Responses to AFO used on a CMT patient
McNally, Patrick K
Description
Collection
Title:
Responses to AFO used on a CMT patient
Creator:
McNally, Patrick K
Date:
3/13/2001
Text:
> Members:
>
> Here is the list of responses to my initial problem with a pt with CMT,
> (Initial
> question is quoted at the end of this posting).
>
> What I ended up doing is using 3/16 Copoly in a solid ankle design with
> PolyCarb reinforcement. I applied 1/4 PPT for relief of the met heads
> 1-5 and accommodated the plantarflexion angle with a heel lifts/wedges
> (B)
> to decrease pressure at the met heads during stance (mid -> terminal).
> Upon
> follow-up, the response is positive. The pain is eliminated and uses them
> for
> independent ambulation, to include Basketball during PE.
>
> The initial failure was due to my allowing this passive dorsiflexion to
> occur
> during stance by choosing softer materials than necessary to correct the
> pain mechanism (tight heelcords (B) with painful met heads
>
> Respectfully, Patrick
>
> Patrick K. McNally, CPO
> Arkansas Children's Hospital
> 501-320-3562, fax - 501-320-6264
> mailto:<Email Address Redacted>
>
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> RESPONSES
> Based on my past experience I'll bet his Gastocs are tighter than you
> think.
> He is probably loading primarily on the met-heads. Since you are using
> TPE
> try to add a 1/4 to 1/2 inch heel lifts to accommodate for the
> contracture.
> Either refer him for PT or give him a home program to gradually stretch
> his
> heel cords. Over time as he gains ROM decrease the lifts.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> Since the painful met heads existed before the orthotic intervention, I
> would discuss this with an orthopedist. These patients are typically
> followed by a neurologist and most of their needs are met pretty well with
> that model. This patient may have some underlying structural problems
> best
> managed by an ortho doc. The ROM problems are a given and can cause us to
> simply accept it and move on, but I would look at forefoot varus/valgus
> (accommodate it if it is there), inflammatory response (drugs, modalities,
> and time-in-brace will help those), displaced fat pad (add padding),
> excessive time on the forefoot in gait (heel lift to accommodate the
> plantarflexion angle, beveled heel, and dramatic rocker sole), and most
> importantly a thorough history. He should be attending an aggressive
> physical therapy program!! Oh, by the way, you may discover that he walks
> quite a bit in his bare feet.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> As you know, most CMT patients present themselves with an
> equinocavovarus foot. From your description, your patient would
> appear to be in a similar position. When doing a bio analysis of their
> foot/feet most of the patients I see actually have a rigid 1st ray or
> forefoot valgus. For most of my CMT's I apply soft or hard UCB's.
> When AFO's are made, the foot section is modified similar my UCB's. Cast
> modifications and postings are according to their bio mechanics. To
> whatever I make I add heel lifts, heel posts and appropriate forefoot
> posts to level the 1st ray or 1st to 5th ray if the forefoot is in
> valgus. I use polypro for my hard UCB's and AFO's. For my soft UCB's,
> two layers of puff with reinforcement sandwiched between the layers.
> Intrinsic modifications are made to the cast, postings and lifts are
> added to the plantar surface of the AFOs or UCBs. I hope this helps.
> If you have any questions you may contact me at (337) 291-1016.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> Try adding about 3/16 elevation just proximal to the met heads. Met bar
> pad. You may also try a rocker sole.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> You did not mention a total contact footplate for this patient. I would
> support his entire foot and reduce the forefoot load by using a
> substantial
> met raise to support that arch. Supporting the toes will also help reduce
> the tendency for them to claw. Accommodating the plantarflexion may not be
> helping unload the met heads either. Since he is young and active, you
> might want to consider allowing him some dorsi and plantarflexion with
> trimlines posterior to the malleoli but with wrap around trimlines at the
> midfoot to give him good coronal plane control. Or, since he has not ever
> had orthotic management, perhaps a SMO/AFO combination would be helpful so
> he could use each section for the best biomechanical purpose. For
> example,
> when he needs a lot of mobility, the SMO would still provide great
> hindfoot
> and midfoot alignment. When he needed to walk long distances, or on
> uneven
> ground, the AFO would provide extra control and stability.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> I presume you did all the obvious things like supporting the arch area
> well, relieving the met heads by using a metatarsal mound and adding
> plaster
> to the cast over the heads themselves? Is your AFO a wrap around design?
> Perhaps that would help by offering some support around the sides as well.
> Hope this helps.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> You might want to contact John Camp C.P.O.
> American prosthetics in Bettendorf, IA. he has written a few articles on
> C.M.T
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> This young man could benefit from custom molded Visco elastic (P.Q.) full
> length total contact inlays with a 1/4 thick 3lb density pink Plastozote
> top
> cover in Super Depth shoes with rocker bottom soles. It could give him
> relief and possibly prevent further retraction of the arches and hammering
> of
> the toes. If Not properly treated this condition gets worse with time.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> Your case regarding your CMT patient....16y/o male 6'1 etc...is very
> interesting to me. While my knowledge remains limited, it continues to
> increase because of my interest in the matter and because of people like
> yourself posting questions such as your patient above. I am a resident
> Orthotist presently and am 4 months into my residency in the Newington
> system. I have been working at the Connecticut Children's Medical Center
> and have come into contact with 6 CMT patients already. The main type of
> management we have used has been PLS AFO with high lateral borders along
> the midfoot and a rear foot lateral Gillette to deal with the varus and
> to accommodate the cavus foot. My Residency research project is on the
> management of CMT as well so you can see my interest.
> With regard to your patient....I am sort of vague on your treatment of
> his metatarsal pain and didn't quite understand what you meat
> regarding.... >I designed AFO's for him. I used TPE in
> a solid ankle design, applied 3/16 PPT for relief of the met heads
> 1-5 (drop out design, not inserted after vacuum forming). Is the solid
> ankle design necessary? Perhaps my experience is too limited to
> understand. In any case...here's some ideas I have and have seen
> utilized (and am also sure you may have tried)! We like to add
> metatarsal pads onto the brace after they been vacuum formed and are
> ready to be delivered. This gives us very good control of where to put
> them. I am not sure what type of feet your patient has, (I know you
> mentioned a cavus foot), but what about calcaneal varus, forefoot
> adduction, etc....by keeping his foot in some degree of plantar flexion
> and then posting the heel, wouldn't that be accentuating the overactive
> tibialis posterior (which is the cause of the cavus and calcaneal varus).
> It would seem to me that the posterior tib which also plantarflexes the
> foot somewhat would be allowed to contract more in this case. Again, I
> haven't seen your patient....The metatarsal pad sounds like a good bet
> and I would even try to keep his foot at neutral and not plantarflex it,
> as mentioned above.
> I hope this is at least somewhat helpful....I'm just starting out, but am
> very interested in this all! Please let me know what you decide to do
> and possible outcome.
>
> Thank you very much.
> Todd McCoy
>
> INITIAL QUESTION:
> I have a young patient suffering from CMT. He is a 16 y/o male 6' 1
> & 210 lbs., independent ambulator without assistance. His gait displays
> an antalgic shortened stride (B). He has the typical cavus foot (B),
> decreased ROM (+/- 3*) (B). His chief complaint is marked pain
> at the met heads 1-5 (B). He comments about a high pain tolerance,
> as he is able to walk throughout the day with his pain. He plays
> basketball at school and it has recently affected his sport. He
> has no previous experience using orthotics.
>
> About 4 weeks ago I designed AFO's for him. I used TPE in
> a solid ankle design, applied 3/16 PPT for relief of the met heads
> 1-5 (drop out design, not inserted after vacuum forming) and
> accommodated the plantarflexion angle as not to increase
> pressure at the met heads during stance with rearfoot posting.
> He returns with no relief of symptoms.
>
>
>
>
>
>
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>
> Here is the list of responses to my initial problem with a pt with CMT,
> (Initial
> question is quoted at the end of this posting).
>
> What I ended up doing is using 3/16 Copoly in a solid ankle design with
> PolyCarb reinforcement. I applied 1/4 PPT for relief of the met heads
> 1-5 and accommodated the plantarflexion angle with a heel lifts/wedges
> (B)
> to decrease pressure at the met heads during stance (mid -> terminal).
> Upon
> follow-up, the response is positive. The pain is eliminated and uses them
> for
> independent ambulation, to include Basketball during PE.
>
> The initial failure was due to my allowing this passive dorsiflexion to
> occur
> during stance by choosing softer materials than necessary to correct the
> pain mechanism (tight heelcords (B) with painful met heads
>
> Respectfully, Patrick
>
> Patrick K. McNally, CPO
> Arkansas Children's Hospital
> 501-320-3562, fax - 501-320-6264
> mailto:<Email Address Redacted>
>
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> RESPONSES
> Based on my past experience I'll bet his Gastocs are tighter than you
> think.
> He is probably loading primarily on the met-heads. Since you are using
> TPE
> try to add a 1/4 to 1/2 inch heel lifts to accommodate for the
> contracture.
> Either refer him for PT or give him a home program to gradually stretch
> his
> heel cords. Over time as he gains ROM decrease the lifts.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> Since the painful met heads existed before the orthotic intervention, I
> would discuss this with an orthopedist. These patients are typically
> followed by a neurologist and most of their needs are met pretty well with
> that model. This patient may have some underlying structural problems
> best
> managed by an ortho doc. The ROM problems are a given and can cause us to
> simply accept it and move on, but I would look at forefoot varus/valgus
> (accommodate it if it is there), inflammatory response (drugs, modalities,
> and time-in-brace will help those), displaced fat pad (add padding),
> excessive time on the forefoot in gait (heel lift to accommodate the
> plantarflexion angle, beveled heel, and dramatic rocker sole), and most
> importantly a thorough history. He should be attending an aggressive
> physical therapy program!! Oh, by the way, you may discover that he walks
> quite a bit in his bare feet.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> As you know, most CMT patients present themselves with an
> equinocavovarus foot. From your description, your patient would
> appear to be in a similar position. When doing a bio analysis of their
> foot/feet most of the patients I see actually have a rigid 1st ray or
> forefoot valgus. For most of my CMT's I apply soft or hard UCB's.
> When AFO's are made, the foot section is modified similar my UCB's. Cast
> modifications and postings are according to their bio mechanics. To
> whatever I make I add heel lifts, heel posts and appropriate forefoot
> posts to level the 1st ray or 1st to 5th ray if the forefoot is in
> valgus. I use polypro for my hard UCB's and AFO's. For my soft UCB's,
> two layers of puff with reinforcement sandwiched between the layers.
> Intrinsic modifications are made to the cast, postings and lifts are
> added to the plantar surface of the AFOs or UCBs. I hope this helps.
> If you have any questions you may contact me at (337) 291-1016.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> Try adding about 3/16 elevation just proximal to the met heads. Met bar
> pad. You may also try a rocker sole.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> You did not mention a total contact footplate for this patient. I would
> support his entire foot and reduce the forefoot load by using a
> substantial
> met raise to support that arch. Supporting the toes will also help reduce
> the tendency for them to claw. Accommodating the plantarflexion may not be
> helping unload the met heads either. Since he is young and active, you
> might want to consider allowing him some dorsi and plantarflexion with
> trimlines posterior to the malleoli but with wrap around trimlines at the
> midfoot to give him good coronal plane control. Or, since he has not ever
> had orthotic management, perhaps a SMO/AFO combination would be helpful so
> he could use each section for the best biomechanical purpose. For
> example,
> when he needs a lot of mobility, the SMO would still provide great
> hindfoot
> and midfoot alignment. When he needed to walk long distances, or on
> uneven
> ground, the AFO would provide extra control and stability.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> I presume you did all the obvious things like supporting the arch area
> well, relieving the met heads by using a metatarsal mound and adding
> plaster
> to the cast over the heads themselves? Is your AFO a wrap around design?
> Perhaps that would help by offering some support around the sides as well.
> Hope this helps.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> You might want to contact John Camp C.P.O.
> American prosthetics in Bettendorf, IA. he has written a few articles on
> C.M.T
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> This young man could benefit from custom molded Visco elastic (P.Q.) full
> length total contact inlays with a 1/4 thick 3lb density pink Plastozote
> top
> cover in Super Depth shoes with rocker bottom soles. It could give him
> relief and possibly prevent further retraction of the arches and hammering
> of
> the toes. If Not properly treated this condition gets worse with time.
> ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
> Your case regarding your CMT patient....16y/o male 6'1 etc...is very
> interesting to me. While my knowledge remains limited, it continues to
> increase because of my interest in the matter and because of people like
> yourself posting questions such as your patient above. I am a resident
> Orthotist presently and am 4 months into my residency in the Newington
> system. I have been working at the Connecticut Children's Medical Center
> and have come into contact with 6 CMT patients already. The main type of
> management we have used has been PLS AFO with high lateral borders along
> the midfoot and a rear foot lateral Gillette to deal with the varus and
> to accommodate the cavus foot. My Residency research project is on the
> management of CMT as well so you can see my interest.
> With regard to your patient....I am sort of vague on your treatment of
> his metatarsal pain and didn't quite understand what you meat
> regarding.... >I designed AFO's for him. I used TPE in
> a solid ankle design, applied 3/16 PPT for relief of the met heads
> 1-5 (drop out design, not inserted after vacuum forming). Is the solid
> ankle design necessary? Perhaps my experience is too limited to
> understand. In any case...here's some ideas I have and have seen
> utilized (and am also sure you may have tried)! We like to add
> metatarsal pads onto the brace after they been vacuum formed and are
> ready to be delivered. This gives us very good control of where to put
> them. I am not sure what type of feet your patient has, (I know you
> mentioned a cavus foot), but what about calcaneal varus, forefoot
> adduction, etc....by keeping his foot in some degree of plantar flexion
> and then posting the heel, wouldn't that be accentuating the overactive
> tibialis posterior (which is the cause of the cavus and calcaneal varus).
> It would seem to me that the posterior tib which also plantarflexes the
> foot somewhat would be allowed to contract more in this case. Again, I
> haven't seen your patient....The metatarsal pad sounds like a good bet
> and I would even try to keep his foot at neutral and not plantarflex it,
> as mentioned above.
> I hope this is at least somewhat helpful....I'm just starting out, but am
> very interested in this all! Please let me know what you decide to do
> and possible outcome.
>
> Thank you very much.
> Todd McCoy
>
> INITIAL QUESTION:
> I have a young patient suffering from CMT. He is a 16 y/o male 6' 1
> & 210 lbs., independent ambulator without assistance. His gait displays
> an antalgic shortened stride (B). He has the typical cavus foot (B),
> decreased ROM (+/- 3*) (B). His chief complaint is marked pain
> at the met heads 1-5 (B). He comments about a high pain tolerance,
> as he is able to walk throughout the day with his pain. He plays
> basketball at school and it has recently affected his sport. He
> has no previous experience using orthotics.
>
> About 4 weeks ago I designed AFO's for him. I used TPE in
> a solid ankle design, applied 3/16 PPT for relief of the met heads
> 1-5 (drop out design, not inserted after vacuum forming) and
> accommodated the plantarflexion angle as not to increase
> pressure at the met heads during stance with rearfoot posting.
> He returns with no relief of symptoms.
>
>
>
>
>
>
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list.
Citation
McNally, Patrick K, “Responses to AFO used on a CMT patient,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/216190.
