Case Report: The Infant Flatfoot

Transcription

1 Sergio Puigcerver (1) ; Juan Carlos González (1) ; Roser Part (1) ; Eduardo Brau (1) ; Luis Ramón Mollá (2) (1) Instituto de Biomecánica de Valencia, UPV. Valencia, Spain; ibv@ibv.upv.es ; (2) Molla Ortopedia S.L. Xàtiva (Valencia), Spain; luis@ortopediamolla.com ; Case Report: The Infant Flatfoot Personal data intake and anamnesis An 8 years old child comes to the clinic. This patient comes because he does a lot of sport and his parents have detected that, since 3 months ago, he trips a lot, he falls down constantly and mentions his pain at the end of the day. Analysis of footwear The first step is to explore the footwear, in which no relevant deformation and wear is observed. Non weight-bearing exploration Regarding the non weight bearing biomechanical study, the only remarkable evidence is the tibio-fibular joint (TFJ) with the knee in extension, because it is decreased at dorsal flexion under the 15º (bilateral). In plantar view, the child presents a significant hiperqueratosis pattern in the hallux with a Rolling off in the right foot. Weight bearing exploration In the weight-bearing exploration, it can be remarked the Fick s angle decrease, lower than 15º, as a consequence of the left foot in abduction. With the palpation of the osseous prominences at the posterior view of both feet, we find the scaphoid bone prominent. It can also be remarked the 20º valgus in calcaneous relaxed position (CRP), and 8º in calcaneous neutral position (CNP) of the right foot. But the left foot presents values of 10º in the CRP and 0º in the CNP. In the lateral view we find an important decrease of the internal longitudinal arch (ILA) in both feet. Image 1. Weight bearing exploration The subtalar joint axis is very little medialized in both feet.

2 Image 2. Weight bearing exploration In order to verify that the subtalar joint axis is very little medialized, it was decided to measure it with a laser beam. In this way, it was concluded that the axis of the subtalar joint is normal, as it can be seen in the figure. Footprint Analysis Image 3. Measure of sobtalar joint axis In the footprint analysis by means of the podoscope, we can observe that the patient presents a grade 2 flat foot in his right foot, and a normal footprint in his left foot, although he presents a slight abduction on this foot.

3 Image 4. Podoscope image The image obtained by means of the digital scanner shows a slight pressure on all metatarsal areas, bilaterally, and a gentle pressure on the heel, which is more relevant in the right foot. Gait Analysis Image 5. Digital scanner image Finally, in gait analysis, it is worth highlighting the midfoot and heel support phases because there is a decrease of the dorsal flexion of the tibiotalar joint. In the last one it is also worth remarking the increase of the inversion of the subtalar joint. The remaining gait phases are not affected. Diagnosis The patient has a physiological flat foot for his age but, since he presents symptoms, it is decided to do a treatment with orthoses for prevention of a evolution to a pathological flat foot in older ages. Treatment It is considered important a preventive treatment for the control of pronation dute to high sporting activity and for the pain that the patient presents at the end of the day. The treatment consists of: Physical therapy: triceps surae stretching exercises before and after doing any activity. It is recommended to do this exercise during 30 seconds and 5 repetitions.

4 Orthotic treatment: insole with supination wedge and medial longitudinal arch support, thus providing supination forces which the patient lacks. Mould The plaster cast is taken in non weight-bearing situation. The modification of the mould is carried out by the calcaneal-cuboid blocking, in both feet. Realization of the insole The first step is to fill in the negative with plaster and then take the positive. In case that the modifications produced during the taking of the cast are not those that we consider more opportune, it is necessary to do rectifications on the cast. In particular, to get a more prominent arch and to place the subtalar joint in a neutral position Since the goal is to make a preventive insole for the child, a high density material is selected for the shell of the orthosis (such as a 3mm polypropylene), achieving in this way a better control of the pronation forces by placing a wedge beneath it. The wedge is made of medium density cork. Finally, the lining has a thickness of 1 mm, 20º Shore A hardness and the material is open cell EVA foam. Thereafter the polypropylene is thermo-formed on the mould. Then the wedge is stuck with glue under the polypropylene in the medial area of the calcaneous and the medial longitudinal arch support. Next the materials are thermoformed on the polypropylene in order to obtain the appropriate shape and to get a proper union. Afterwards the lining material is cut to obtain the desired perimeter of the insole according to the patient s size. Finally, the lining is stuck on the polypropylene base and is thermoformed again in order to give it the definitive shape of the foot. Finally, it is necessary to sand the orthosis with an angle of 45º with respect to the sander so that the orthosis can be put correctly into the shoe and there are not bends or indentations left. Initial Validation Image 6. Produced insole At the time of delivery of the plantar orthoses, the patient underwent a series of questions to identify which structures of the orthosis hurt or produced him disconfort. The most remarkable answers where that the patient felt the arch support al little high and that the insole material was a little hard. In spite of it, these are not the characteristics that must worry us because the objective was him to feel slightly the arch and control the rearfoot pronation forces. The patient will feel a softening of the material with the use of the orthosis and, as a consequence, a decrease of the arch s height adapting to his needs. This effect will have te be checked in the next review in order to verify that there is not any problem. As a conclusion, the patient remarked through the initial assessment protocol that the plantar orthoses where quite confortable.

5 Validation during the review The patient went back to the clinic for undergoing a checkup after wearing the orthosis for 15 days In this chekup, the parents of the patient remarked that the child does not trip nor fall as many times as he used to do, he does not feel pain at the end of the day, and that the stretching exercises have been very satisfactory after doing sporting activities. It was observed that the orthoses were completely adapted to the contour of his plantar structures and, after an evaluation on the treadmill using the orthoses it was found that he had indeed improved his gait. Having that all, the patient was scheduled for 6 months later and thus control the child s evolution until the substitution or withdrawal of the plantar orthoses is considered timely.