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Advice please: Orthotic prescription after ankle arthrodesis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by penny claisse, Apr 28, 2010.

  1. penny claisse

    penny claisse Member

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    A patient has been referred to me who had had an ankle arthrodesis 4 months ago to address severe ankle pain that resulted from what his orthopaedic surgeon has described as a lifelong 'severe hindfoot valgus' of his right foot with a grossly mobile 'ball and socket' ankle joint. Over the years he wore an orthosis of HUGE proportions with 80mm heel cups and medial arch support.

    The surgery was perfomed arthroscopically and titanium screws completed the ankle fusion. The Achilles tendon was lengthened and the hindfoot was corrected to a neutral position. The outcome is that he now has a greatly reduced valgus rearfoot position when standing relaxed, a forefoot parallel to the rearfoot,he can dorsiflex his ankle to a neutral position and currently has a small range of subtalar frontal and tranverse plane motion available. This right leg is also shorter than the left by 15mm. Meanwhile the left foot is very mobile and stands relaxed in full subtalar deviation and heel eversion, has only a mild forefoot supinatus and a low subtalar joint axis.

    I have taken non weightbearing casts of both feet and am considering the prescripton.

    In the past I have treated patients who have had triple arthrodesis so that the rearfoot has been completely rigid. Previously I have used an EVA orthosis to provide shock attenuation with heel raise where necessary and advised a 'rocker'style shoe to promote a more comfortable gait . However this patient has some movement at the ankle joint and at the subtalar joint.

    I would be grateful for any advice on this prescription. He prefers 3/4 length devices. I would like to use a carbon fibre shell for the left foot and am confident to prescribe this. But should I aim to provide a similar rigid or semi-rigid device with cushioning inside the shell for this patient's right foot or use an EVA?
  2. Graham

    Graham RIP

    Probably a full contact EVA device with an MBT/Sketchers type rocker shoe?!
  3. RobinP

    RobinP Well-Known Member

    Does he really need coronal and transverse plane control? What is the problem you are now dealing with - ie is it painful or are you trying to prevent recurrence. The description of the post operative foot ankle would appear to be satisfactory with no major deviation and ?pain free? so what is the benefit of trying to influence its alignment

    Raise heel to accommodate the LLD and improve functional dorsiflexion range, assuming plantarflexion ROM is satisfactory. MBTs give inherant coronal plane instability which shouldn't be a problem if you are saying that the fusion is good but if you are concerned, a running trainer with good rocker, rigid sole may be better.
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    You say there has been an ankle fusion - but then also state that he can 'dorsiflex the ankle to neutral'. This is a contradiction.

    What typically occurs after ankle fusion is that the STJ and TN joints try to compensate for the lack of sagittal plane movement. Generally they develop OA given enough time. Given there was a 'ball and socket' ankle joint -this has probably already occured - review the weight bearing x-rays.

    Your job is to try and protect those joints. Don't use a heel raise. The ankle is fused - you need a sole raise to lift the whole foot up.

    Hope this helps,

  5. Jeff Root

    Jeff Root Well-Known Member

    I completely agree. More than likely, the MTJ will develop osseous adaptations and axial changes over time due to compensatory changes that result from ankle fusion. The orthosis should be used to provide MTJ stabilization and limit STJ motion for this purpose. How much calcaneal inversion and eversion do you get with open chain motion of the STJ? I agree that a heel lift is contra-indicated as it will attempt to plantarflex the foot at the ankle. A full sole raise is an excellent suggestion.

    You can clinically evaluate the MTJ to see if the patient has already developed increased mtj mobility (i.e. hyper-mobility, sorry Kevin ;) or motion that is contrary to normal). Take a look at the opposite MTJ and check for asymmetry of motion. The frontal plane position of the device (corrected cast) will be important because you don’t want to create any excessive varus or valgus moments in the ankle, especially if the fusion is incomplete. It might be worth looking into the ankle issue to see why there is motion. The patient might ultimately develop ankle pain, with or without orthoses. Informed consent dictates that you advise the patient of this and that you don’t know if the orthosis will prevent it, and it could possible cause it given the ankle history.

    Jeff Root
  6. RobinP

    RobinP Well-Known Member

    Sorry - I misunderstood the original history. Although it said ankle fusion, the presence of talo crural range made me assume that the fusion was to the STJ post osteotomy.

    Thus, coronal and transverse plane control a necessity.

    Apologies and feeling suitably thick

  7. penny claisse

    penny claisse Member

    Many Thanks to everyone for your analysis and suggestions.

    An important point made by LuckyLisfranc:
    You say there has been an ankle fusion - but then also state that he can 'dorsiflex the ankle to neutral'. This is a contradiction.

    Apologies are due as I stated that:
    'he can dorsiflex his ankle to a neutral position'
    I should have said:
    'his ankle is held (firmly) in a neutral position' when he is non weightbearing.
    ie.The ankle is fused. He has a very minute amount of plantarflexion and virtually no dorsiflexion remaining.

    In open chain I estimate that he has 30% of subtalar inversion and eversion remaining. When he is weightbearing he stands with his heel in approximately 5 degrees of eversion to the floor and the ankle also appears slightly medially deviated. He can then actively invert his heel to almost vertical. The midtarsal range of motion appears almost 75% of the unoperated foot.

    I checked out the surgical procedure report further that stated: the hindfoot was corrected to a neutral position with a plantargrade ankle joint (and) the soft tissue released in order to correct the gross hindfoot valgus. When the ankle joint was brought into an acceptable clinical position there still appeared to be valgus slope at the ankle joint, but if this was corrected to a neutral position the hindfoot swung into varus. Therefore the clinical position of the hindfoot was accepted. The forefoot supination was correctable passively and it was not deemed necessary to perform a midfoot osteotomy or fusion.

    Therefore he has a plantargrade foot with a fused ankle joint. I agree with Jeff and LuckyLisfranc that a full sole lift rather than a heel raise would be indicated.

    As the hindfoot and ankle still have a slightly valgus position AND there is a degree of calcaneal inversion and eversion available plus the midfoot has similar mobility to the unoperated foot, Jeff rightly says that the orthosis should be used to provide MTJ stabilization and limit STJ motion.

    So my last question is: Bearing in mind that this male patient is only 29 and wants to wear 'normal' style shoes most of the time

    1. What material would be best for the orthotic? Any further suggestions greatly appreciated. Would a semi/rigid carbon fibre/polypropylene composite shell , that is thin and shoe friendly, with a poron lining, provide enough shock attenuation for this foot? It will disappear into his slim business shoe or Should the full length, medium density EVA device be the best way forward after all?

    Thanks for working through this with me.

    Penny C
  8. drsha

    drsha Banned

    First my comments as related to this thread.

    Interesting that all of you can render opinions from afar without ever having seen the patient (or even a picture) but you claim that I should not be able to.

    This is a case where the right foot will not respond to any rearfoot skiving which means that at least for this foot, SALRE doesn't play any import.
    Sagital plant mechanics are of great import here.
    Your system does not apply to a case of this sophistication since it is so cookbook.

    Let's see if my Functional Foot Typing evaluation and following its rules for casting, posting, materials, after factoring in concomittant patient disparity adds clarity or confusion to this case.

    This patient has an FFT diagnosis of
    Rigid Rearfoot/Flexible forefoot, right
    Flexible rearfoot/flexible forefoot. left with TIP short right (please test for foot type and for a relative equinovarus of the joints of the ankle and confirm or deny my distant thoughts for accuracy).

    I suggest:
    The right limb needs shock absorption and the foot needs sagital and transverse plane vault and forfoot correction and a lift (preferably heel lift and not a platform).
    Material should be semi rigid polypro (of a thickness according to weight to allow for shock absorption) and posts should be soft durometer crepe (and replaced frequently).
    The foot should be cast according to foot type-specific FFT technique with concentration on vaulting and sagital plane forefoot correction (or however you would currently do that) an aggressive 1st ray cutout and forefoot leveraging bar (2-5 varus posting) according to the level of deformity by your examination.

    The left foot needs a deep heel seated, semi rigid shell with a 0 degree rearfoot post and the vaulting and sagital plane forefoot corrections patient specific as described for the right foot (same forefoot type eh).

    I would only use the rocker shoe as a last resort should the above fail as it will allow for continued degenerative compensation of both feet, bunion deformity, left > right as one example. It can however be used as an exercise vehicle to maintain postural strength.

    In addition, physical therapy consultation should be considered to develop motor control of peroneus longus, B/L and to monitor the possible sequelae of the TIP that the surgery produced as a complication.

    Level V EBM
    Shavelson DE, A Closer Look at Neoteric Biomechanics; Podiatry Today: Volume 20; Sept 1, 2007; p.28-35
    Shavelson, DE, Neoteric Biomechanics; Podiatry Management: September 2008; p. 122-126

    Good luck in handling this sophisticated case.

    Dr Sha

    PS: You did not mention the patient activity level, weight, postural discomforts (ankle,knee, hip, low back) which would impact my decision making process in deciding on postings, cutouts, lefts, etc.

    If you send me your casts, I can confirm this patients foot type, TIP and add consulting thoughts on how we can correct flaws in your positive poured casts at the lab end of the process and I will work with you on this case without fees as a courtesy. www.foothelpers.com
  9. Jeff Root

    Jeff Root Well-Known Member


    I don't think that the shell material is all that critical in this case, provided it is sufficiently stiff to support the foot. A standard poly or carbon shell based on patient weight should suffice. I don't see any "extreme" forces (in either magnitude or direction) that need to be resisted unless the patient is obese. I don't see any need for a softer, accommodative type of material or device.

    The next question I should ask now that you have provided information about stj and mtj motion, is how does the foot function during gait? Specifically, how much stj inversion and eversion occurs during gait? If he functions maximally pronated throughout the stance phase of gait, then the orthosis should be designed to resist stj pronation. It's possible that the stj pronation moments could increase after adding a lift to the shoe, so this is something to evaluate later.

    You said he has approximately 30% of his stj rom remaining and the heel is 5 degrees everted in resting stance. Is his 5 degree everted relaxed calcaneal stance position his maximally pronated position? If so, I would try to keep him from functioning maximally pronated. I assume he has about five to seven degrees of stj motion available (i.e. 30% or 1/3 of the average of about 18 degrees). I would correct the heel to about 2 degrees everted relative to the floor to allow for some inversion and some eversion, assuming that 5 degrees is his maximally pronated position. You could also make an argument to correct him to his maximally inverted heel position (which could be inverted or everted to the floor depending on stj direction and range of motion) to resist the valgus moments in the rearfoot. It’s a judgment call on your part.

    The decreased rom at the mtj appears to be the direct result of a decreased rom of the stj. The mtj has an increased rom when the stj is pronated and a decreased rom when the stj is supinated. Given the decreased rom of the stj, you want to protect the mtj because it will likely adapt and develop more triplane motion as a compensation for the decreased stj and no ankle rom. The good news is, he has a stable mtj to start with. Otherwise, he would have issues during propulsion and this would be a far more complicated case.

    You could use a high medial heel cup and a medial rearfoot post flare to resist heel eversion. As Dr. Shavelson mentioned, you could consider using a rearfoot post with no motion. This is another judgment issue. You need to inform the patient to notify you immediately if he develops any knee, hip, or low back symptoms because it could be related to his orthoses and these judgment issues. You might need to increase or decrease post motion, depending on patient feedback. Keep a close eye on the knee if you use a rearfoot post with no motion, be prepared to add motion or even remove the post if necessary (i.e. first, do no harm!). Just be sure to communicate and document your instructions to the patient. Have him use a conservative break-in and tell him not to hesitate to discontinue use of the device and call you if he develops any other symptoms.

    I too would be happy to make your orthoses no charge. I don’t see this as a challenging case from a mechanical control perspective, so claims of great success by any lab would be overrated at best. This issue is about treating your patient right now, not about who has the best theory to underpin foot orthotic therapy for the future.

    Jeff Root
  10. drsha

    drsha Banned


    Sorry to be blunt but
    If you don't consider a 29 year old with a STJ fusion who wants to wear normal shoes and lead a normal life for 50-60 years as a complicated or sophisticated case, perhaps this exposes your lack of clinical experience or training.

    In an EBP sense, claims of great success from any lab remains Level V evidence at best and of no applicable relevance to this case.

  11. Jeff Root

    Jeff Root Well-Known Member

    Dennis I believe it demonstrates just the opposite. I don't see any immediate clinical issues that warrant anything different than what I have proposed. In terms of the long term ramifications, I think I have addressed them. We are treating the patient today with consideration of the long term issues. The orthoses at this stage are a proactive application, which I fully support. I thought about asking for more history to base my recommendations on, but I’m trying to be as concise and brief, yet helpful.

    I am keenly aware of the long term ramifications of ankle fusion and the likelihood of compensatory changes. In two, five, ten or fifty years the patient's needs will change and it can be addressed at that time. I don't think that have in any way minimized the potential implications of ankle joint fusion Dennis. I just don't think we need to make it any more complicated than necessary. I have attempted to anticipate future issues to the best of my ability and to recommend an orthotic prescription to address it, based on the patient's current status and biomechanical conditions.

    I think Penny's questions were sincere and valid. I have a little clinical knowledge and experience that she may find clinically helpful. I have attempted to share it based on the available information, which is not necessarily the complete picture. If you can't appreciate my clinical insight and knowledge based on my line of questioning, then so be it. I think Penny can, and right now she is the only one whose opinion about this case matters to me. With all due respect Dennis, I have to disagree with your assessment of my level of clinical experience. I had an adequate mentor, to say the least.

  12. Jeff Root

    Jeff Root Well-Known Member


    Let me rephrase this because the second sentence came out entirely wrong. It is Penny's opinion that is important because she is the one charged with actually treating this patient. I appreciate other opinions, whether I agree or disagree, because I can learn from them and the Podiatry Arena is an excellent place for all of us to learn. I view clinical inquiries in an entirely different light than theoretical discussions, because we are directly impacting the quality a specific patient's life. Dennis, if you disagree with my clinical advice to Penny, then please feel free to criticize it for the benefit of Penny and her patient.

  13. penny claisse

    penny claisse Member

    My sincere thanks to Jeff Root and drsha for your detailed analyses of this case and generous offers to make the orthoses over in the USA. I think that I have a little more work to do before making a decision on this, but I am grateful for such support.

    You have both given me a much greater insight into the longer term implications for this ankle fusion where there is some hindfoot and midfoot flexibility and I understand that this patient will need careful ongoing follow up .

    Additional history: He is not obese, is approximately 178cm with a uk size 9 and half (US 10 and half) right foot and a uk size 10 and half (US 11 and half). He has put all sport on hold over the past six months and is attending the gym to do non weightbearing cardio work and upper body weights. His right calf bulk is 50% of the left calf and he is having regular physio and working on strengthening exercises on this leg. He had his first surgery on the ankle at age 14 and before this last procedure 4 months ago the right leg was functioning at 40mm shorter than the left - compared with now at 15mm shorter. Before surgery he was in intense pain for the last 5 years. Now he has mild discomfort in the right ankle and occasional pain in the non operated left medial ankle.

    I do have photographs of his anterior and posterior relaxed stance positions and a posterior view of the degree to which he can invert his right heel. However I am certain that I would have to gain his consent before sharing these and ?would it be best to do this by private email to you both directly if you felt it would be valuable. Please let me know if you would like me to go ahead with this?

    Meanwhile I will have another look at his gait but my first observations suggest that he is functioning in a maximally pronated position throughout the stance phase. I will also get a more comprehensive look at his surgical notes to understand the degree of arthritis in the foot and ankle before surgery.

    Finally is it possible for this young guy to have an orthosis for his right foot of proportions that he could wear in a normal shoe for business/socially? Amazingly he had been wearing the monster heel cup device in his right shoe previously even though it poured out over the the top of the upper - but he would be so grateful to be more 'normal'.

    Penny C
  14. Jeff Root

    Jeff Root Well-Known Member


    I would be happy to look at his photographs. You can email them to me at jroot@root-lab.com. I think you should be able to post them on the Arena provided you don't identify the patient, but I'm no legal expert.

    When and where does the patient experience ankle pain and with what activity? Here is a clinical experiment you can try that may help you decide how to correct his orthoses. Have the patient stand with about 70% to 80% of his body weight on the right foot. Have him slowly internally and externally rotate his leg to see if he can reproduce the ankle pain. If so, can he locate it? Is the pain associate with the relative position of the leg (i.e. supination or pronation motion)? If the pain occurs with internal leg rotation, all the more reason to correct to the least pronated end of his rom (near heel vertical?).

    You can also have him shift his weight anteriorly and posteriorly. Is there pain associated with sagittal plane changes in force? Potentially a slight heel lift might still be an option if pain occurs with attempted dorsiflexion of foot. These are just a few more ideas to consider.

    I don't see any reason why he shouldn't be able to use a conventional orthosis since the ankle is fused.

  15. drsha

    drsha Banned

    You can forward the photos either way.

    Dr Sha

    PS: this is a good example of how bioemchanics can work EBM

    PPS: I did not critisize Jeff's suggestions as they are no less valuable than mine. I critisized him calling the case uncomplicated. I just feel if my average patient were this complicated over 30 years, I would be selling paint for the last 28.
  16. Jeff Root

    Jeff Root Well-Known Member

    Dennis, please see what I originally wrote. I didn't say that this case wasn't complicated. What I said was, I don't believe the mechanical control issue is that complicated. This case requires more thought because of the patient's history. It's not routine, which is why I was interested in it in the first place. I have seen more than enough cases of plantar fasciitis in my day, and I can't even watch television without hearing about it constantly from the local retail arch support store.

    I hope we have this straightened out now. :drinks

  17. efuller

    efuller MVP

    Another thing that doesn't sound quite right is an ankle joint fusion with correction of the heel varus done arthroscopically. Additionally, a ball and socket ankle joint often develops in response to lack of motion of the STJ. Was there any surgical work done at the STJ or calcaneus? How was the hindfoot corrected?

    Regardless, you have to address what is going on in his foot now?
    More on that in a later post.

  18. efuller

    efuller MVP

    I agree here as well. Since the ankle is fused, I would also agree with the rocker style shoe with a SACH heel.

    If no STJ work was done in the surgery then this makes me suspicious there was a coalition in the foot prior to surgery. A STJ coalition can limit midtarsal joint motion.

    I agree with Jeff that what you do with the orthotic is not that critical. What you doe with the shoe will be more important than what you do with the orthotic. You can have a shoe maker/ orthotist slice the shole off of a "normal" shoe and add the leg length modification and rocker to that and reapply the outer sole. His future problems are more likely to come from lack of ankle joint motion and the limb length descrepency created by the surgry.


  19. efuller

    efuller MVP

    I disagree that the rocker should be last resort. If the ankle really is fused he will develop the knee hip and low back problems. Think about how you have to alter gait when you wear a fully buckled ski boot. I beleive the term that folks use is hip thrust for the style of gait where you try to get over a rigid ankle. An orthosis is not going to really help the gait disturbance caused by a fused ankle.

    Last edited: Apr 29, 2010
  20. matthew malone

    matthew malone Active Member

    I thought i would chip in and have a say. Firstly i agree with Eric, I think a rocker is so important for these cases, i would never consider a rocker as a last resort. I work in an Orthopaedic Clinic where i see about 10 ankle fusions per week. I have to say that most are done quite well and i know most of the surgeons aim for the ankle to be set around 90 degrees, although most of the time i see them in 85 degrees of equinus. The majority of patients i see also have massively reduced if any STJ ROM.

    From my experience they seem to respond poor to just orthosis alone! I think its is so important to address the sagittal plane function in these patients and often the use of aggressive shoe rockers helps this. I adapt the patients own shoes and will often ask for a heel to toe rocker, with a 30 degree angulation at the heel (like MBT) and a 12mm rocker to kick in around the midfoot. At the same time i often create more acommodative devices to help reduce (minimally) any aggressive hindfoot valgus and improve heel shock absorbtion. But that depends on the level of control needed. The thing is that every patient is so different, some have available ROM at the rearfoot and some dont.

    With your patient penny if he also has a leg shortening on the rocker side then its easy to ask the shoe company to incorporate an additional raise into the rocker. With it being only 15mm currently just adding the rocker to that side would create a raise anyhow.

    When reading through all of the posts, i havent really heard any one thing that i wouldnt do, and i have tried most things above, i think all the above points are pretty valid, it would just depend on the type of patient in front of me as too which i would choose.

    Thanks for listening
  21. drsha

    drsha Banned

    My limited experience is that the MTJ takes over a decent amount of the sagital plane deficit without much ado in cases of 1" or less (25mm) and an elevation allowing for the shortage with heel lift equal to the amount of fixed plantarflexion of the dropfoot and an orthotic that compresses, I find the patient will appreciate a more normal shoe and cosmetics than the visual insecurity the rocker added to a shoe brings to the table.

    I also thought that the suggestion of rocker shoes (not a rocker Rx'd to an existing shoe) was a bad idea as it has the inherent biomechanical and physical problems that any Sketcher type shoe would have.

    The concept here is to find out from your patient psychologically whether he wants to walk normal in a funny shoe or funny in a normal shoe (about 50/50 in my experience but more towards cosmesis in a 29 tear old) and then lean towards that direction.
    Hence the rocker is a last resort for me if Dr. Malone is correct and function rises as an issue in a normal shoe.
    Dr Sha

    PS: This thread, with all its clinical variations produced by serious biomechanists, is proving the import of the practitioners skills and experience and his/her ability to accommodate the unique needs of the patient at hand with care in delivering EBM Biomechanics. The call for Level I EBM to justify care is often a red herring in the biomechanical clinical arena.
    I find there to be two schools of thought highlighted by Jeff and I.
    1. Treat the patients immediate comfort and functional needs and then deal with negative consequences as they arrive and
    2. Use EBM to anticipate the future pathology and quality of life issues the patient will have and apply care that will address the long term needs of the patient possibly sacrificing some immediate comfort in order to preserve long term quality of life.

    I believe that Dr. Root was after #2 and his work has been diluted and damaged by time and we are poised for an upgrade.

    Finally this thread is so delightful to participate on because we are all admitting to our clinical differences and disparity and focusing on what we can do to help the treating doctor answer questions that have arrison during a patients care instead of trying to get converts to our personal biases as on other Arena threads that are so much more combative.

    I'm for more of these.
  22. Peter

    Peter Well-Known Member

    Hi Penny

    the answers you have got are varied, and each are valid but that largely depends on what you are trying to achieve for your pt.

    That aside, I agree with Matthew Malone, with a rocker sole/stiffener and raise to balance the LLD, and enhance sagittal progression.

    One point I must add, if in-shoe Rx doesn't go well, consider an AFO with the shoe modifications.

    Just my two-penneth
  23. efuller

    efuller MVP

    I agree that it's the patient's choice. I would offer/ prescribe the shoe modifications (rocker and lift). If the patient decides to leave it in their closet, on occasion, then that's ok. But, it should at least be in their closet. From the history given, I don't see how an orthotic is going to help a fused ankle with a short leg.


  24. Penny:

    Thanks for providing such an interesting case to us. Your clinical description has been precise and thorough. I thank you for that.

    I treat cases like this quite frequently, but generally of ages older than your patient. For a 29 year old with an ankle fusion, your prime considerations are:

    1. Allowing the patient to perform as many activities as possible in a pain-free manner.
    2. Preventing future pathologies that may result from abnormal compensatory motions in other joints due to his complete loss of ankle joint motion and the limb length discrepancy.
    3. Create an orthosis-shoe solution for him that is not only functional but cosmetically acceptable for his line of work/social needs.

    Of course, the standard treatment for an ankle fusion is some form of rocker-soled shoe. In today's market, we now have the MBT and Skecher Shape-Up shoe that comes standardly with a rocker sole design (I have attached a some photos that I took while walking through Rome yesterday of some of the Skecher Shape-Ups). Clogs also have a rocker sole standardly. However, due to his consirable limb length discrepancy, it will probably be easier having his right shoe modified with a rocker sole and heel/sole lift than to try and modify a MBT, Shape-Up, or clog with a full sole lift.

    It is also important to have custom foot orthoses made for this patient. The goal of the foot orthosis on the right foot is to decrease any pathological rotational forces (i.e. moments) on the subtalar joint, midtarsal joint and midfoot joints which will certainly occur due to the patient no longer having the ability to dorsiflex their foot relative to the tibia due to the ankle joint fusion. The idea with the orthosis is not to prevent all subtalar, midtarsal and midfoot motion. Rather, the idea, is to have the orthosis limit any excessive ranges of motion that may lead to joint, ligament, tendon damage or muscular fatigue/injury within these joints.

    As far as specifics for the right orthosis, I would most likely use a standard length polypropylene shell 4-5 mm in thickness [without a topcover for dress shoes/with a topcover for athletic shoes] with a standard 4 degree/4 degree rearfoot post, no skives, with normal medial arch fill, 14 mm heel cup and balanced to vertical or 1-2 degrees inverted and with a possible heel lift [if you wanted to have less heel/sole lift added to the shoe sole]. It sounds like you don't need any help on the left side orthosis, but certainly using a much stronger anti-pronation orthosis design on the left side makes good sense.

    Thanks again for such an interesting case for the Podiatry Arena.

    Attached Files:

  25. penny claisse

    penny claisse Member

    Thank you for your continued input on this case. You are all helping me to put together a really comprehensive plan for his immediate care and longer term follow up that has options for him to consider and be fully involved in.

    As a young patient with an ankle fusion on one hand he could be very resistant to shoe modifications and want only to consider this option at a later date if /when the foot and ankle became symptomatic. Or, as he has had interventions/surgery and orthoses in the past he might be less resistant to using shoe mods at least for everyday activities but not want to wear 'funny shoes' for social activities. Or he might go down the fully conservative path.

    I can now email images of my patient's standing positions to those who have already posted their addresses and so will mail Jeff, Dr Sha and Kevin. I appreciate Eric, Peter and Matthews input too, who have most recently posted their comments but do not have their mailing details yet.

    Also I now have answers to Jeff's questions:

    Answer: No pain at all with any of these manoeuvres.

    Answer: No pain at all with this manoeuvre.

    My question: When you are walking what do you feel your foot and ankle is 'straight', 'falling inwards' or 'falling outwards' in any way?
    Answer: Falling inwards slightly ( as I observed).

    My question: How painful or uncomfortable is your ankle right now (standing relaxed) Answer: I have no pain/discomfort at all now or doing any everyday activity BUT if I walk for some distance - 2 miles plus - my right leg gets tight and sore at the front (anterior) - scored on a VAS scale of 3 out of 10 and my left ankle gets slightly painful.

    Answer: No pain at all in any of knee, hip and back but see above for leg and ankle. Weight =80 Kg

    Penny C
  26. drsha

    drsha Banned

    Kevin discusses using an orthotic that limits excessive mption and gives reasons for that and then [roceeds to recommend and picture a shoe whose advertized claim is that it forces you to exercise ranges of motion and muscles that by creating excessive motion.

    I understand the need for sagital plane motion from the shoe as it is plainly reduced by the right sided surgery. All I said was that rather than go immediately to the rocker shoe (I would most likely end up there) and marry your patient to it for the rest of his life, I would try to use a more normal shoe first coupled with an orthotic that maximizes sagital plane correction in order to try to keep the patient looking like the rest of us and switch to the rocker bottom if that failed.

    This involves establishing a deeper relationship with the patient, more work, more monitoring, more fine tuning, more caring and this is the EBM reason that I say that the "PROVERS" (led by Robert Isaac on other threads) have stifled clinical biomechanics by arguing whether the word EBM (coined about 15 years ago) or the science of EBM (started with the first RTC many years before) is the meat of my work) are not as capable clinically as the "CARERS".
    Please note that Kevin is a "Carer" and the rest are absent on this thread.
    Dr Sha
  27. CamWhite

    CamWhite Active Member

    It's been an interesting week. I don't know why this happens, but pain issues seem to come to our store in packs. This week, I felt like an arthritic/fused ankle support group took a field trip to our store.

    We have carried the MBT brand for several years, but we now also carry Ryn shoes. I believe Ryn shoes are a far better solution for those who need better frontal/coronal plane control in a heel-to-toe rocker shoe.

    MBT & Skechers use memory foam for cushioning at heel strike. Since memory foam has no real structure or support, the shoes induce medial/lateral instability. While this is well-tolerated by many, it's a problem for others.

    The Ryn shoes have a structured air-tunnel system. Since there is no soft memory foam to collapse, the shoes provide much better frontal plane control. The shoes also have sufficient depth to accept prescription or OTC orthoses, if needed. Additionally, I was able to fit one customer with a rather bulky plastic AFO in an extra-wide regular shoe (Drew), but also in Ryn shoes. The customer fared much better in the Ryn. His gait was fluid, his posture was good, and he was able to walk without a "hitch" in his gait. Every one of the customers with arthritic ankles felt better wearing Ryn shoes. This has also drawn the attention of a respected orthopedic surgeon in Austin, who is now recommending these shoes to his patients with foot & ankle arthritis.

    The heel-to-toe rocker sole shoe category of footwear is dominated by Skechers (HUGE advertising budget) and MBT (first to market). Both brands are unstable. Ryn, Finn Comfort "Finnamic" and Mephisto Sano are examples of heel-to-toe rocker sole shoes with much better frontal plane control. Of these brands, Ryn and Mephisto are the most friendly for prescription or OTC orthoses.

    The final consideration for these shoes is terrain. All of these shoes perform well on flat, level, predictable surfaces. Unstable rocker sole shoes perform poorly on uneven terrain, including grass, sand, side-hills and cobblestones. The memory foam will collapse wherever the terrain takes the shoe. The "stable" shoes provide much better support and control for the wearer.

    I produced a video a while back, designed to help the lay person make better decisions about this category of footwear:

    I wrote this post because many people automatically associate MBT/Skechers when they think about rocker sole shoes. For your patients that need better medial/lateral stability, I believe there are other brands better suited for these individuals.
  28. penny claisse

    penny claisse Member

    To all colleagues who have participated in this thread and have freely shared their experiences and given valuable advice and generous offers of help with the orthotic devices, many, many thanks and here is an update:

    I decided to go it alone and take full responsibility for the prescription of the orthotics for this patient and ordered them from my usual lab, taking on board the need to maximise sagittal plane motion, limit frontal plane motion, provide a raise equal to the slight right ankle plantarflexion and go some way to reduce the leg length difference in the shoe, but get as normal a 'feel' and action as possible. This was for starters. I went for the 1st ray cut out to the right shell too and produced a surprisingly normal looking pair of orthoses that produced a really good visual effect on both feet, felt comfortable .

    I backed this up with advice on shoes - high tops good to start and my patient was very pleased with the initial overall result. We are going for gradual wear up and we discussed the possible dangers ahead and how to make him as future proof as possible.

    He is not very keen on a customised right rocker shoe only but is very interested in the approach where he could wear rockers on both feet and still be 'normal'. We discussed the pros and cons (re medial and lateral stability, inclines etc) of the different types of available rocker shoes on the high street - MBT, Skecher and he will check them out - I myself also went out and tried several other offerings with more stable rockers so that I could really put myself into his position and offer support. Then I read the latest mail from CamWhite and discovered Ryn and Mephisto shoes - they seem an excellent option that will probably suit him well and I will pass this recommendation on to him.

    So now he is out there at the beginning of a journey but feeling really optimistic about life - and I feel confident that I have given him a good start and can support him as he progresses.

    Again many thanks to you all and especially Kevin, Jeff and drsha who really got stuck into this case.

    All the best

    Penny Claisse
  29. RobinP

    RobinP Well-Known Member

    I'm sure you just want to put this thread to bed now penny but if the patient is very resistant to the idea of having a 15mm raise + rocker on one side, then an option may be to split the raise.

    If you take a shoe like this as an example of a work shoe. The sole unit is moulded polyurethane(I think). The point is that it is a 1 piece sole unit and can be bandsawed down the middle.

    On the short side, add a 7mm raise only, throughout the whole sole unit and ask the company who are doing it to incorporate a 10-12 degree toe spring rocker.

    On the long side, ask them to lower the heel only by 7mm and add in a similar rocker for a more symmetrical appearance.

    The overall differential between the shoes remains at 15 mm but the effect is that the longer side shoe still looks quite "normal" If the adaptations are done neatly then it should still be fairly cosmetic. As it happens, this particular shoe has a removable inlay of 3mm thickness which may give you a little scope for you orthotics.



    Attached Files:

  30. drsha

    drsha Banned

    Dr. Claisse:


    I nominate this for "Thread of the Year" as it was an experiment in Biomechanics EBP without the meanness that often follows my posts.

    It has come to a satisfactory ending and I believe, very well captained by you on behalf of your patient.

    There was a great deal of import put on the patients needs and values and, especially around the area of TIP (LLD), where there is virtually no evidence, cliical decisions were fruitfully and scientifically made.

    This has allowed you to upgrade your practice because you were willing to go the extra mile and I have sense that your decisions are a great starting point that will allow your patient to meet many of his needs that you unveiled.

    I am pleased that you seemed to have incorporated some of my clinical opinion in your decisions as this Arena has spent a long time trying to undermine my clinical abilities in order to mask what I believe are their own deficiencies (personal bias).

    I remain available to you as this case will need to be monitored and fine tuned but you have established a protocol to follow in similar cases that you (and all of us) confront and in the trenches, faced by a patient , THAT IS WHAT (I believe) EBM PRACTICE IS ALL ABOUT!

    I look forward to more of these clinical challenges in the future.

    Dr Sha
  31. penny claisse

    penny claisse Member


    Thank you for your further dissection of the 'rocker and raise' option with suggestions for keeping the modifications as discrete and straightforward as possible. I am sure that such 'smart' and even 'elegant' solutions to therapeutic footwear issues (smart and elegant as in 'keep it simple' but also good to look at too?) are as essential for older patients with ankle fusions (more and more of them around now?) as well as young patients like mine. I will take your advice and use it appropriately with him and I suspect with others to come.


    Thank you for your kind comments. I too have really enjoyed the discussions and the access to so many top level participants in this field who have provided kindly and thought provoking mentorship derived from experience straight out of their own clinics. This experience has helped me to grow as a clinician. I agree that this has shown the Arena at its best. Bravo!

    Penny Claisse
  32. Admin2

    Admin2 Administrator Staff Member


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