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Help with Rearfoot Varus - Forefoot Pronation

Discussion in 'Pediatrics' started by miles7826, Dec 2, 2010.

  1. miles7826

    miles7826 Welcome New Poster


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    Hi all

    I need help with a 5 year old patient of mine. The kid on weight bearing and when walking overpronates his feet while at the same time the rearfoot alternates from varus to valgus. When standing still shifts his weight on the outside of the feet and his rearfeet lock to varus (all his shoes wears off on the outside of the heel). Regarding the forefoot pronation which is quite a problem as it causes ovelapping of the toes I am planning of trying to counter it with a 3mm forefoot varus post plus an extended and high lateral wall up to the 5th mth.
    On the heel I will keep the walls high to try and give more control on the heel, and the medial wall will be kept high just under the medial malleolus.
    The main question is what is your opinion on the whole approach I am planning and would you actually post the heel to correct the varus attitude? Non-weight bearing the STJ comes to neutral.

    Thanks guys

    Chris Vlachopoulos
     
  2. Hi Chris :welcome: to Podiatry Arena.

    Your description above is quite confusing you may want to rewrite it and consider that we can not see the patient.
     
  3. DSP

    DSP Active Member

    Hi Chris,

    As Michael has pointed out, it would be a great help if you could provide a more detailed subjective history and be a little more methodical in outlining your objective findings so that we can all appropriately understand your concern.

    Regards,

    Daniel
     
  4. miles7826

    miles7826 Welcome New Poster

    Hi guys

    Yes I see what you mean. I will try and put it a little bit simpler.
    - 5 year old kid. Neurologic condition but no official diagnosis.
    - Walks with over pronated feet, rearfoot valgus, and foot slap due to weaknees.
    - At the same time however, while his forefeet are overpronated, he balances on the outside borders of his feet (supinated).
    - Arch is there. Is not collapsing.
    His walking is all over the place and sloppy.
    I need to control pronation (extended lateral wall - medial forefoot wedge) - even out weight distribution under the fore foot-control STJ (it can go to neutral).

    Putting a forefoot medial wedge to counter forefoot pronation is quite difficult since at the same time all of his weight is on the outside of his foot (the exact opposite of what happens in pronation). This is NOT always the case but it mostly is, meaning that sometimes he is shifting his weight on the medial border of his feet. This is a very weird case to me , I am a CPO, I believe that an EVA FFO is not sufficient for this patient, but I'd like to try it. A medium density EVA with high walls and extended lateral wall. I feel that an AFO won't be well tolerated by the kid.

    I really can't put it in a different way, this is the simplest way. Just wanna know your thoughts and give me any ideas, I'd appreciate it a lot. I have a video of this patient as well without showing his face but I wouldn't want to upload it on the internet anyway.

    Thanks

    Chris
     
  5. Hi Chris It not that it it needs to be made simple it´s the terms your using.

    Overpronation

    STJ neutral

    What I can gather is that at rearfoot strike the STJ axis is laterally deviated , then we rapid STJ pronation and dorsiflexion of the foot at the ankle from RF strike to midtstance , with this rapid STJ pronation we now have a medial deviated STJ axis and there is a foot slap which can be heard - this can be contributed to weak muscle ( the Tib Ant I guess but you don´t say)

    Then we get Over pronation of the forefoot - whatever that is.

    I still don´t know what this means are you saying that the forefoot is inverted on the rearfoot ie a FF supinatus but the child is attempting to reduce the effect of the FFsupinatus by Supinating the foot. ??? But I´m just guessing
     
  6. Mike, did he just use the O word:butcher:...
     
  7. Miles.

    Your really need to tidy up your terminology. It makes little sense.

    Assuming we overlook the O word (and we really should!) Your presentation is a paradox.

    It is impossible to have a pronated forefoot and a pronated sub talar joint. On account of the ground gets in the way. It would be clearer if you talked about forefoot inversion / eversion. Forefoot pronation very much depends on which / what axis you are looking at and which school you belong to but classically, forefoot pronation is forefoot eversion relative to the rearfoot. Rearfoot pronation is also eversion relative to the leg / ground. They can't both be everting.

    So we need to know what the segments are doing relative to each other. In general I would be very, very VERY careful about using a forefoot varus post / extention on a child with ovvvvv. Ovvvvveeeee; Nope can;t say it. With the "o" word.

    Wanting to help, but don't understand what you're saying.
     
  8. Ian Drakard

    Ian Drakard Active Member

    Hi Chris

    If you have a video as you mentioned it may save a lot of confusion over the description and terminolgy if you posted it. If the patients face isn't showing (and you use a generic file name) and the parents are happy there should be no problem.
     
  9. RobinP

    RobinP Well-Known Member

    c
    Hi Chris,

    I agree with all that has been said with respect to terminology and the best way of learning how to present patients is on the Podiatry Arena by reading the biomechanics threads.

    I'd like to go back a bit. What are you trying to achieve?

    You have a 5 year old with possible neurology?

    The arch is not collapsed but the feet are "overpronated" but the patient is on the lateral borders of their feet but you "need " to control pronation.

    There is foot slap present and gait instability features. There is also overlapping toes.

    Instead of trying to arrive at Rx for a foot orthoses. List the problems that are present and whether or not you can affect them and what is then required.

    With regards to the biomechanical foot problems. Is the lateral border shoe wear as a result of lateral translation of the calcaneus secondary to gross pronation?

    FF varus(medial forefoot) posting? Not many justifications for this.

    Why is EVA not enough?

    Although you may not have a neurological diagnosis, you need to diagnose the other problems. What is causing the foot slap? What is causing the overlapping toes(not sure that just being overpronated can be warranted as a cause) Is the foot position really a factor in the poor gait or are the problems more proximal/sensory feedback issues?

    I hope this helps

    Robin
     
  10. elainehoey

    elainehoey Member

    Hi

    Does the patient have a metatarsus adductus foot type. May explain why the child supinates both feet on weight-bearing yet pronates ehen walking.
    Just a thought.

    Elaine
     
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