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hi all,

25 year old male with post polio residual paralysis of right lower limb and
had undergone subtalar-arthrodesis 5 years back. now he is having severe pain over the right heel at every step while walking, and he came with using auxiliary crutch.

o/e, has calcaneus deformity and
thinned heel pad and callosities were seen.
severe tenderness over he center the heel region.
inferior border of calcaneum palpated well like conical shape.

and x rays shows changes in inferior border of calcanuem.

aim to make him walk with pain free heel without support.

options i have been thinking of modified foot wear to offloading heel pressure .

and or any surgical procedure will help him, like flattening of inferior border of calcaneum

suresh

 

Re: pain dut to calcaneus deformity-managment

he has been tried with MCR foot wear and also silcone heel foot wear.
but no use.

 

Re: pain dut to calcaneus deformity-managment

Suresh,

Pressure = force/area. The area of heel contact looks really small because of the angle of the calcaneus. I don't know what MCR foot wear is. Does his lateral column bear weight in stance? My first try would be a total contact orthotic with the goal of increasing the area over which the force of body weight is applied.

Does anyone have experience with surgical scars after plantar calcaneal surgery? If it were my foot, I'd want to talk to someone with experience in that kind of work before I'd have the surgery.

Regards,
Eric

 

Re: pain dut to calcaneus deformity-managment

G'day,

Interesting case! Thanks for the post!

As Eric pointed out, the contact area is small, so be aware of how much pressure will be going through the calcaneum and the metatarsal heads. The calcaneum fused in an almost vertical position is an interesting one, but you have to deal with what you have. Abnormal weightbearing certainly is the issue, and medical grade footwear would certainly be a good place to stary to try to get a shoe to properly accomodate for this foot.

I agree with Eric, a well formed total contact orthotic would probably be of most benefit here, probably out of a moderate density EVA (220-260?) to as to provide support as well as cushion. An accomodative rather than a corrective device will probably be of more assistance. Also extending the device past the metatarsal heads may help in weight redistribution and reduce deforming forces on the foot. Perhaps a device that then becomes the insole of the shoe, in a similar way to the way prostetits/orthetists make orthoses rather than how us podiatrists make them?

Be aware also, that as polio is fundamentally a neurological disorder and affects the upper motor neurones, muscle imbalances muct be taken into account. Some great papers exsit by Kevin Kirby regarding balance of forces around the subtalar joint axis, and it is important that you take these into account so as not ot make the foot any more unstable. Also be aware of the possiblilty of the possible chance of muscle fatigue in later life and possible post-polio syndrome. Kinda makes management now really important.

Cheers again and good luck!

 

Suresh

I see no signs of past subtalar arthrodesis - posterior and middle facets easily visualised. I assume this is functionally viable.

This is a posterior cavus deformity with high calcaneal inclination, such that as other posters have mentioned there is acute focus of pressure on a small area of the medial tubercle.

I would treat conservatively with orthoses and footwear, but I would not think it to be unreasonable to consider some type of remodelling of the plantar medial surface should this fail. This could be approached from the infero-medial aspect of the calcaneus with care to the calcaneal branches of the PT nerve. A low axial calcaneal view (or Kirby view) in weight-bearing would assist in visualising the amount of bone that could be resected from the medial tubercle. More complex procedures to address the global cavus deformity and motor dysfunction (eg triple arthrodesis) might also helop, but should be reserved for more significant subtalar and midtarsal degeneration down the track.

LL