Responses to ankel orthosis for high tone supination

Responses to ankel orthosis for high tone supination

Vicky Jarvis

4/16/2004

I have previous sent these responses, but haven't seen them posted, so will try again now. Thanks for all your help. Heres the original post:

 I have a teenage patient who has an ankle injury after a sport
accident 1 year ago, this has resulted in high tone that causes extreme supination of her foot and internal rotation of the tibia. Medical/surgical treatment including botox has not helped. It is possible to manipulate the foot into a neutral position, the manipulation causes pain particularly under the patella, but once in neutral there is no pain. I have succesfully made a bivalved night orthosis. I now need a replacement for the Walker currently used during the day as the height difference is causing hip problems. She cannot tolerate joint movement whilst weight bearing, but her physio is hoping to build up tolerance. My question is has anyone got any treatment ideas for this type of problem?


Following some of the advice I laminated an orthosis with mainly carbon frame around the calf with good strapping anteriorly just above the ankle, camber axis joints and flexible resin foot wrap with carbon reinforment of the sole plate and joint attachments. This works extraordinarily well in controlling her, and though its a tight fit, has been well accepted. She is now able to walk with some joint movement. I don't think this is a long term solution, pre-preg would be far stronger, however we're hoping with more medical treatment that the problem can be resolved.

Thanks again, heres all the responses:

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External rotation of the tibia with supination. Why not go with
laminated solid ankle for strength dual side element.? BAR 2804


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Challenging case. I find that I can much better control transverse
plane
rotation with a full circumferential design--similar to floor reaction
trim
lines. This makes the device far more rigid--approximately 5 times
more
rigid, than a circle with a mere slit in it, because of the moment of
inertia. Good luck


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  Very interesting problem. I use prepregs extensively. It has taken
me
about three years to finally find a composite combination which stands
up to
daily abuse. Please feel free to contact me if you would like us to
fabricate an orthosis for you.


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Sounds like your client may be suffering from the effects of Complex
Regional Pain Syndrome. See:
<URL Redacted>

Your orthotic treatment is appropriate, but no doubt your client may
also
need aggressive physiotherapy in the form of TENS or Ultrasound
treatment to
address the underlying neurological condition, which if left untreated
will
progress.



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I have two of these type of patients one a strong male 18 year old and
one
a 45 year old female. The male is a result of reaction to a
immunization
and the female is a result of a accident. Both present with varus
heels
plantar flexion or supination as you said. both when they are seated
and
relaxed can be moved into neutral/90 degrees and a little past. however
when the walk with no brace there foot spasticly goes into varus so bad
that they are walking on the lat. side of their foot.

On the female I have in a flexible inner boot( 1/8 polyethel) and a
solid ankle afo over that out of (1/4 poly pro)with varus tab with a
heavy push. The male I have in a Solid ankle afo 1/4 copoly with
ankle
reinforcements and varus tab. I have currently made three brace for
the
female and two for the male over the last three years. Each one has
been a improvement on the last. I now have them both postioned in a
slightly supinated postion that seems to be the trick. Basiclly when
casting I push as hard as I can to get the postion and then leave it
there. I cast seated with the foot in the air like you would for a c.p.
child cast. I have found that joints only weaken the plastic shell and
control is lost in these really powerful spastic patients also if they
are firing their plantar flexors the joint never actually is used
during
the gait cycle. I have had no luck with anything but plastic. The
carbon afos are not forgiving enough for me when it comes to
adjustments
with these hard patients I have found ability to adjust to be number
one.
And metal just does not get a good enough grip to control. Both
patients are now very happy and are walking farther with less pain. I
feel the real diffrence in the braces I have made for them over the
years
is postion. With the foot in pronation it seems to solve all the
problems I had with the past braces that were made in a neutral
postion.
This is just what I ended up with with a lot of trial and error. Not
saying its the right thing to do just what I did.

----------------------------------------------------------------

This sounds like dystonia which can occur with reflex sympathetic
dytrophy
(or complex regional pain syndrome) and you might want to have her
check
with a doctor about a trial of Neurontin and/or a sympathetic block for
it.

Immobilization- which I can understand why she need just to get around
without excruciating pain- may actually aggravate the situation.

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 I have had some success with these patients by incorporating high tone points to the AFO. In some patients, a high tone insert works well also. This seems to work better when the internal rotation to attributed to the biomechanics of supination and not hip involvement. This is my assumption from your description of the patient. The PB is non functional and the PL is tight. The EHL may also be constantly firing. When the foot and ankle are placed in neutral the TA and or the TP are relaxed but the PL is still tight pulling down the 1st ray from its insertion point. If this is what is happening, the high tone points and biomechanical alignment you add to the insert or AFO should decrease the tone, reduce or eliminate the internal rotation and provide a more stable gait.









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