RESPONSES: internal rotation deformity

RESPONSES: internal rotation deformity

zach harvey

10/7/2003

Thanks to all who responded to my inquiry. I've
delayed posting a summary, hoping the patient would
come in, but unfortunately, she's moved out of
town...Anyway, my original question was:

I'm generating ideas on treating an 18 year old post
club foot surgical realignment 6 years ago. When
sitting, ankles invert and forefeet abduct. When
standing, weight is on the lateral side of feet in a
supinated postion. Patient can voluntarily pronate
when standing, but has pain in knees and hips as
they pronate as well. Foot/ ankle complex corrects to
neutral bilaterally, but when corrected, knees and
hips internally rotate. Internal rotation becomes
worse with dorsiflexion. I'm thinking about solid
ankle AFO's with internal medial posts, but I
welcome other ideas/ past experiences...
Thanks, Zach Harvey, CPO

RESPONSES:

Whenever we fit patients w/bilateral solid AFO's, it
is akin to making them walk in ski boots.. do you have
to lock up the ankle? Obviously, limited ankle
motion joints would provide for a less jarring,
smoother gait pattern. What PF/DF ankle strength does
the patient have? Has the patient used AFO's their
entire life or have they developed their own normal
way of ambulating without AFO's? Be careful of taking
away compensatory alignment/movement that works
dynamically for the sake of what looks good
statically. Bottom line is that your patient develops
internal rotation problems when forced into our
version of normal and when dorsiflexion is
increased. So the amount of DF needs to be limited
(not eliminated). Mediolaterally, it sounds like you
are trying to re-distribute weight bearing forces more
evenly to the bottom of the foot (increase
medial, neutralize excessive lateral forces). I would
be surprised if you can accomplish this inside the
shoe with only medial posting to the AFO.
It would be great if this worked, but usually the
outside of the shoe needs to
accommodate the additional medial wedging. You have
to be very accurate in determining the exact amount
and location of extra medial posting/wedging. During
the casting procedure, have your patient partially
weight bear on a piece of 1-1 1/2 SunMate foam to
where he/she feels even pressure across the plantar
surface of the foot(prior to any internal
ankle/knee/hip rotation kicking in). Make sure that
both feet
are bearing weight on the same thickness of foam
during casting or the leg length discrepancy will
produce inaccurate M/L angles in the casted foot.
Your positive plaster mold will reveal a very accurate
measurement of what varying thickness is required
along the medial border (i.e. -the forefoot probably
needs more than the hindfoot). I hope you have great
results with this patient. Lisa Urso, CPO

  Laterally post the calcanei but support the
longitudinals at 3* shy of neutral. Some IR will
occur. Some temporary stretching and drawing symptoms
may occur. Focus on stretching the medial achilles
without allow the posterior tibialis to stretch.
Once the achilles and medial calcaneotibial
ligaments are stretched enough to allow 3-4* of
calcaneal eversion the lateral wedge must be
removed to prevent over correction. May take four
months and then it may take eighteen months. Follow up
is important here.
   Mark Collins BOC O/P, C. Ped.

Try a very well modified Arizona type brace with a
rigid AFO built within the leather.I have a great deal
of Charcot foot patients that demonstrate this type of
behavior.I use the leather suspension to control
volume changes and correct as needed through out the
patient's day.
Brian MooreBOCO

It may seem a bit radical but why not suggest one more
surgery to de-rotate the tibia bilaterally? After all
this guy is only 18 and has a lifetime of wear and
tear on some less than ideal ankles. Why not
reduce the strain on the system?
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, Michigan, USA
www.amputee.com

Zach:
What you might try is a solid ankle AFO, add a relieve
in the posterior tibilal tendon insertion area, like
the oos brace but even more severe if that makes sense
that will stabilize the heel, then on the area of the
plantar surface of the 5th metatarsal shaft place a
pad to lift that area don't know how to explain it we
call it a bridge this forces the forefoot to
adduct and pronate without too much rotary influence.
Hope that helps
Paul

Dear Zach
Consider using a foot orthosis with a lateral rear
foot skive and a 1st ray cut out The rear foot skive
will create a pronatory moment around the axis of the
sub talar joint after initial contact , and, if
your client has a mobile mid tarsal joint the
pronatory moment will secure the 1st ray to the
ground at late stance phase via the 1st ray cut
out.... Just a thought. Good luck and best Wishes
Phil Rees Research and Development Manager
Salts Healthcare
Birmingham U.K.

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