12 yrs old developed flat foot after DDH

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Hi, I'm a pod student who is eager to make a right diagnosis for a patient.

I know I'm not qualified yet but I would like to gain some professional

insight about the clinical case that I've witnessed today.

A 12 years old boy with severe flat foot (I assume it's congenital?)

on his left side with bad ankle pain.

His right foot also has some low arch issue but not as severe

as his left foot. He is diagnosed with hyper-flexible joints.

He also had a past medical history of developmental dysplasia of

hip and received a surgery when he was 8 years old. He was on the wheel chair

for one year due to the surgery.

I am assuming that the main problem is with his very weak tibialis posterior

muscle that can't support the left longitudinal arch.

Also, partially maybe due to his limited left hip ROM, the internal

rotation of the left femur caused his left foot to pronate dramatically in relation to

his right foot.

I read some posts and it seems that there are not strong evidence that

clarifies a direct relationship between hip ROM and pronated foot but

I think the hip pathology somehow contributed to his flat foot deformity.

Right now, he is suffering from left ankle pain and foot pain due to his flat foot.

He got his orthotics but it doesn't seem to correct his collapsed arch..

What would be a good treatment for this case? Would PT muscle exercise help to

relieve the symptom?

Please enlighten me!! I need some help!

 

As you know, there is little evidence of a high level for you to follow in this case. My low level evidence that exists for The Foot Centering Theory of Structure and Function and The Inclined Posture suggest the following:

1. I would consider that the hip surgery and dyscrasia has caused a limb length discrepancy. I believe you will find the right side to be functioning short.

2. The orthotics you speak of were probably well made subtalar joint neutral cast and so they have captured his collapsed feet in a collapsed position and are destined to the failure you have observed. We need a structural upgrade from STJ Neutral in order to establish a new force equilibrium that allows PT (and PL) to gaining enough leverage so that they can respond to the same (or better) training that you have implemented.

According to Foot Centering Theory, what this lad needs are device shells that are cast in a more optimal functional position (less collapsed in both the RF and FF). This translates to the fact that they would be more vaulted, shorter and narrower than the ones that he has received. They should be prescribed with a deep heel seat and a 0 RF Post as well as a 1st and 5th ray cutout with a 5-6 mm (or more) 2-3-4 forefoot leveraging post. I would add a 1/8-3/16" heel lift on the right side if it tests short (I predict it will).
These Foot Centering Orthotics will then make PT and PL more trainable. If this fails, I would consider STJ Stenting followed by the above Foot Centering Orthotic, ORF and MERF program.

Dennis

 

Hi and welcome to the forum.

Ligamentous laxity means the ligaments are loose and will allow additional joint range of motion. Flat-foot is a common presentation with ligamentous laxity.

Your patient's clinical presentation is probably due more to bodyweight, foundations which can't support bodyweight, and gravity, than anything to do with the hips.

These cases often respond well to a UCBL-type of device.

 

l would also be looking to see if there was a LLD.

What sort of shoe is the orthosis going into, is it up to the job?

Its one thing to have a great orthosis, but if its not supported by a decent shoe all is lost.

l would be looking to also supply the child with a lace up ankle boot rather than a shoe, to try and get a little more support for the ankle.

It needs to fit firm to the ankle and be laced up firmly.

Good luck.

 

Very good advice David. The orthotic is reducing the pronation moment below the STJ axis, while a supportive boot will provide support above the STJ axis. A UCBL is a good idea too if there is abduction of the forefoot on the rearfoot.

Ligamentous laxity is indeed a major problem. The plantar ligaments of the medial longitudinal arch (MLA) and plantar fascia are so important in providing support when the ball of the foot hits the ground. With ligamentous laxity, the forefoot will dorsiflex in midstance and the MLA will collapse. Due to the laxity of the ligaments (and likely medially deviated STJ axis) the PT tendon will have a shorter lever arm to to reduce the pronation moment. Difficult foot to support.

Question, where in the ankle is the pain? Commonly, the pain is not in the lateral ankle area but just anterior and distal to the lateral malleolus in the sinus tarsi. Palpate deep within the sinus tarsi to see if it is tender to rule out sinus tarsi syndrome from the floor of the sinus tarsi causing an internal supination against the lateral process of the talus.

So many questions to ask. Does the patient have generalized ligamentous laxity? Can he hyperextend his elbows and knees and touch his forearm with his thumb? Have you done a through biomechanical exam of the hips? Have you done a gait analysis? What is the patella position of the right and left knee? Is there a genu valgum present? Is the left foot toeing in more than the left? Is there a pelvic tilt? Is there a shoulder drop? Does the patient have a leg length discrepancy? Do a complete biomechanical exam to understand the entire picture.

This is a challenging patient and a good opportunity to learn. My personal advice is to not be eager to make a diagnosis for your patient. Be eager to be aware of what you do not know and learn it. Be eager to study hard so you may understand the fundamental concepts and continually improve on fitting the pieces of the kinematic puzzle together.

Your a first year student and took the initiative to go on Podiatry-Arena and I have no doubt you will be an excellent practitioner. Best of luck.

Steven

 

Thank you so much for a great advice. Some of the things are still difficult terms for me to understand but I'm so thrilled to crack them all and learn them all!!! The patient is using his orthotics with his ordinary foot wear that covers up to his ankle. (I will suggest them to look at the options of UCBL type of device, after I learn about them..is there a post about this?) I really loved everyone's comment. THANK YOU!! I'm going to see the boy again next week and ask all the questions that you guys suggested. His parents are good friend of mine. Also they don't mind me making a clinical observation from their son's case. So I'm quite lucky. I've just learnt about the gait analysis this semester so yes, I can give a shot and do the gait analysis on the Patient. Btw, the parents suggested me to do low dye taping occasionally when he feels pain in his ankle. what types of low dye taping would be suitable for this case? a low dye taping for pronation would be good enough? Or ankle support? after reading drsha's post I guess both of them won't really do any help...It's embarrassing that I know so little.. But hopefully this will be a start of learning a lot more to become a decent podiatrist in the future. Again, thank you!!

 

What you've guessed from my low evidence ( sorry..) is so right. He got only one orthotics made for his left (after his collapse). It has no 2-3-4 leveraging post.( He got it from a student clinic and his orthopaedic surgeon said he got no issues with foot at all) It only lifts his heel position. If you don't mind would you please give me a detail how the orthotics that you are suggesting would make PT and PL more trainable? Is there any book or journal that I can read regarding this sort of clinical case? Thank you so much for your comments Dennis!!