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Post by robertisaacs on May 4, 2008 18:48:54 GMT
This foot limps into your clinic (obviously not on its own, there is a patient attached). How do you go about offloading the lesions. You have... lets say 10mm of depth to play with under the mets before the poor lamb gets dosal IPJ blisters. The 1st and 5th met and 1st IPJ lesions are rather large corns, the 2nd is large and diffuse callus. The red markings are from where the skin has been marked out for an insole and are not clinically significant . The patient works on her feet on concrete floor all day AND does long sponsered walks for charity. What sort of insole would you prescribe here? Or would you not prescribe an insole? What, in fact, would you do? Look forward to responses. Don't be shy! Have a go. Prize for the best answer . Regards Robert
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Post by robertisaacs on May 4, 2008 18:51:50 GMT
PS Except for Del, who knows the answer already!
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Post by Admin on May 5, 2008 10:47:22 GMT
*Take a neutral cast. * Look at cast to see which side of foot needs propped up to keep the STJ in neutral (an approximation of), and prop it up by 2 degrees on a suitable shell (depends on footwear) * Simple poron cushioning (say 5mm) for forefoot - nothing for 1st MPJ. I'm assuming the footwear is not over-worn, and that she is wearing heels which are right for her (ie comfortable)? * Refer to someone who will enucleate and tidy up the lesions. * Re-evaluate after orthoses have been worn for 2 weeks. Is what I would do (but maybe not if this was a real case in front of me ). Cheers,
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Post by billliggins on May 5, 2008 13:05:45 GMT
Xray to look for i) lomg 2nd met, ii) hypertrophic medial sesamoid, iii) hallux limitus iv) bone/joint abnormalities in 5th MTPJ. Depending on result, shortening osteotomy 2nd met. and any other appropriate bone work then send to David H for his suggested t/t.
(Of course, one could always use pixie dust to increase the collagen under the points of pressure, or failing that grow a new foot!)
Bill Liggins
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Post by robertisaacs on May 5, 2008 18:39:31 GMT
;D I love the way everyone brings their own approach and how different those approaches are! I'm now thinking i should have put this in discussion rather than education. You wan't to move it boss? David, your way sounds awful complex to me! . Regards
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Post by TimVS on May 6, 2008 13:09:37 GMT
Check range of motion and joint stiffness. Is there a functional equinus here? Loads of FF pressure. Hard to tell but looks like 1st ray is plantar flexed and rigid/semi-rigid, including the hallux? So an accommodative flexible device to the sulcus or even full length with maybe a 1st ray cut out. . Lots of padding on the top cover. Minimal posting. Encourage supportive walking boots with nice thick soles for her sponsored walks. Check with the tekscan if device is offloading the pressure areas sufficiently and adjust accordingly. Mobilisations perhaps. Active/passive stretches post. compartment if required Bet she's had lots of orthotics already though
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Post by robertisaacs on May 6, 2008 14:41:32 GMT
You'd see her twice then .
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Post by dtt on May 6, 2008 15:19:10 GMT
One pair Rx'd at each visit perhaps ?? ;D Cheers D
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Post by TimVS on May 6, 2008 16:24:23 GMT
Oopsee! I thought it was post one get one free
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Post by lawrencebevan on May 6, 2008 16:59:53 GMT
David (Holland)
Re your Rx. What would be the thickness of the shell that you woudl shoot for? Would the heel cup be totally unposted?
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Post by robertisaacs on May 7, 2008 6:56:26 GMT
A few offers of 1st met / ray cutouts.
Given the fact that if you take load off one place it will load somewhere else and that the second met is already overloaded is that really a road we want to go down?
Likewise bearing in mind that a neutral cast is generally somewhat inverted from the patients existing WB. Do we want to be chucking more load onto the 5th met?
In fact, given that we have overload lesions on the 1st AND 5th mets do we really want to be doing anything in the frontal plane?
Thats the tricky bit with this foot. Easy to address one of the problems / lesions, damn hard to do so without making another one worse!
;D ;D ;D
Liking both of those posts though. Like that you considered footwear, soft tissue / stretching issues AND orthotics. THAT is holistic in a useful way. Karma for thee.
Regards Robert
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Post by Admin on May 7, 2008 7:34:59 GMT
David (Holland) Re your Rx. What would be the thickness of the shell that you woudl shoot for? Would the heel cup be totally unposted? Hi Laurence, Standard 1/8th" shell, and yes, no heel posting. Reasons: We want the shell to last. We don't need to post at the heel because any excessive STJ movement/moving away from STJ neutral in weightbearing can normally be controlled adequately by a comfortable heel-height and low (2 degs) FF post at whichever side of the cast needs it. I emphasise normally - Robert has the upper hand here - he's seen the pt . I'm working from a dodgy photo and limited information!
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Post by lawrencebevan on May 7, 2008 7:36:22 GMT
Robert
I agree with you Ian casted orthotic could "invert" and overload lateral forefoot but I would plantarflex the 1st and probably valgus balance the orthotic and have the front edge kept slightly thicker. I would (following your suggestions on the insole thread) look to put a lot of soft cushioning under the forefoot so use 6.4 slow release poron not regular with a cover with some elasticity. if space permitted I would add 3mm med eva extension with apertures for each lesion.
Footwear crucial - straight lasted not curved and plenty wide!
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Post by lawrencebevan on May 7, 2008 7:43:02 GMT
David thankyou
I understand your proviso of "normal".
1 What if the pt was a runner, any typical Rx change? 2 What if the pt had a medialy deviated axis or very everted heel or a foot posture index of say 10-11 (very pronated)
LaWrence
No catch, just learnin'.
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Post by lawrencebevan on May 7, 2008 7:44:43 GMT
David
Also.. 1/8th shell - milled orthotic or pressed? UK made or US made?
Lawrence
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