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Contra-indication for functional orthotics?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Sarah-Jane, Sep 15, 2009.

  1. Sarah-Jane

    Sarah-Jane Member

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    Hi, this is one of my first posts so go easy on me!!

    Did anyone else learn in uni that genu recurvatum is a contra-indication for a functional orthotic?

    I remember our Biomech lecturer telling us that it is not recommended when t is present......I think he said its because it might push them even further into hyperextension.... I'm trying to visualise what an orthotic would do to a hyper-extended knee.

    If someone has hyperextended knees and associated "hypermobility", surely if they are getting pain/symptoms in the feet or elsewhere it would be a good thing to control the foot as much as possible, deep heel cups etc.

    I saw a 21 year old patient the other day with plantarfasciitis. She is very "bendy" as she called herself and has hyperextended knees. I spoke to my colleague about it and he agreed that I need to control the feet with a functional orthotic, no reservations about the genu recurvatum.

    If anyone has any opinions I'd be mighty grateful.
  2. Sarah-Jane:

    Welcome to Podiatry Arena!:welcome:

    I have been making custom foot orthoses for patients with genu recurvatum for the past 25 years without a problem so your lecturer didn't know what they were talking about.

    One concern is that genu recurvatum is often times associated with a gastrocnemius equinus deformity and if the orthosis restricts arch-flattening motion too much, then some believe this will tighten up the gastrocnemius muscle so much that the genu recurvatum deformity will worsen. I've never seen this happen.

    If you will simply have the patient wear the orthoses in a shoe with a slightly higher heel-height differential, have them avoid flat heel shoes, or if you put a slight heel lift onto the rearfoot post of the patient's orthoses, then this is all that you will need to have their orthoses not cause a problem in your patients with genu recurvatum deformity.

    Good question and please feel free to ask many more. That is how you learn!:drinks
  3. Craig Payne

    Craig Payne Moderator

    I have heard people say that, but never seen a problem. If there is a problem, then it is as Kevin said, that is is the assumed equirement for those with genu recurvatum to need a greater ROM at the ankle joint.
  4. Ian Linane

    Ian Linane Well-Known Member

    As above.

    However, as a slight digression I have found some folks with knee hyper-extension issues find orthoses quite positive in that they no longer (without orthoses) feel pushed back into extension but have a choice (when wearing their orthoses) to extend or adopt a more suitable knee posture for themselves.

    Last edited: Sep 16, 2009
  5. Sarah-Jane

    Sarah-Jane Member

    Kevin, Craig and Ian

    Thanks very much for the replies. I reckon my lecturer had the wrong end of the stick. I will see how it goes with this patient, I might try a small heel lift on the orthoses like you mentioned Kevin.
    No doubt I'll have more questions!
    Thanks again
  6. betafeet

    betafeet Active Member

    Hello all,
    I would like to take this subject to another level, as I am reconising many more patients with joint hypermobility scoring 10 on the Brighton Scale. These bendy patients are also presenting with many other problems such as shoulder dislocation, back, knee and hip pain also IBS, endrometriosis. Often having a member of the family with scoliosis.

    I feel these patients are often not being treated holistically and would like to investigate how I can help these patients more effectivley.

    I would be greatful if you can direct me to any relivant research papers on Hypermobility Syndrome management.

  7. From: Allan M. Spencer: Practical Podiatric Orthopedic Procedures. Ohio College of Podiatric Medicine 1978

    “Rigid Devices

    it is paramount to recognise both the indications and contra-indications of the devices.

    Peroneal spastic flatfoot
    Rigid foot types commonly seen in arthritics and the elderly

    There is a group of conditions which may be considered to be Relative Contraindicated for the use of rigid devices. However, these conditions may respond well to such a device made from a pronated cast:

    Equinus conditions
    Supinatus conditions
    extremely flexible flatfoot conditions
    pes cavus foot conditions
    tarsal coalitions”

    Jude, try googling "Rothbart", but I suspect you already know that.
  8. Jude:

    What is your definition of "holistic treatment"? What medical therapeutic approaches are included within "holistic treatment", in your opinion?
  9. betafeet

    betafeet Active Member

    Hello Kevin,

    By holistic I refer to the patient being assessed as whole rather than just individual symptoms being treated and no one relating one symptom with the other.

    I would like a better management programme of these patients, can I do more?

    For instance:

    A young girl of 24 presents with a verruca whilst taking a history of this patient I identify she has had multiple shoulder dislocations. Is at present under investigation for Endometriosis and has constant back pain with a Sway back Posture. On the Brighton scale she scores 9 failing to touch floor with both hands but she states she could do as a child.

    My management strategies at present would be:
    Treat what she really came for the verruca, although these long term problems may be compromising her immune system. Also postural training with core strengthening a referral to a physiotherapist for long term management and orthotics only if deemed necessary. Ask her to make her Gynaecologist aware she is hypermobile.

  10. Jude:

    Thanks for that.:drinks
  11. betafeet

    betafeet Active Member

    Kevin the most interesting paper I have found is:

    The differential diagnosis of children with joint hypermobility: a review of the literature
    Tofts LJ, Elliott EJ, Munns C, Pacey V, Sillence DO
    Pediatric Rheumatology 2009, 7:1 (5 January 2009)

    Do you know any papers relating to Podiatry and Hypermobility Syndrome?

    Please accept my apologies for spelling error: Beighton score not Brighton scale must need to visit there again!

  12. Jude:

    When we wrote our chapter on "Evaluation and Nonoperative Management of Pes Valgus" about 18 years ago (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992.), I did some research on hypermobility syndrome and discussed it's mechanical significance in pes valgus deformity in children using this reference (Kirk, J.A., Ansell, B.M., and E.G.L. Bywaters: The hypermobility syndrome: musculoskeletal complaints associated with generalized joint hypermobility. Ann. Rheum. Dis. 26:419, 1967.) Here's the chapter for your continued research on the subject.

    Attached Files:

  13. betafeet

    betafeet Active Member

    Thank you Kevin most useful it seems you have been ahead of your time, this is such a vast subject that I feel I have been neglectful of. Now just awaiting some infomation leaflets for chiropodists, physiotherapists and osteopaths ..etc, from: Ehlers-Danlos Support Group UK.

    The below also made interesting reading:

    Joint hypermobility syndrome in childhood. A not so benign multisystem disorder?
    Rheumatology (Oxford). 2005; 44(6):744-50 (ISSN: 1462-0324)
    Adib N; Davies K; Grahame R; Woo P; Murray KJ
    Arthritis Research Campaign Unit, School of Epidemiology, Stopford Building, University of Manchester, Oxford Road, Manchester M13 9PT, UK. navid.adib@man.ac.uk

  14. Griff

    Griff Moderator

    Hi Jude,

    What is the tenth point on the Beighton scale you are measuring? It was my understanding that the maximum score was 9?


  15. Jude:

    "Joint hypermobility syndrome" is something that few podiatrists are educated on during podiatry school. In fact, the whole idea that there is a large range of passive load-deformation characteristics of the joints of the foot and lower extremity from one individual to another or from one age to another, is a poorly researched subject.

    The cross-sectional area and elastic modulus of ligaments from one individual to another may vary widely. This leads to large differences in the motion produced at a joint for a given external force applied to the segment in question. When I wrote that section in our chapter, it seemed quite obvious to me that we needed to pay more attention to the load-deformation characteritics of the joints of the juvenile flatfoot if we were to hope to better understand it.

    Here is the section from the chapter on Biomechanical Effects of Ligamentous Laxity from my original manuscript that I submitted for publication on the subject for the chapter over 19 years ago. Note the much greater length of what was submitted from what was finally published in our chapter (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992)

  16. betafeet

    betafeet Active Member

    Ian I wrongly included skin elasticity thank you for your correction.

    Kevin your help has been much apreciated, I now need digest all this which I think is only the tip of the iceberg and start putting this knowledge to use. I have conected to a physio now who is to work along side me with some of these cases.

  17. Sally Smillie

    Sally Smillie Active Member

    I've found in hypermobile children (who never have any ankle equinus, usually way too much), that funtional orthoses reduce the genu recurvatum by eliminating the degree of internal rotation of the lower limb, thereby giving the pelvis a posterior tilt, closer towards neutral. This then reduces the excessive lordosis and allows normal stacking of vertebrae. If you ask, they will often say the suffer lower back pain. This can be really helpful. patients that move like this often have reduced core stability as this stance is inactive for the postural muscluature. You can have a big impact of them holistically by addressing this - orthoses can be a powerful tool, but not on their own. Just don't leave it at that, I would see them jointly with a physiotherapist, or refer off to one you know will follow them up. They may also need a strengthening program.

    Good luck. and great to see pods thinking a bit higher up. Feet are attached to bodies that need to funtion as a whole, not just on their own.

    best wishes,
  18. davidl

    davidl Member

    Dear Jude

    You might find Ferrari's paper useful.

    Joint hypermobility: the use of a new assessment tool to measure lower limb hypermobility.
    Ferrari J, Parslow C, Lim E, Hayward A.
    Clin Exp Rheumatol. 2005 May-Jun;23(3):413-20

    David Liddle
  19. Sally Smillie

    Sally Smillie Active Member

    Actually, Jill's lower limb hypermobility score is a very useful clinical tool I use routinely now. It incorporates 12 points on the lower limb, compared to 1 in a beightons score, so would seem much more senstitive to lower limb hypermobility.
    Last edited: Sep 25, 2009
  20. betafeet

    betafeet Active Member

    Hello all, thank you for all the input but cannot locate J Ferrari's: The New 'Lower Limb Assessment Score', is there a fomula out there or is it in the full article? (on my wish list) abstract below, also Sally Smillie's lecture looked interesting: The Clumsy Child - Podiatric management of children with Developmental Coordination Disorder (Dyspraxia) Sally Smille: http://www.members.feetforlife.org/download/7148/A4.3-Sally-Smillie-DCD-Bournemouth-Oct-2008.pdf

    Clin Exp Rheumatol. ;23 (3):413-20 15971435 (P,S,G,E,B)
    [Cit?] [Rec] [Com] [My] [Fav] [Sel] [Hid]

    Joint hypermobility: the use of a new assessment tool to measure lower limb hypermobility.
    J Ferrari, C Parslow, E Lim, A Hayward
    Department of Podiatry, School of Health and Bioscience, University of East London, UK. j.ferrari@uel.ac.uk

    OBJECTIVES: The aim of the study was to compare the use of a new assessment tool for diagnosis of hypermobility in the lower limb to the Beighton score for generalised hypermobility. METHODS: Three groups of children were compared (n = 225) and included a "normal" population of 116 school children, a "possible hypermobile" group of 88 children attending afoot and gait clinic and a "known hypermobile" group of 21 children referred from a paediatrician or rheumatologist. The Beighton score was used to measure generalised hypermobility. The Lower Limb Assessment Score was used to measure hypermobility in the lower limbs. RESULTS: The Lower Limb Assessment Score was able to distinguish between the three groups of children better than the Beighton score. At a threshold of 5/9 indicating hypermobility, the Beighton score identified hypermobility in 34% of school children; the lower limb score identified hypermobility in 21% of school children after a threshold was identified. There was disagreement between the scores in school children where 26.7% of children appeared to have a positive Beighton score that was not accompanied by a positive lower limb score. In the "known hypermobile" group the Beighton score was positive in only 10% of children when the lower limb score was negative for hypermobility. CONCLUSION: In this group of school children, the Beighton score appeared to over-diagnose hypermobility at the threshold of 5/9. Specific thresholds for diagnosis need to be set dependant on the age and ethnic group of the population being studied. The Lower Limb Assessment Score may be a useful score for health professionals specifically interested in lower limb hypermobility.

    Forever Your Humble Student
  21. betafeet

    betafeet Active Member

  22. Sally Smillie

    Sally Smillie Active Member

    the download above is pictorial of the Ferrari, Lower Limb Hypermobility Score, as well as Beightons. There is an error in one of the positions, but I would contact Cheryl regards to this. From a quick going over this, I noticed that the ankle anterior drawer was mid-air, and I recalled it was meant to be with foot on plinth.
  23. DTT

    DTT Well-Known Member

    Hi Jude

    If you contact Robert Isaacs, he treats floppy kids all the time in his NHS job so I would assume he would have plenty of references for you, in the unlikely event he misses this thread of course :D

    Hope your keeping well
  24. scfitzner

    scfitzner Member

    I recently had a 6 y/o come in to the office with a more mild form of osteogenesis imperfecta. His large bones have responded to treatments but in the last 6 months he has had 3 foot fractures. He has extreme hypermobility in the feet. I can see some of the pros and cons of a rigid device. In the short term my question is are the orthotics going to place too much stress in the foot causing potential problems or prevent them? I am also concerned about the long term potential implications of not having a functional orthotic. What do you think?
  25. efuller

    efuller MVP

    Orthoses shift stress from one location to another. You need to look at the individual bones that are fracturing. For example, an arch support, or pressure in the arch, can move stress from the met heads to a more proximal location. This should reduce the stress on the metatarsals and you would be less likely to have metatarsal fractures. You could analyze the stress for all the bones that have fractured.

  26. Depends on the orthotic. I'd not use anything too rigid in a case like that. A neutralish cast in hi density EVA with no arch fill and very high medial and lateral flanges in an boot would be my suggestion.

    Remember, movement does'nt hurt, force hurts. Its not the amount of movement, its the sudden stop at the end. I want him decellerating slowly, through the elastic deformation of EVA and the boot, not coming to s sudden shuddering stop when he hits the unyeilding shape of a UCBL.

    But thats just me.
  27. Sally Smillie

    Sally Smillie Active Member

    I'ma huge fan of the UCBL type devices. But on this one I agree with Robert (I refer to the osteogenesis imperfecta case).
  28. Don ESWT

    Don ESWT Active Member

    To All,
    Just have a 9 year old and her 45 year old father EDS. The 9 year old has the worst cast of HAV I have seen and the youngest. I am organising custom footwear for both people. Any other suggestions?

    Don Scott
  29. Sally Smillie

    Sally Smillie Active Member

    Can I ask why you have prescribed custom f/w? I'm not sure why you would do this. I'd be more inclined to prescribe appropriate retail F/W. What type EDS? If skin of the foot not affected, high quality retail would be better. I bet you any money the 9yo will never wear them.

    See if there is a functional hallux limitus, then in stance correct to more of a stj neutral position and see how much this position improves the hallux movement. If so, prescribe an appropriate orthosis. If they are as mobile as some EDS's can be - but don't assume. I've seen EDS kids less hypermobile than a benign hypermobility syndrome kid. Sometimes I make an ottoform toe spacer to use in conjunction with the orthosis.
  30. Perthpod

    Perthpod Active Member

    'this will tighten up the gastrocnemius muscle so much that the genu recurvatum deformity will worsen'

    Hi Kevin,

    Whilst i understand a genu recurvatum leading to ankle equinus through gastroc tightness, I dont understand how tightening the gastroc more can lead to recurvatum? Sorry, my biomech.s is rusty. I would have thought tightening the gastroc would flex the knee?
  31. efuller

    efuller MVP

    Yes, the gastroc crosses the knee and creates a knee flexion moment with tension. However, in gait, an early heel off will put more weight on the forefoot. With the body's center of mass behind the foot, the force couple of gravity and ground reaction force will create a moment that will tend to rotate the top of the tibia backwards, which would tend to create the recruvatum. That's how an equinus causes a recruvatum. The top of the tibia is forced backward when the body momentum is forward.

  32. Freeman

    Freeman Active Member

    When the gastroc (which originates above the knee, and inserts on the posterior calcaneous) shortens when the patient is standing, the only way the heel can become fully weightbearing is to 'push' the knees backwards....or bring the ground up to the heel until the knees are straight. (heel raise)

    Incidentally, you may also observe compensations much higher up as you may see the hands on the hips stabilizing the low back and a anterior head tilt. I generally take photos of this posture for the patient to see , temporarily 'correct' them, take another picture, and show them this as well...then send them on to physio, massage and whoever else may fit into the bigger picture to help them along.

  33. Contra-indications to Orthoses.

    I am trying to compile a list of contra-indications to the use of shoe-orthoses,I can then refer to it and quickly screen out those patients for whom these devices would not be appropriate.Can anyone with more experience than I have give me any suggestions?Jeffrey Jones.
  34. Griff

    Griff Moderator

    Re: Contra-indications to Orthoses.

    Here is my list of people that I will not supply foot orthoses to (or at least think hard and twice before doing so):

    1. Anyone who says "orthotics don't work" within the first 5 minutes of a consult
    2. Anyone who attends clinic with a plastic bag containing > 5 pairs of previous orthoses
    3. Anyone who requests a new pair of orthoses which are "identical" to their previous pair from another practitioner
  35. efuller

    efuller MVP

    Re: Contra-indications to Orthoses.

    My exception to that is if the entire bag does not have a medial heel skive, or some other modification, in a foot that needs a medial heel skive, or that other modification that has not been tried yet.

  36. The ability to determine any other etiologies for a patient with multiple problems means you are making a diagnosis. The body is one unit that cannot be separated when treating a patient and most of the time finding the common link to how all of these seemingly independent problems are unified..

    A structural problem in the foot can cause problems anywhere in the body. Many "hypermobile" patients' have an underlying problem that is undetected. Many times a simple leg length discrepancy undetected will cause a myriad of incorrect diagnoses, that may successfully be gone when a simple lift is placed in the short leg.

    Good luck you are reasoning correctly:eek:
  37. CraigT

    CraigT Well-Known Member

    Agree- Remember that you have the advantage of seeing what doesn't work! I will try a new orthosis with the above type patient if I cannot see design characteristics that I believe are needed- I often would make this gratis if it did not work as I see these patients as great learning opportunities.
  38. I had a bet once with a 7 pair in bag patient, Highly unprofessional I am sure, but his 2nd sentence was I will leave now if you tell me I need another pair of orthotics.

    Bet was free if they did not work - I got paid and a very nice bottle of red.
  39. docbourke

    docbourke Active Member

    Putting an ankle into fixed equinus causes hyperextension at the knee. Try walking with a fixed plantarflexed ankle and you will see why. An orthotic that puts the foot into plantarflexion at the ankle may possible worsen knee hyperextension but it would have to be a stilletto height orthotic

  40. efuller

    efuller MVP

    A fixed equinus, can cause a recruvatum. However, the equivelent of a small heel lift from an orthotic is not a fixed equinus as there is still ankle joint range of motion available in the direction of dorsiflexion. There is a different behavioral response that can occur with a large amount of fixed plantar flexion of the ankle and that is knee flexion. As you look at wearers of high heels, you will notice that the vast majority of them tend to flex their knees rather than have recruvatum.

    So, I don't think that a genu recruvatum is really a contraindication for othotics.

    I recall the teachings of John Weed. He said that if you had an equinus then you should use a pronated cast because a neutral cast would not be tolerated. My explanation of his observation is that with equinus a higher arched orthosis will be more painful and that a lower arched device would not. You could also add more medial arch fill in the cast to achieve the same end.



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