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Orthotic Advice needed for TCJ and STJ fusion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by footphysio, Jun 3, 2023.

  1. footphysio

    footphysio Member

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    Hi there,
    I am not a frequent user of this platform so I hope my case is appropriately explained.
    I am a physiotherapist working with a client who has undergone a talocrural joint and subtalar joint fusion. She has also developed Complex Regional Pain Syndrome in the same foot.

    Aside from the pain seemingly from the CRPS, she has significant heel pain and has developed right sided low back and posterior hip pain, a more significant convex lateral arch (she has this more moderately on the right as well) and 5th met styloid pain. She has also developed hypermobility at the midfoot.

    In standing, her foot sits in mild planter flexion, mild calcaneal and forefoot varus. Her heel and medial forefoot do not touch the ground.

    She has been provided with
    orthotics with the following specifications:
    3mm polypropylene
    1.5 mm nyplex bottom cover
    EVA neutral forefoot extension to sulcus
    Poron arch full
    16mm heel cup

    The orthotics appear to provide good contact, but she states there is not full contact in the centre of the midfoot or the first metatarsal. She also states she feels like they are pushing her into too much varus. They do not provide relief of her heel pain and she walks with significant lateral shift to the left - she states this is to avoid the heel pain mainly, but clearly it is also altered by the fusions.

    I am not the orthotic provider, but the practitioner who is does not seem to have a good understanding of what to do to help. I would like to be able to help and perhaps temporarily alter her orthotics the best I can to see what helps then suggest these alterations to the provider and have the alterations made permanent. I would think adding a heel lift to make the heel and the metatarsals contact the ground at the same time and perhaps making the orthotic more contoured to her foot to make contact where it currently is not, add a valgus wedge to decrease the feeling of her foot being in too much varus and cushioning the heel. I wonder if also making the forefoot extension more rigid would help protect her midfoot from becoming more mobile. As she has no hindfoot mobility at all, I'm wondering if this would cause any harm. We are looking for rocker bottom shoes, but are having trouble finding some in Canada so are looking into custom made.

    My question is: what suggestions do you have to alter this lady's orthotics with this lady's heel pain and to normalize her gait as much as possible?

    Thank you.
  2. Craig Payne

    Craig Payne Moderator

    That is the challenge. The fusions meet you probably not going to be able to change anything with the gait with a foot orthotic.

    Best you can normally do in these situations is a full length EVA type device that contours to the shape of the foot to try and improve comfort ..
  3. Dan T

    Dan T Active Member

    Some (anecdotally) promising results in CRPS with fascial manipulation (stecco method), with a colleague. Carla Stecco has done some dissections which show nerves passing through fascial layers. The densification of hyaluronic acid aggregation in some fascia has also been observed in T1ρ-Mapping on MRI and this does break down following manipulation. This could well explain the phenomena of CRPS following surgery and the anecdotal results achieved, mentioned above. I would encourage them to find a decent Stecco practitioner as I understand the general medical options put to people with CRPS is medication, councilling and amputation. It's definitely not a cure all for everything but certainly seems to have some application here.
  4. Dan T

    Dan T Active Member

    Also you can do a TCI and add a make shift Eva rocker to it. HOKA BONDI would be good shout until the orthopedic footwear get sorted
  5. footphysio

    footphysio Member

    Thank you for the replies. Aside from rocker shoes do you think having a stiff forefoot extension to mets may protect the mid foot from becoming more hypermobile? Also, a rocker bottom insole seems like it would rock inside the shoe and cause irritation -especially with sensitivity due to CRPS?
  6. efuller

    efuller MVP

    CRPS makes diagnosis of mechanical pain really difficult.

    Is the heel pain referred? Is it at the plantar fascial attachment? By convex lateral arch do you mean a dorsiflexion subluxation of the forefoot on the rearfoot. That would make sense for styloid pain.

    Now there is something to be treated, especially if the current orthotic does not address this. Does the forefoot sit inverted because there is no further eversion range of motion? Was the foot fused in varus? If there is no eversion range of motion available then a forefoot varus extension may help offload the styloid.

    It may feel that she is in varus because she is fused in varus. A varus wedge may make that feeling worse, or it may make the foot feel more "balanced" by distributing force on the bottom of the foot. I've seen both.

    If the heel does not touch the ground in stance, because the foot is fused in plantar flexion, add a heel lift. The valgus wedge may make things worse if the foot has been fused in varus.

    Most running shoes have some rocker, some of have quite a bit of rocker. Do you have access to shoe repair. A metatarsal bar and a heel lift can be added to an existing shoe to create a rocker.

    If the foot has a rocker bottom, to off weight the midfoot you could add thickness to heel and forefoot. This works better if the pain is in the middle of the foot (styloid). That modification could make the pain worse by increasing tension in the plantar fascia (heel pain.)

    With a dramatically abnormal foot (post fusion) it will take experimentation.[/QUOTE]

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