AFO Pistoning Problem non Toe Walker

The patient was seen today for adjustments to her left SAFO and her right UCB. She was still getting pressure at the back of the heel on the right side. I believe she is pistoning inside the brace. I fared the proximal trimline in the heel section. I encouraged mom to tighten the shoelaces tighter. Mom is concerned because the patient is externally rotating her foot on the left as she walks. I noted that the strap that is on the posterior section of the SAFO was very tight. I loosened this to allow her more plantarflexion. The patient is not a toe walker therefore the strap is loose for her. She was also getting pressure on the navicular. This was heat relieved and I added a pad along the 5^{1 metatarsal to adduct her foot more in the brace. The patient ambulated for approximately 50 feet. Her gait looked improved. I told mom to monitor the areas to ensure that they do not get worse. Because they have turned into calluses, they would take time to dissipate. I advised her to put lotion on the patient's feet at night. This would help soften the calluses. Everything else appears appropriate. The patient will be seen as needed.

Adjust Broken Footplate /AFO Short Articulated

The patient was seen today for repair of a broken brace. The patient had a cracked right AFO-Short Articulated across the bottom of the footplate. It was completely broken off and being held together with duct tape. This was beyond repair, and we will need to fabricate a new one for him. The patient has no change in his medical condition since we last saw him. His left AFO-SA continues to do well. The brace is intact and his skin does not have any areas of irritation. I checked the skin on his right foot, and even though he has been wearing the broken brace, there are no areas of irritation or skin breakdown. We kept the right AFO-SA today and will duplicate this brace, as the patient has not been having any problems with it. We received a prescription for a new AFO.

HKAFO ADJUSTMENT

PROGRESS NOTE: Patient is seen today for fitting of his left lateral upright HKAFO attached to a right wraparound AFO. All trim lines brought back to appropriate height. All areas checked for pressure. No excess pressure was found. Scoop pads were placed in the braces bilaterally. The height of the HKAFO appeared appropriate. The shoe lift on the left side was slightly too tall for the patient. We will take these back and cut ¼ inch off from these so the patient can ambulate with a smoother gait. With the shoe lift on the left side he stands with the knee flexed. When he stands straight. The right leg is off the ground. We will shorten these, diffuse them and mail them to his parents. We will see the patient back in 2 weeks to ensure that the shoe lift is the correct height and everything is functioning well with the brace. He was told to monitor his skin for any red marks and to ensure that they dissipate within 30 minutes. He was instructed if they did not, to stop wearing the braces and to schedule a return visit for adjustment.

Tuberous Sclerosis - Bilateral AFO Wrap Arounds

RX: Tuberous sclerosis.

HISTORY: This 19-month-old male has no allergies, has not had any surgeries and currently takes phenobarbital. He receives physical therapy 2 to 3 times per month at home. The patient reports that he has a rotating therapy schedule with occupation and speech therapy also. The patient is cruising and pulling to stand. He has not had previous devices.

EVALUATION:The patient presents with pronated feet bilaterally. His heels are in valgus and his forefeet are abducted. This is exaggerated upon weightbearing. He has mild tone and no clonus. Range of motion at his ankles is to 90 degrees with his knees straight. His knees and hips are normal. He has no gait to evaluate.

LAB: Fabricate bilateral AFO-Wrap Arounds

Dandy-Walker Syndrome - SAFO's

RX: Bilateral Solid Ankle AFO’s

DIAGNOSIS: Dandy-Walker Syndrome

HISTORY: Patient is an 8 ½ year old male with no allergies. He has had brain surgery along with multiple shunts. He walks with minimal assistance. He receives PT 3x weekly, and he has worn SMO’s in the past.

ASSESSMENT: The patient is a moderate pronator bilaterally with normal tone. His calcaneus is everted and his forefoot is abducted. These abnormalities were corrected as much as possible during the casting procedure. Our orthotic goal is to maintain the ML plane at the ankle as well as stabilize standing.

PLAN: Fabricate bilateral SAFO’s

OA Knee Braces - Load Shifting or Shiftless Loading

Monarch Beach - Lonnie Paulos, MD delivered a speech last week at the St. Regis Resort to a group of orthopedic specialists about the effectiveness of unloading braces.

Dr Paulos said that the #1 indication for prescribing load shifting braces is arthritis of the knee (Esp. Osteoarthritis -OA), and yes, based on all the literature, shoe wedges and knee braces do work to lessen pain.

The following is more from Dr. Paulos's presentation.

What is knee OA? It is the articular cartilage breakdown or loss (smooth lining that covers bone to decrease joint friction. OA can occur in the medial and/or lateral comparment of the knee joint.

The prevalence of knee OA is 12% overall in the USA and begins in the 4th decade, increasing in prevalence with age. OA affects women at a younger age, but is more prevalent in men. The risk factors for knee OA are advancing age, genetic make-up, gender, and hormonal status. Dr. Paulos also includes developmental deformity, muscle weakness that limits flexibility, decreased joint proprioception, obesity, join overuse or injury from repetitive activity, and poor nutrition as potential causes of knee OA.

Sports also can induce knee OA. Dr. Paulos stated that moderate running showed no risk unless the runner had been injured or had a structural abnormality, and that the evidence of OA in older runners was similar to that of non-runners. The highest prevalence of OA, especially at the elite level, was in soccer, and that the risk of hip and knee arthrosis is high with injuries excluded. Weightlifters had a positive risk for patella femoral OA possibly due to body mss and squatting maneuvers.

There is a problem. Arthritis is America's new epidemic. 1 in 5 Americans have arthritis, and OA affects an estimated 20.7 million Americans. OA is the leading cause of disability in the United States.

What are the treatments? A few are to self-medicate, on-line advice, friends, family practice/primary care, rheumatologists, and or surgeon.

Pharmacological Treatments? acetaminophen, NSAID's, analgesics/topicals (Dr. Paulos seemed especially fond of topicals), intra-articular injections (viscosupplementation / HA Supartz, Hyalgan, Synvisc, Orthovisc, Euflexya) cortisone or steroidal, nutriceuticals/supplements.

Non-pharma & nonsurgical interventions? A few would be orthopedic devices (canes, orthotic wedges, and braces).

Surgical intervention? Athroscopy debridement with a osteochondral transplant known as an OAT's procedure. Tissue engineering (Genzyme/Carticel) known as autologous chondrocyte implantation. In this procedure the surgeon removes a small healthy tissue sample and cultures it in the lab for 4-6 weeks. The cells are implanted to cover the defect with membrane. Adhesion occurs with fibrin glue. High tibilal osteotomy and uni/total knee arthroplasty are other surgical procedures.

Patient education: modify risk factors by decreasing frequency and intensty or a complete change in activity, rehabilitation, fitness (lose weight) assistive devices and bracing.

Obesity is a leading cause of OA. The forces across the knee is 3 times the body weight with each step - 10 times with stairs. Weight loss of 11 pounds can decrease OA by 50% with the strongest effect in women and a stonger correlation for weight loss than gain.

Physical Therapy can improve joint ROM and periarticular muscle strength, improve joint proprioception, and develop exercise habit. The exercise habit in increase strength, endurance and flexibility. Exercise will optimize weight, protect joints through improved biomechanics, improve cardio vascular function and a state of well-being.

Orthotics and Braces: heel wedges, heel and sole wedges, brace, sleeve, valgus or varus-producing functional brace, Biona-Care - electromagnet sleeves.

Knee Arthritis - Orthotic Treatment: The literature indicates that patients with mild knee OA did best with an in-shoe heel and sole wedge 1/8 - 1/4". Their pain scores decreased while their functional scores increased

Knee Arthritis -Bracing - Fact and Fiction: Hypothesis - by unloading an arthritic compartment of the knee...patients will experience less pain:increased activity. How does OA bracing reduce symptoms associated with compartmental osteoarthritis? It does so by creating an externally applied three point bending moment tht reduces contact pressure, reducing OA pain. The longer the brace the greater magnitude of the brace., and regardless of brace design ratonale (push or pull) the mechanics of three-point bending are identical.

Do Braces Really Work? - An emphatic - YES! All studies evaluating medial OA using valgus producing knee braces found that biomechanical unloading occurs, and that pain scores decreased and functional scores increased. But not all braces a created equal! Our surrogate studies (Finger and Paulos) have shown that DonJoy's OAadjuster to be 3 times more effective in load shifting, and is why I use the OAadjuster for my moderate unicompartmental OA patients who want to remain active.

The Most Important Use of the OAadjuster? I use the OAadjuster for my varus or valgus osteotomy patients to protect their ligament, meniscal, chondral or osseous procedures over a finite period of time.

Summary - Load shifting braces work to control coupled motions, shift the load where desired, and work best at full extension. DonJoy's line of OA braces allow me to match the product with the patient for best results.

Thank You - Lonnie Paulos, MD

Delivery of Bilateral Shoe Orthotics

Patient here today for delivery of bilateral foot orthotics. A good fit was achieved. Proper donning and doffing instructions were given. A gradual wearing schedule was discussed and agreed upon increasing by 2 hours daily. Explained to patients mother that if child developed any red marks that did not go away within 30 minuts to contact our office for adjustmen. Patient ambulated in the office and the alignment looked good. Patient stated that orthotics felt comfortable. Patient will be seen as needed.

Bilateral Ankle Foot Orthosis - Pressure Left Medial Malleolous

Patient was getting pressure on the left medial malleolous as well as some forefoot abduction occuring in brace. A pad was added along the shaft of the 5th metatarsa, and the area around the medial malleolous was heat relieved. Redonned the orthosis and everything appeared appropriate. Patient was not being pinched by the plastic, and his foot pposition in-brace was much improved.

Solid-Ankle AFO's

DIAGNOSIS: Cerebral palsy and diplegia

RX: Bilateral solid-ankle AFO's

HISTORY: 14-year-old female has no known allergies, and is not taking any medication. She has not had surgery and receives PT at school. She currently has bilateral AFO-SA's with compcore reinforcement at the ankles, and ambulates using a forearm-supported walker.

ASSESSMENT: Presents with fairly neutral feet bilaterally. Her heels rest in neutral and her forfeet are adducted; however, upon weightbearing she pronates mildly with her heels in valgus and her forfeet to neutral. ROM at her ankle mordus is to 90 degrees with her knees flexed. She exhibits mild tone and no clonus, Bilaterally she internally rotates greater on thre right than on the left. Casted her today for bilateral AFO's.

ORTHOTIC GOAL: Maintenance of patient's foot alignment in a neutral position and to prevent him from falling into pronation attempting to relieve left knee and bilateral ankle pain.

PLAN: Fabricate bilateral AFO's SA with compcore reinforce.

Insoles with Custom Shoes - 5th Toe Amputation

DIAGNOSIS: Diabetes and osteomyelitis and 5th toe amputation left foot.

RX: Shoes and insoles

HISTORY: 58-year-old female no known allergies, diabetic 5th toe amputation due to infection. Patient presents with residual Charcot joint with a history of previous ulcerations. Her skin integrity is good. She has neuropathy below the knee bilaterally. Patient can dorsiflex to 90 degrees bilaterally, but the left foot only dorsiflexes to 90 degrees through pronation by pronating. She has pitting edema bilaterally.

ORTHOTIC GOAL: To protect the foot from mechanical stresses and shear forces.

PLAN: Fabricate bilateral total-contact insoles with custom shoes. Custom shoes chosen because of the difference between the left and right feet.

Osteoarthritis Shoe Insert with Wedge for Knee Pain

Have had several patients with medial OA knee pain who were unable or unwilling to wear knee braces, but wanted to put off getting a total knee. I fabricate a 3/16" lateral heel and sole wedge and glue it to the lateral border of super thin and flexible carbon fiber (cf) plate we fabricate. The cf insert is better than a leather insert because it doesn't deform and will spread the vertical and surface load more evenly. The insert fits into a shoe with little problem. The user can usually can tell immediately if the OA wedge helps relieve their knee pain.

Boston Overlap Brace

Have an athlete with a pars fracture I am fitting with a Boston Brace (BOB) this afternoon. I use the B.O.B. because it has respected research papers I can give to the parents.