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What point do we go from Orthotics to Orthopaedic Boots?

Discussion in 'Pediatrics' started by Kahuna, Jan 27, 2011.

  1. Kahuna

    Kahuna Active Member

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    Hi All

    I have a 3yr old boy referred to me by his paediatrician.

    The paediatrician has diagnosed Benign Joint Hypermobility Syndrome as per the Beighton Score (8 out of 9).

    on exam, his genu recurvatum is clear as is his slow speed and uncertainty in gait. he walks completely on the medial borders and has a marked rearfoot valgus.

    He has responded well to UCBL type, deep heel cup 20mm orthoses from the hospital over the past six months. But on assessment today, I feel further support is needed.

    The paediatrician, orthopaedic consultant, physiotherapist and neurology-paediatrician have all assessed over the past year and found nothing remarkable/underlying in their tests, and have ruled out congenitally dislocated hips, muscular dyst, CP, and the other usual concerns.

    what would a podopaediatrician recommend? Is this an indication for knee braces? Piedro boots? Orthotist?

    Many thanks!!
  2. We move to boots at the point at which we cannot adequately control the foot with in shoe devices.
  3. Nilsen

    Nilsen Active Member

    if the hypermobility is isolated from other diagnoses, which it sound like it is, you'll usually see a gradual improvement over time. slow speed and uncertainty in gait is not unusual in 3-year olds. how old was he when he started walking? you say he has responded well to insoles-how? what parameters of his gait improved?
    if they did, how do you know the insole did it and not time? can you influence the recurvatum with the insoles? does he complain of any pain/ problems?

    once you start putting these hypermobile kids in boots they are preeeeetty hard to wean off (also because the parents get used to free shoes!). but Boots are useful if you need to move supination moments higher
  4. Kahuna

    Kahuna Active Member

    Thanks for the quick reply Nilsen

    To answer your questions, he was 18mo when he started walking - struggled to w/b on the recurvatum prior to that.

    Good Q about whether the orthoses or nature itself has improved his situation, but he walked better immediately on having the orthotics fitted, and his parents report he is more sure on his feet and stable with the orthotics in place. The parameter most noticeably changed was correction of the hugely everted heels.

    The recurvatum itself is not easily influenced or affected from the orthotics. This is what made me think about knee braces - good idea?

    He is pain free.

    The only other point to report is that he finds it very difficult to walk up or down stairs.

    I note your comment re Boots.

    Many thanks
  5. Nilsen

    Nilsen Active Member

    i'm worried about myself now, i woke up in the night thinking about this.
    just to check that we're talking about the same thing; by recurvatum you mean knee hyperextension in mid-late stance rather than any structural deformity?
    Knee braces to control knee hyperextension is difficult enought using the long lever arms (legs) of a grown man, my little orthotist brain is having panic attacks at the thought of doing it on a short podgy 3-year old leg (happy place, happy place)
    I'm assuming parents/carers are worried, judging by the amount of people involved.
    is he compensating for lack of trunk/hip stability? easy to test, use hands or elastic wrap around trunk/hips, check gait (physios are good at this)

    another important factor in my mind in controlling knee hyperextension is the angle of the shank in stance, if this is reclined, progression in stance becomes difficult and the knee can hyperextend. this can be treated with boots if mild (piedro boots are too low, something like the european hight nimco boot is needed) or Ankle Foot Orthoses with a heel wedge to incline the shank. A lot of bracing for an otherwise normal sounding boy?
    anyway, the dog is crying to be let out now..........
  6. RobinP

    RobinP Well-Known Member

    Absolutely agree with Nilsen.

    Think of it this way....3 year old with BENIGN joint hypermobility. No pain, I presume. Has responded well in terms of walking stability and kinematic observations to orthoses in shoes.

    Do you need to do any more?

    Yes, controlling the recurvatum might be possible with a higher boot such as Nimco or Piedro multi purpose boot but knee bracing would be the last thing that I would try for all the aforementioned reasons of lever arms. Also, compliance is generally poor in adults, let alone a 3 year old for such orthoses.

    Good luck

  7. Boots n all

    Boots n all Well-Known Member

    l would be reluctant to put a boot on him unless l had to, we dont want to reduce any, be it develpoing or present, dorsiflextion/plantarfelxtion wich an ankle boot will do.

    An ankle boot may, for the same reasons, make it more difficult for the child to get from the ground to standing

    To control/ better support the medial aspect try a medial flare to the existing footwear's sole, very quick job and not too costly.

    l have attached photo's of a 20 monthold boy with DiGeorgie Syndrome, we did custom orhtosis and what l call a half boot.

    It does not stop or inhibit any dorsiflextion/planterfextion but offers support up to the Mels. as you can see.

    The clients didnt want a medial flare at first, so we didnt, after a week they agreed, sorry dont have a clear photo of it, but the results speak for themsleves.
    Sorry the pics arent the best they are from a talk l gave late 2010 and are from movie clips

    Please note in the first photo, Mum has to hold him up he is unable to support himself, the pic say it all.

    First photo, as presented to us
    Second photo, the half boot without medial flare, not working
    Third photo, 6 months later bare foot

    hope it helps you

    Attached Files:

  8. RobinP

    RobinP Well-Known Member

    Good results David. Will wearing boots reduce plantarfelxtion /dorsiflextion other than when wearing the boots?
  9. Boots n all

    Boots n all Well-Known Member

    :wacko: sorry Robin that doesn't quite read right to me, might be me, it is Monday morning after all.:morning:

    Wearing an ankle boot will reduce most moments at the STJ, were as the half boot should not, the portion touching the Mel. is just a soft padded collar that we made from pig skin and a soft PU foam, overall this little boot we made sat about 1.5cm deeper than a shoe.
  10. BAMBLE1976

    BAMBLE1976 Active Member

    I have to say that I would be less worried about reducing the ankle joint range and more worried about what the hyperextending moment at the knee is doing to the soft tissue long term. I agree that knee braces are a no no at this age due to the forces involved. I would definitly refer to an orthotist for their opinion as the higher style nimco boots will help reduce the shank reclining moment during stance phase whilst allowing the prescribed foot orthosis to function correctly, especially if in a UCBL as most shop bought shoes/boots are not up to accomodating this type of device!


  11. Lucy Best

    Lucy Best Member

    As an orthotist, I say, refer the child to an orthotist! There are a few options - one is an articulated AFO to control the pronation/valgus heel, but still keep any available dorsiflexion. To control the knee hyperextension the joint would need a plantarflexion stop (i.e to prevent plantarflexion) and probably some wedging under the heel to tilt the shin forward. Another option is a DAFO style device. With boots, it may look good from the outside but inside the foot is still allowed to pronate.
  12. RobinP

    RobinP Well-Known Member


    How does that control recurvatum Lucy?

    Can you be sure that it will still pronate inside the boots? Can it still pronate inside a DAFO or an articulated AFO?

  13. Lucy Best

    Lucy Best Member

    Hi Robin,

    There are lots of styles of DAFOs to help control knee hyperextension depending on the severity and frequency of the hyperextension. See http://www.dafo.com/patient-groups/knee-hyperextension/ for photos of designs. You need to prevent ankle plantarflexion and thus a backward leaning of the shin to prevent knee hyperextension. The more severe the knee hyperextension, the higher up the posterior section of the brace needs to be.

    For the 2nd question, I am assuming the patient does not have a rigid pronated foot, i.e. it can be corrected to neutral in/eversion.
    An orthotist would usually cast the patient (and ideally rectify the cast themselves too) which forms the model for the AFO of DAFO to be manufactured from and thus there should be a very close fit around the foot. The cast should be taken in neutral in/eversion (or even slight inversion for a pronating foot). If there is a plantarflexion contracture this should remain in the cast/completed brace and the heel built up externally to accommodate it. Even a DAFO made from very thin flexible material will become stiff around the ankle once it is fastened up. In comparison, a boot is not usually formed around a cast of the patient's foot so is larger here. It is made from flexible leather so does not provide so much support. Even if a boot is stiffened on the medial side, a well fitting AFO or DAFO will give more pronation control. For pronation control similar to an AFO you need to add a caliper with a medial T strap to a boot. This is an option for those patients who cannot tolerate AFOs or who have fluctuating oedema.
    If the foot is pronating inside a DAFO or AFO you should be able to see it as a standard shoe is usually worn over the brace. If this is the case then extra padding is needed under the longitudinal arch or proximal to the medial malleolus or if the medial trim line prox. to the malleolus of the AFO is not forward enough, the AFO needs to be remade with the trimline further forward. If the foot is still pronating with an articulated AFO it may need to be made with a rigid ankle or a limit on the dorsiflexion.

  14. RobinP

    RobinP Well-Known Member

    They are all essentially AFOs with the exception of the first two and I don't think that their posterior aspect is any higher than on a pair of Nimco boots.

    Also, you don't need to necessarily control ankle plantarflexion. The aim of the game is to influence the ground reaction vector such that the extension moment at the knee is in equilibrium with the internal flexion moments being produced by the musculature at a given point in the gait cycle. As it happens, I think the research by Elaine Owen shows a mean shank angle to floor of 14 degrees to be the optimum(don't quote me on that one) How this is achieved is immaterial.
    They would certainly be in the minority

    Why is that?

    Yes it will. What is the greatest reason for non compliance of a DAFO - pressure and/or friction around the navicular? Would that be because the foot is still pronating inside the device. Do you want to eliminate all pronation?
    Lucy, I admire your theoretical orthotic viewpoint but you need to start thinking about moments. I am not criticising because I only took that step myself 18 months ago.

    The original post is talking about a 3 year old with Joint Hypermobility. We know nothing about the degree of recurvatum and we have been told that he has responded well to current orthotic prescription. Do you not think that moving to AFOs might be quite a jump? I'm not saying that you are wrong, merely making the observation that such treatment might be overkill for an asymptomatic 3 year old.


  15. Lucy Best

    Lucy Best Member

    Hi Robin,

    Yes, you are right - most of the DAFO examples do include an AFO. They are a combination of AFO + DAFO so giving better pronation control than an AFO alone.

    Elaine Owen's research shows that the optimum shank to vertical angle is 10-12 degrees and yes, you can get this from the boot alone with an appropriate heel height.

    However we know from Kahuna that:
    " his genu recurvatum is clear as is his slow speed and uncertainty in gait. he walks completely on the medial borders and has a marked rearfoot valgus.

    He has responded well to UCBL type, deep heel cup 20mm orthoses from the hospital over the past six months. But on assessment today, I feel further support is needed. "

    I don't know whether more support is needed to control the valgus rearfoot or the hyperextending knee. If he needs more than a UCBL device to control the valgus rearfoot/pronation, the next step up would be a DAFO or AFO. If it is the hyperextending knee, then yes, I agree, the combination of a high boot such as the Nimco with the UCBL may solve the problem.

    I feel that it is a great pity that many orthotists are in an unfortunate position not to be able to cast and rectify as much as they would like due to contractural time constraints. I believe that for the best orthotic outcome the orthotist should have sufficient time to do this when necessary (and this is the way that I work).

    We cast in neutral in/eversion to help prevent bony foot deformities caused by long term excessive pronation/supination. It is impossible for an AFO or DAFO to fully prevent all pronation/supination so sometimes the orthotist may choose to cast in a bit of inversion (for the overly pronating foot), so that when the foot moves in the pronating direction within the AFO or DAFO it goes to about neutral. A device that is padded at the medial side will be more comfortable and thus the pt can tolerate better, but it will allow a bit more pronation movement.

    The prosthetic/orthotic degree course is heavy on biomechanics and orthotists are trained to think about kinetics (forces and moments) and kinematics as standard.

    Obviously I am not prescribing an AFO for this child as I have not seen him, but I think it would be a good idea for him to be referred to an orthotist as all the options we have discussed will be available.


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