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HELP - Clinical advice required, not seen anything like this before.

Discussion in 'Biomechanics, Sports and Foot orthoses' started by UncleWayne, May 20, 2009.

  1. UncleWayne

    UncleWayne Member

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    Hello all.

    I am seeking assistance with a pt i saw recently. I have not seen such drastice inversion in a patient and am asking if there is possiblity of a more systemic involvement.
    I am going to attach photos as I think they speak a thousand words.
    Pt was from eastern block so there was a slight language barrier which made medical Hz difficult.

    A 44yo male roof plumber presented last week.
    Complains of difficulty with walking any distance, arrived in jeans & enclosed f/w which was occluding initial gait pattern. Gait was very slow & lumbered (if such a word)
    States his condition started about 6 years ago initially in right foot then 1 yr later in the left. Initially ankle pain associated but does not have any significant pain now. States he is able to function quite normally @ work but cannot walk any distance.
    Examinations are best explained with photos. See below
    View attachment 1382

    View attachment 1383
    Obviously ROM is limited thru ankle & STJ. pt states he has always had a lrger base of fibula but has increased in size.
    So far I have only request xrays to assess osseous status.
    The patient has been in the public system seeing orthopods on roughly a yearly basis with out doing anything, his latest visit he was told he required surgical correction. the patient has not been happy with this as they have watched iot progress for so long. He has now sought other avenues but i feel it may be a little late & my view is surgery is likely option.

    Initial thought it could be Charcot Marie Tooth but pt says there is no family Hz of any systemic mediacl conditions.

    I am not sure where to go from here, any help would be useful.
    Apologies if the history is not completely up to standard.


    Attached Files:

    Last edited by a moderator: May 22, 2009
  2. Wayne:

    Send this guy to Sacramento and I'll treat him for free! What a find!

    This patient appears to have a maximally supinated subtalar joint (STJ) while still maintaining his forefoot plantigrade. This is very rare bird, a type of foot that I have only seen once or twice in 25 years of being referred some very unusual feet. His STJ axis is extremely laterally deviated, possibly passing lateral to the whole plantar calcaneus.

    Try putting a lateral wedge under this forefoot (i.e. Coleman Block Test) to see how much, if at all, the STJ can pronate from this position and to see where the calcaneus will rest with the foot maximally pronated. I would imagine his maximally pronated position is inverted and he is very close to being maximally supinated at the STJ.

    My first guess for diagnosis is also Charcot Marie Tooth (CMT) Disease. Test every one of his extrinsic muscles. If the peroneus brevis and anterior tibial muscles are weak, then assume CMT disease until proven otherwise. In addition, before you let anyone touch him with a knife, send him to a neurologist for a nerve conduction study and electromyogram. This would be a great case report since it is such an unusual case and unusual looking foot.

    Adding valgus forefoot and rearfoot wedges inside the shoe or to the shoe sole should help him walk much better since it will allow him to use his gastrocmeus-soleus complex during late midstance and propulsion without added lateral instability.

    Please keep us posted of this very interesting case.:drinks
  3. W J Liggins

    W J Liggins Well-Known Member


    Interesting one! He certainly falls into the age bracket for CMTD. It would be worth carrying out a detailed gross neurological examination to detect any stocking/glove signs of neuropathy, finger clawing and patella and Achilles tendon reflexes. If he does suffer from CMT Disease then there is bound to be some family history so it might be worth pressing him on that matter too.

    I agree with Kevin that the opinion of a neurologist should be sought and am a little surprised that the Orthopods have not done so already.

    All the best

    Last edited: May 20, 2009
  4. twirly

    twirly Well-Known Member

    Last edited: May 20, 2009
  5. David Wedemeyer

    David Wedemeyer Well-Known Member

    This is a great case to share Wayne. Do you have his films available to share with us?
  6. Lawrence Bevan

    Lawrence Bevan Active Member

    He needs SoleSupports!! :D

    His feet are already in the MASS position, cher-ching!
  7. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I have seen one other instance of this before, about 5 or 6 years back.

    The patient was essentially walking on their lateral malleoli. Neurology consults could not conclude a cause, and it was ultimately considered idiopathic.

    It was managed with bilateral triple arthrodesis as a salvage procedure, short of permanent confinement to a wheelchair.

  8. UncleWayne

    UncleWayne Member

    Thank you all for the replies.

    I saw this gent again yesterday with his xrays, he only had films with him so I am currently having them put on disk so I can up load for your viewing.
    Obviously they illustrated the extreme varus tilt of both tales with excessive OA changes in both ankle joints. There is also significant posterior subluxation of each tibia on each talus.

    Kevin, I have add FFVL posting to the inlay of his f/w but he actually slid off the RFVL posting. I have also taped his L foot to as much eversion as possible with FFVL posting also & will trial for few days. A loss of ligamentous integrity of the lateral aspects of the ankle joints seems very likely also.

    From what I can get from the patient he has had some sort of neurological testing but he didnt really know what. I have asked if he can get any records or reports/results from the hospital to see where we are at.

    Bill, One interesting statement he did make yesterday was that, when he was younger, his grandmother told him 'he walked a bit like his grandfather', unfortunately he never met him as he passed quite young.

    I am due to see him again next week & should have scans available by then.

    :confused:Would any sort of orthotic device really help this patient. If so any possible suggestions to help keep him on the orthotic?

    Just want to keep everyone posted.

  9. Boots n all

    Boots n all Well-Known Member

    Have two female clients like this, not quite as bad as yours thats for sure.

    We produced TCO's, bringing the ground up to them and custom ankle boots with mild heel rocker and toe rocker sole and a lateral flare on the sole.

    One has an office job the other in a deli, your client may need a little extra to cope with his job description.

    If l knew how to up load a movie of her bare foot gait l would:wacko:

    This is a pic of one of those ladies standing, weight bearing, note the 1st MPJ and 2nd do not make contact with the ground


    Attached Files:

    Last edited: May 21, 2009
  10. Boots n all

    Boots n all Well-Known Member

    l have marked your picture here below with a red line, vertical from the Lateral Mal straight down.

    This line would be the inside line of the boot, the TCO would fill the cavity between the boot and foot, not looking to correct as most of the time there is no or little ROM available any way.

    In this way we can cradle the foot in the boot reducing the pain and strain caused by the movement, hopefully preventing this foot/ankle shape becoming any worse.

    At the midstance part of gait does his foot drift even more laterally?
    This will indicate just how much the sole needs to be flared and the possible extension of the counter/heel stiffener needed.

    Hope it helps

    Just noticed your in Brisbane, give Ernie Tye a call, http://www.brisbanefootwearservices.com.au

    Foot note/Question: l had in the back of my mind that the hair growth would not be there or reduced with CMT for some reason? certainly not with this client, does he have Peripheral Neuropathy

    Attached Files:

    Last edited: May 21, 2009
  11. A patient of mine that surfs Podiatry Arena just pointed out to me that she could read the patient's name on the images posted by Uncle Wayne. I only see the names if I drag my mouse over the images. This needs to be remedied due to patient privacy concerns.

    Make sure when you post clinical photos to Podiatry Arena that you take out the patient's name from the photo file name.
  12. Admin2

    Admin2 Administrator Staff Member

  13. Dean Hartley

    Dean Hartley Active Member

    How many hours a day does he work on a roof? Maybe an acquired deformity from standing on a pitched roof, day in day out. Maybe he is a 'work-o-holic'. Or maybe his foot type has been exacerbated by his work stance. :dizzy:Haha not really sure about this, sounds a bit ridiculous, but just throwing some ideas out there. Would it be possible to acquire a deformity such as this?

    Obviously CMT would have to be the likely diagnosis.


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