Hyperdorsiflexion responses

Hyperdorsiflexion responses

Cheryl Lewis

4/27/2011

Hello All,
 
Thanks to all who replied - the combined experience of the participants of this listserve is a fantastic resource!!!
 
Many people felt this was Congenital Vertical Talus (CVT) which is what I thought it might be at first but in researching CVT it mentioned that this is a rigid condition - this child was definitely not rigid and could easily be corrected to STJ neutral. There is no question the foot position appears like CVT.
 
One response was reverse clubfoot and has a journal article link to research from the J of Bone and Joint describing this condition when CVT is not present. I have a feeling that is what this child has. He is seeing another specialist who will provide the definitive Dx next week.
 
I have posted all the responses I rec'd below. Thanks again to all who replied!
cheryl
 
 
While working at Scottish Rite in Dallas, I did manage a kid with this unilateral deformity. I used a rear entry AFO design with good success. I managed him for about 1 1/2 years. He was lost to follow up.

 I am not aware of a hereditary component.
I have had two patients with similar presentation that I can remember. The
most recent one we used Surestep SMO's to maintain a midline position via
compression, because like you I could easily position the foot. The patient
was hypotonic and stood in excessive pronation as you described. It was
fabricated to a mold.
 
Another patient I did have was serial casted, but in that patient it was
more apparent that he had an excessively over active Anterior Tib muscle.
That child had really good success and was fit with FO's when done.

 
 
Also seen this only once... search talipes equinovalgus or reverse club foot. I agree with your gut that AFO is needed. Also good pediatric orthopaedist!

Good article about a child in same age range is found here: <URL Redacted>
 
I would consider using a dorsal / lateral AFO.

 
 
This sounds to me to be congenital vertical talus. Before treatment is
started a complete work-up needs to be done by a pediatric orthopedist so
you, and the parents, know what they're dealing with and the best options
before the child gets much older.
Google CVT
__________________________________
 
Sounds like the patient may have had vertical talus, it which case they do casting and often surgery followed by AFOs. My recommendation is for him to be seen by orthopedics again for follow up. At sick kids (Toronto) we end up putting the kids post op in AFO, with plantar stop, heel in varus, molding in an arch and slight forefoot adduction. Not sure you would be able to accomplish this through a SMO.

 
 
I have some ideas for you... I'm missing a little info though regarding gait? Step length, foot projection angles and cadence?
Here's my recommendation... You definitely need an SMO type grab on this foot type. It can't be a traditional midline trims though. It needs to be circumferential in it's fit. I would stay away from an off the shelf anything as you'll never control the alignment of the foot and ankle.
Based on the information you provided I would use an SMO and AFO combo....
SMO:You have an opportunity to meet in the middle here. I would utilize a Surestep SMO or this fit strategy.
AFO: In addition I would use a Baby Gait Toe Off AFO to resist the end range dorsi-flexion you described. These two products work great together. Very dynamic.
Shoes: Because of the increased girth of both products together I would use a Tsukihoshi brand shoe. This shoe is flexable, wide, deep and flat. (the most accommodating shoe for pediatric orthotics) This a commercially available kids shoe that can be purchased on zappos.com. Very cute too!
The nice thing about this approach is you can always discard the AFOs from the picture if he indeed responds well to the SMOs alone.

My first try would be the Sure Step SMO's (like no other product out there) they are great for these little guys and made by measurement. You should know in the first week if not days if things are going to work out, then add AFO if needed. I could only imagine that with that much dorsi flexion you are begging for the achillies to kick in blocking the mid foot should tighten up the system.

You could tell dad that a AFO/ SMO system is far better than a cast being that we have way more foot control than one would have in a cast, less risk of skin break down and more way easier to assess the progress ( he also can take a bath!).

Having a child with the desire to walk and a PT that is willing to think about options is a great starting point, feel free to call if questions.

Good luck

Your best bet is to stay out of it. The PT and you are trying to
design a treatment plan without the doctor. The father already has seen one type work
for his son. I tend to agree with the father and cast the patient during
the last cast change to have a clam shell brace ready for night, and some
type of containment afo, with a possible inside UCBL foot closure boot. Cascade
has some nice design in their catalog. Get picture of these braces to show if
you are going to follow this route since a picture replaces a lot of air.
Agree with the father that the doctor should see the patient again and
attend the visit with the PT if he will let you. If your seeing this patient at
a clinic it would be best for all of you to meet on neutral ground.
You will be scolded by the doctor if you push the direction you are going and may
lose him as a referral source. The doctor makes the rules. I personally
found this out myself on a case, and sincerity is not a value or a crusade when the
rules are that the doctor makes them.
Be happy at the level we work with, and stay an adviser not a director.
Good luck
 

Cheryl Lewis BSc(HK), CO(c)
Certified Orthotist
519-436-9670 CK Ortho Inc