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Set out below are the details of a case I have seen this week for a 62 year old male who has an accident at work in 2012 and crushed his right ankle joint.
He gets severe pain when weight bearing on the right forefoot, which of course with the right foot ankle joint fused and fixed in plantarflexion he must do during walking. He has had a shoe made by the NHS which is a simple heel lift of 30mm on the right.
After reading thru the case could you suggest / discuss any intervention design you might go for? He is not really interested in any sort of external brace or cam boot.
Do you think extra pitch needs to be built into a bespoke shoe or do you think an adapted OTC shoe such as Dr Comfort could be modified to give a good outcome. I've suggested modified DrC might work but I'm not sure about the pitch of the shoe with the plantarflexed foot - X ray Picture attached
Main complaint:
Painful right ankle following traumatic injury
Instructions:
Rehab of injury to right ankle - Initial Biomechanical report request by Broadspire.
History:
2 years ago a Brick culvert (arch) collapsed on Mr P causing crush injuries resulting in severe right ankle injury. See Report sent by Broadspire for follow up treatment and rehab - orthopaedic and physio. Also tore ligament in left knee but rehab of knee is fairly good.
R Ankle is very painful to walk on for more than 15mins also ankle swells.
He reports that for several years previous to accident he did have lumbar back pain that laid him up for a week or so at a time. No other med hist admitted except for Blood pressure medications.
Mr P reports shooting pains when weight bearing ambulation that gets worse with time. Also another shooting pain that goes down the right leg that comes on when either walking or non weight bearing - see note above on previous lumbar pain
Patient objective:
Objective of Rehab and this Podiatric biomech treatment is to allow Mr P to return to light work (construction) and walk with less pain. He would like steel toe cap boots and a variety of footwear for various activities including trainer type shoes.
Initial Bmech assess [13/01/14]
No ankle saggital plane RoM (Range of Motion) - very restricted STJ rom. midfoot Roms restricted esp 1st ray. 5th ray is almost normal, frontal plane RoM midfoot very restricted.
Visual of walking with NHS orthopaedic shoe (built up heel right only plus more roomy upper) is quite symmetrical with a little antalgic hesitation on right stance phase during early left swing phase and some minor rocking side to side with early off loading of right foot onto left foot.
Low stiff 1st ray/mpj right. equinus forefoot and of course equinus ankle right. Left foot fairly normal/standard in all respects.
In stance without shoes the right heel is 30mm off the ground with forefoot weight bearing and this effectively makes the right leg longer by this amount.
The right hip therefore is that much higher than the left - this may be causing an impingement in the lumbar spine and contributing to a sciatica type pain.i.e. there is a functional LLD = leg length difference
In walking with NHS modified shoes mr P keeps the upper body straight but the left pelvis lifts and drops during swing thru to foot strike as the pelvis rotates about the right hip - this is likely to cause overuse stress in the right hip abductor muscles and hip joint.
The interesting point to note here is that by dropping onto the left foot and shortening the left swing phase Mr P has developed an antalgic compensation to off load the right ankle in the saggital plane progression and from direct ground reaction force, which effectively reduces ankle dorsiflexion moments and ankle joint compression forces during right stance phase. This feels advantageous to Mr P in terms of pain relief at the ankle but as explained earlier may have a detrimental long term effect in terms of pathological changes in the lumbar spine and right hip.
Today [13/01/14], as a test, I fitted extra temporary heel lift to the left shoe in order to make both legs functionally equal length. Mr P felt this was more comfortable in resting stance. However he felt the ankle was more painful during walking.
This anomaly is due to the fact that when he walks with equal leg length he does not have the off loading effect of shifting the body weight onto the left leg both in magnitude and timing which resulted in less load for a shorter time = less pain.
He also takes equal length steps, whereas in the former the left step has a truncated swing phase in order to quickly off load the right side, this also reduces propulsive phase time and force magnitude in the right foot. Therefore, in the latter case, the ankle is loaded with greater forces for a longer time in this configuration. However what may be required here is a rocker action shoe with an increased pitch and heel lift to off load the dorsiflexion moments about the ankle and learning to take shorter steps. The left also requires heel lifts to equalise functional LLD.
I also note the 1st ray/mpj right foot is low and stiff but there is no accommodation for this in the NHS orthotic design. This effectively blocks saggital plane progression (forward motion) and increases dorsiflexion moments about the ankle joint.
Main points of intervention:
Mr P has right ankle that is fixed in dorsiflexion following a traumatic crush injury that resulted after healing in a fragmented and fused ankle joint. This is painful to weight bearing ambulation and especially from dorsiflexion moments about the ankle joint due to ground reaction forces (GRF) acting on the forefoot at late stance-propulsive phase of gait.
Objective:
To reduce the dorsiflexion moments and GRF compression forces about the ankle joint during walking.
Conclusion and recommendations:
1) Make shoes with equal height heel lift additions, 2) add rocker design in to shoe sole unit. 3) Redesign foot orthoses including 1st MPJ c/o right. additional option 4) Fit rigid ankle brace with rocker action - design yet to be decided.
I tried him with a TM Airwalker but he was adamant that he would not use it even tho this would completely off load right ankle external dorsiflexion moments,
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Stress distribution comparisons of foot bones in patient with tibia vara: a finite element study
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