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Foot Orthotic ? for persistent ulceration

Discussion in 'Biomechanics, Sports and Foot orthoses' started by sesadler, Sep 2, 2010.

  1. sesadler

    sesadler Member

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    Good Afternoon!
    Have a situation on which I'd LOVE some input.
    Pt is 49 y.o. male, 6'5", 225 lbs.
    Has Hx of microvascular disorder that mimics that of DM neuropathy (although Pt indicates that hyperbaric chamber therapy has helped greatly with this).
    Very low fat pad on plantar foot.
    Hx of ulceration on 5th MTH bilateral:
    Right 5th MTH resected. Toe still present.
    Left osteomyelitis in 5th MT resected to midshaft + 5th toe.
    Current open ulceration at Left 4th MTH ~ 5mm open (10-15mm ttl including surrounding hyperkeratotic buildup).

    I met with the Pt and his DPM today to discuss how to proceed orthotically. He's used trilaminar inserts with MT bars / relief pockets since '07. Has been casted using foam box as well as slipper cast with not significant difference in results.

    NWB Pt exhibits a very high arch with significant inversion bilaterally.
    Rearfoot to forefoot on the ulcerated side with pt prone shows a FF varus (flexible).
    WB Left heel everts to compensate for the FF varus.

    In designing the new insert to into his shoe (with a rocker sole), what suggestions could you make with regard to: intrinsic / extrinsic mod's, materials, would allowing the 1st to drop into a pocket help divert some pressures off?

    Any help would be greatly appreciated - and any additonal information I can provide let me know.

    Thanks !!

  2. efuller

    efuller MVP


    So, it seems that the problem is high lateral load. There are two quite different foot types that will have high lateral load. One type is the partially compensated varus foot that does not have range of motion to evert to significantly load the medial forefoot. The other type is the extremely laterally deviated STJ axis foot, also known as the rigid forefoot valgus foot. In static stance this foot will tend to rest in a fairly supinated position.

    Are you familiar with the Coleman block test. Place a block perhaps 2" high under the lateral forefoot and look at the calcaneal position with and without the block. If the foot stays inverted and there is no change in position of the calcaneus then you have the rearfoot varus type foot. If, when the foot is on the block, the calcaneus everts significantly then you have the "forefoot valgus" foot.

    If you have the varus foot then you might consider using a forefoot varus wedge to increase the load mdially and decrease the load laterally.

    If you have a forefoot valgus foot then you should use a rearfoot valgus wedge and a forefoot valgus wedge with a height equal or less than the available range of motion. This wedge can end proximal to the metatarsal head to decrease load on the ulcerated area. A 5th met head resection in this foot would make the problem worse by removing a part of the foot that has the best lever arm to cause pronation in a foot that needs to be pronated. Another way of saying the same thing is that a 5th met head resection will tend to shift the center of pressure more medially and this will increase supination moment, or decrease pronation moment from the ground.

    I hope this helps,

  3. Jeff Root

    Jeff Root Well-Known Member

    I basically agree with Eric. I suspect a forefoot varus that compensates by eversion of the heel in stance. The patient might have a plantar displaced lateral column and or an equinus. These can be a significant pronator of the STJ and can create lateral forefoot overload. I would not cast out any ff supinatus. I would want full varus support in the device and probably minimal medial arch fill to provide increased ground reaction force medially. If you want to cut out the 1st met later to improve windlass, you still have that option.

    I would address the 4th met (probably a transfer lesion due to 5th met amputation) with a forefoot extension with an aperture sub 4th. You could also try adding some plaster filler sub mets 4 and 5 to help offload the lateral forefoot (approx. 2 to 3 mm). Make it full thickness distally and then tapper it towards the base of the mets. This will create a small pocket in the shell plantar to the met shafts, especially distally.

    A medial heel skive might also help to offload the lateral forefoot if there is an element of uncompensated ff varus. Regardless of how you make it, the patient should be instructed to watch closely for evidence of excess pressure elsewhere (i.e. first, do no harm!). A diabetic type cover of plastazote and PPT might be worthwhile as well. Don’t use an open cell material or a Spenco type cover due to the open ulcer.

    If the lateral aspect of the forefoot curves medially due to the amputation, you might want to fill it with plaster and make the lateral border of the shell mimic a more natural contour to avoid cutting into the lateral aspect of the forefoot.

    Best of luck,
  4. Jeff Root

    Jeff Root Well-Known Member

    And maybe a heel lift if there is equinus!
  5. Boots n all

    Boots n all Well-Known Member

    There is only so much an orthosis can do with these clients that break down just from looking at them (or so it seems)

    l would go for an ankle boot, if he is inverted and his feet have a history of breaking down, its time to try and get leverage/support from somewhere else that wont break down as easy.

    The ankle will not be suffering with the neuropathy as much either, l hope, and he may just straighten up a little more from the sensory feed back that the ankle boot will provide.

    l would make sure the rocker sole was fitted with carbon fiber so the boot can not flex at all, then add a lateral buttress/flare.

    ...and where is the trajectory of the rocker sole leading him? is it right for him, should it be leading him more medially than it is?
  6. Dave Kingston

    Dave Kingston Member

    There are plenty of great suggestions here but as David hinted at you really need to get the ulcer healed before trying any type of foot orthotic therapy.

    You'll more than likely just fighting the good fight and getting frustrated with the orthoses when in fact it is a good prescription...just applied at the wrong stage of therapy.

    The best walker I have found for these type of 'stubborn' ulcers are the Aircast Diabetic range (doesn't matter if your patient isn't NIDDM...just use this version always).

    Link here http://www.aircast.com/index.asp/fuseaction/products.detail/cat/2/id/15 (I have no affiliation to this company)

    Success rate with healing MTH ulcers with this device is great. It really has overtaken a Total Contact Cast as the gold standard.

    Good luck.

    PS Once healed follow the above advice, especially the rocker sole angulation modification (or else the orthotics may cause reulceration whilst actually being deisgned perfectly).
  7. Jeff Root

    Jeff Root Well-Known Member

    Based on the above statement, I had made the assumption that the doctor had made a treatment decision and Stephen was working under that direction. While I can make recommendations to the podiatrist, they are the one who must accept responsibility for the orthotic Rx or the decision to treat with a different modality.
    One of the problems with a walker is patient compliance. From the information provided we can't tell if a walker was ruled out or not, but it appeared to me from the nature of the question that it had the decision was made to use an orthosis. Maybe Stephen can clarify this for us.
  8. efuller

    efuller MVP

    One of the first things you have to do in healing a pressure caused wound is decrease the pressure. Putting them in a standard boot may not offload the area as much as needed. You may need to incorporate the wedges that go into your orthotic into the boot.

  9. sesadler

    sesadler Member

    Indeed, it was the DPM's indication to build a new FO to better offload the area (DPM is not satisfied that the previous builds adequately or properly achieved this). I did ask if some type of walker / cast had been considered, but got the impression that pt compliance would be an issue with that.

    DPM initially wanted to remake the insert with deeper or better placed sub 4 pocket.
    My thoughts on re-evaluation noted the alignment issue of the L FF v. RF and that the existing FO's did not seem to address that at all.

    So one of the main directions we were exploring was whether more biomechanical control was needed or simply better balancing the foot. Pt has always had lateral overload (ulceration issue on 4th MTH goes back to '07). A big concern of mine is how to avoid the lateral drift of the foot since it is missing the most of the 5th shaft and toe.

    Hope that helps - and I REALLY appreciate the input.

  10. Ask the patient, if they would rather go into a walker than have a below knee amputation................ I'm guessing they'd prefer the walker. Watch the change in compliance when faced with that potential future.

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