flexion to alleviate the pain.
Granted, the trade off is possible planter flexion contracture. At 50 this
may or may not be an issue (or previous high heels may be a contributing
factor).

This may be a less expensive (altho non reimbursable) alternative.
5-
Don, I think that you have got this one down pat. I have not been
successful with anything less. Before you make a carbon AFO you might
think about some type of test orthosis for shape & reliefs. I have been
fairly successful with PP and tamarack joins on cases like this.
6-
i was interested recently in some responses some poeple posted about
leather calf corsets to unload the foot ankle complex to address pain
there & wonder if you could incorporate that into your design with DF
limits before the point where the pain kicks in - good luck - would love
to hear what works -


At present E. S. has not done anything.

Thanks again,
Don McGovern CPO