Clubfoot in a 5 year old

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I am a podiatrist working up in Karratha Western Australia. I would really appreciate anyone's advice on a little boy who came in to see me last week. He is a 5 and a half year old boy who was born with a idiopathic clubfoot on his left foot. He was born in Melbourne and had two lots of surgery at the Royal Children’s hospital when he was 2 years old. From what I can understand from the father his first surgery involved reconstruction of the rearfoot and the second involved an Achilles tenotomy. He then moved to Perth and had a further surgery on his achilles tendon approximately 2 years ago. Since then he has been wearing an AFO and his father reports that his son has minimal impairments with movement, he also doesn’t report tripping, any pain or other hazards. The father's main concern is over atrophy and weakness of the gastrocnemius and soleus muscle. Originally the orthopaedic surgeon in Melbourne said that by the age of 6 he should be able to walk without the aid of the AFO, now this little boy is starting to grow out of his current AFO, is it worth sending him down to the Royal Perth Hospital for casting of a new AFO?

The little boy is able to walk without the aid of the AFO but his dad reports that he has become dependent on the AFO and reports that his leg is sore after a period of time when not wearing it (approximately 30mins to 1 hour, depending on the activity). In terms of the left foot he has good ROM at the ankle joint with both the knee flexed and extended, his STJ Rom is restricted for both INV and EV, MTJ ROM is reduce on oblique and longitudinal axis and the 1st MTPJ Rom is WNL. His muscle strength of DF and PF on the left side is reduced and pain free compared to the right side.
Are there a sequence of events that should occur when an AFO is removed? Should a UCBL device or normal foot orthoses be used to reduce the risk of reoccurance?
What sort of physical therapies program should be implemented for this little boy? I would appreciate any advice anyone can give me in regards to this little boy and his family. I haven’t got a review booked with him yet as I told the family I wanted to do some research so that I could tell them the most accurate information. Thank you very much for your help.
Up in Karratha we have limited health services and visiting specialists, so it is possible to send patients with higher needs to the Royal Perth Hospital if required.

 

If he came in here and all this was reported to me, l would be looking at supplying him something halfway between a shoe and the AFO and a quick phone call to his surgeon.

l would be looking to supply a solid ankle boot with an orthosis. He may(?) need to have a rocker heel and toe modification, refer him to a Osteo/Physio with the long term view to build up muscle bulk, strength, flexability and stability to get him into a runner one day.

l would want him in the boot just one or two hours a day, slowly building up the amount of time in the boot without the AFO.

Remember what the orthopaedic surgeon in Melbourne "that by the age of 6 he should be able to walk without the aid of the AFO "

But you are the one there in front of the child so you are going to have to make that decision

 

Thank you for your help, it's always nice to have another perspective on a management plan. Much appreciated