Pes planus with ankle instability

Name: Cherry Holliday
Phone: 0210323431
Email: cherryh@xtra.co.nz
Date: 5.6.2020
Event Number: CAH-1 2020 285239
(The event number should start with your initials, then the year, then which case study submission this is for you, then an internal job number that will allow you to identify the case in your practice. E.g. jcs-2009-01/1435b)
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Job Details
Start Date: 5.6.2020
Finish Date: 23.9.20
Referrer/Prescriber: Orthopaedic Specialist
Brief Patient Description:

Left severe flat foot, 71 year old lady with husband who has just been diagnosed with dementia and is an amputee from neuropathic arthritis also has parkinsons and is profoundly deaf. She is the main care giver and has to mow the lawns and do all the driving to their appointments and shopping.
Has had a lot of pain and would like to walk pain free, does enjoy walks on the beach which she has not been able to do for a while. This is her time out.

Orthotic/Prosthetic Aims/Requests:
To assist walking and provide pain control when mobilising

Abstract
Summary of case study. Include details of patient, method and outcome
71 year old lady with pes planus bilateral left has bony prominences in the instep and this is quite tender, Left foot has valgus heel and the plan according to Pt is some significant surgery to fuse both the hindfoot and the forefoot with complex surgical procedures including realigning the talus.
Goal – immobilise the midfoot and ankle to reduce pain until surgery is approved
Plan – arrange for Arizona brace that hopefully will be slim enough to fit into standard trainers, advised may need to have rocker sole add to footwear. Black in colour leather with laces
Send to fabricator to manufacture and contact when ready, to wear moonboot until AFO ready.

In meantime fit Moonboot with arch support to control foot position and book into clinic week for Cast for Arizona.
Initial Assessment
Clinical Presentation
Subjective:
Pt reports has a lot of pain , is main caregiver for husband with multiple issues, Profoundly deaf, parkinsons and just been diagnosed with dementia, also has BKA as a result of Neurpathic Arthritis.
Reports that the plan from specialist is to do some significant surgery but this not imenent to fuse both the hindfoot and the forefoot with complex surgical pricedures including realigning the talus.

Objective:
Bilateral acquired adult pes planus left foot has bony prominences in the instep tender to touch and valgus heel
Able to achieve 90 deg ankle position with minimal discomfort
Ankle pain when mobilising
Awaiting further surgery

Orthotic Aims:
Reduce the ankle movement DF/PF and provide more ML support, decrease pain
Discussion with Mulidisciplinary Team:
No discussion referral from Orthopaedic Specialist

Orthotic Prescription
Left severe flatfoot
Consider arizona type brace/UCBL +/- external valgus support and moonboot please

Literature Review
Summary and critical appraisal of literature used in clinical management, and/or in support of clinical management. Add more table rows for more articles.
I did not find any articles on orthotic management of this condition with this patient but there are a number of articles on the management of ankle conditions that have aspects which could relate.’
Article 1

Non Achilles Ankle Tendinopathy
Author:
Timothy Ryan Draper, DO, AAFP, CAQ Sports Medicine
Section Editor:
Karl B Fields, MD
Deputy Editor:
Jonathan Grayzel, MD, FAAEM
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2020. | This topic last updated: Jul 31, 2019.
INTRODUCTION — Approximately 50 percent of sports-related injuries are related to overuse. Of injuries seen in running clinics, the majority are due to overuse with about half involving the lower leg [1]. Many such injuries involve a tendinopathy.
The clinical presentation and management of tendinopathies involving ankle tendons other than the Achilles is reviewed here. Achilles tendinopathy, as well as acute ankle injuries, are discussed separately. (See “Achilles tendinopathy and tendon rupture” and “Ankle sprain” and “Overview of ankle fractures in adults”.)

Patient has history of sprain/strain in ankle which could contribute to pain and ankle instability

Article 2
Evaluation and diagnosis of common causes of midfoot pain in Adults

Author:
Karl B Fields, MD
Section Editor:
Patrice Eiff, MD
Deputy Editor:
Jonathan Grayzel, MD, FAAEM
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2020. | This topic last updated: Apr 09, 2020.
INTRODUCTION — Foot pain is common among adults and a frequent reason for primary care visits. Nevertheless, as the differential diagnosis for foot pain is broad and exposure to foot-related problems is often limited during medical training, many clinicians may not be adequately prepared to assess the patient with foot complaints.
This topic reviews the common causes of midfoot pain in the adult, including descriptions of important conditions and a discussion of how to reach a diagnosis. Common causes of forefoot pain and an overview of foot pain generally, including more detailed discussions of foot anatomy and biomechanics, and how to conduct a history and examination of the patient with foot complaints, are reviewed separately (see “Evaluation and diagnosis of common causes of forefoot pain in adults” and “Overview of foot anatomy and biomechanics and assessment of foot pain in adults”). A topic devoted to running injuries, including foot-related problems, is also available. (See “Overview of running injuries of the lower extremity”, section on ‘Foot and ankle injuries’

Patient has history of Arthritis in the mid and forefoot and this is more common in older women and would have been a contributing factor to the tenderness and valgus heel position and the pes planus.

Article 3

Treatment of severe, painful pes planovalgus deformity with hindfoot arthrodesis and wedge-shaped tricortical allograft
Authors
Loretta B Chou 1 , Benjamin W Halligan
Affiliation
• 1 Stanford University Medical Center, Department of Orthopaedic Surgery, 300 Pasteur Drive, Room R111, MC 5341, Stanford, CA 94305, USA. LChou@Stanford.edu
• PMID: 17559763
• DOI: 10.3113/FAI.2007.0569

Foot Ankle Int
• Search in PubMed
• Search in NLM Catalog
• Add to Search
. 2007 May;28(5):569-74.
doi: 10.3113/FAI.2007.0569.

Abstract
Background: This study tested the hypothesis that modification of the standard technique of hindfoot arthrodesis with the use of a wedge-shaped tricortical allograft would improve the amount of correction of pes planovalgus deformity. The results were compared to previous reports.
Methods: Between 1998 and 2005, the senior author (LBC) performed 13 hindfoot arthrodeses on 12 patients using an allograft to improve correction of the deformity for severe, painful pes planovalgus deformity. The average patient age was 55 (range 27 to 77) years. There were seven women and five men. The indications were posterior tibial tendon dysfunction (seven feet), rheumatoid arthritis (three feet), post-traumatic arthritis and deformity (one foot), congenital pes planovalgus (one foot), and tarsal coalition (one foot).
Results: Twelve of 13 feet achieved union by 12 weeks postoperatively. There was one nonunion. The average time to fusion was 12 weeks. All 12 patients were satisfied with the results of the operation. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 87 points, and the AOFAS Midfoot score was 85 points. Preoperative and postoperative radiographs were compared to evaluate correction of deformity. On lateral weightbearing views, the talo-first metatarsal angle improved from 15 to 6 degrees, and the lateral talocalcaneal angle improved from 48 to 35 degrees. On anteroposterior views, the talo-first metatarsal angle improved from 17 to 7 degrees, the talonavicular coverage decreased from 28 to 13 degrees, and the talocalcaneal angle improved from 23 to 13 degrees.
Conclusions: A simple modification of the addition of allograft to a common procedure of hindfoot arthrodesis to treat severe, painful pes planovalgus results is reliable and offers satisfactory correction.
Similar articles
• Modified Evans osteotomy for the operative treatment of acquired pes planovalgus.
Zwipp H, Rammelt S.Zwipp H, et al. Oper Orthop Traumatol. 2006 Jun;18(2):182-97. doi: 10.1007/s00064-006-1170-6.Oper Orthop Traumatol. 2006. PMID: 16820989 English, German.
• Complex reconstruction for the treatment of dorsolateral peritalar subluxation of the foot. Early results after distraction arthrodesis of the calcaneocuboid joint in conjunction with stabilization of, and transfer of the flexor digitorum longus tendon to, the midfoot to treat acquired pes planovalgus in adults.
Toolan BC, Sangeorzan BJ, Hansen ST Jr.Toolan BC, et al. J Bone Joint Surg Am. 1999 Nov;81(11):1545-60. doi: 10.2106/00004623-199911000-00006.J Bone Joint Surg Am. 1999. PMID: 10565646
• Arthrodesis of the subtalar and talonavicular joints for correction of symptomatic hindfoot malalignment.
Sammarco VJ, Magur EG, Sammarco GJ, Bagwe MR.Sammarco VJ, et al. Foot Ankle Int. 2006 Sep;27(9):661-6. doi: 10.1177/107110070602700901.Foot Ankle Int. 2006. PMID: 17038274
• A review of tarsal coalition and pes planovalgus: clinical examination, diagnostic imaging, and surgical planning.
Cass AD, Camasta CA.Cass AD, et al. J Foot Ankle Surg. 2010 May-Jun;49(3):274-93. doi:
10.1053/j.jfas.2010.02.003. Epub 2010 Mar 30.J Foot Ankle Surg. 2010. PMID: 20356770 Review.
• Subtalar arthrodesis for posterior tibial tendon dysfunction and pes planus.
Kitaoka HB, Patzer GL.Kitaoka HB, et al. Clin Orthop Relat Res. 1997 Dec;(345):187-94.Clin Orthop Relat Res. 1997. PMID: 9418639 Review.
See all similar articles
Cited by 2 articles
• Clinical applications of allografts in foot and ankle surgery.
Diniz P, Pacheco J, Flora M, Quintero D, Stufkens S, Kerkhoffs G, Batista J, Karlsson J, Pereira H.Diniz P, et al. Knee Surg Sports Traumatol Arthrosc. 2019 Jun;27(6):1847-1872. doi: 10.1007/s00167-019-05362-0. Epub 2019 Feb 5.Knee Surg Sports Traumatol Arthrosc. 2019. PMID: 30721345 Review.
• Pediatric flexible flatfoot; clinical aspects and algorithmic approach.
Halabchi F, Mazaheri R, Mirshahi M, Abbasian L.Halabchi F, et al. Iran J Pediatr. 2013 Jun;23(3):247-60.Iran J Pediatr. 2013. PMID: 23795246 Free PMC article.

This article shows that this surgical option can achieve a good outcome, and this surgery is what this patient is waiting to have. In the meantime to manage her pain, a method of locking up her ankle effectively giving her a temporary arthrodesis is working for her.

Visit details

Visit 1 (initial meeting)
5.6.20
Met with Pt and her husband moonboot fitted medium fixed with addition of medium burgundy formthotic trimmed at toes.
To be booked into a next clinic for cast for Arizona brace – Arizona picture shown to Pt and Husband.
Will need to have custom FS for right to go into shoe.
Pt happy with this.
Visit 2
25.6.20
Met with Pt and her husband – he is now suffering from Dementia, and she is the main caregiver. She has been wearing her moonboot with arch support and is awaiting surgery some time down the track.
Has bony prominences in the instep and this is quite tender, foot has valgus heel and the plan according to Pt is some significant surgery to fuse both the hindfoot and the forefoot with complex surgical procedures including realigning the talus.
Goal – immobilise the midfoot and ankle to reduce pain until surgery is approved
Plan – arrange for Arizona brace that hopefully will be slim enough to fit into standard trainers, advised may need to have rocker sole add to footwear. Black in colour leather with laces
Send to fabricator to manufacture and contact when ready, to wear moonboot in the meantime.

Visit 3
30.7.20
Met with Pt and her husband for the fitting of her Arizona brace, has a tender left first MTP joint, flared the leather at this area
Fitted brace Pt very happy with the fit and comfort.
Reports feels really great wants to know if she can start walking on the beach –
Advised – start with flat surfaces and gradually wean off the crutch, also wear with longer sock.
Fitted into the new shoes need to ensure that any shoes open really low to allow good access, use shoe horn to ensure back of shoe does not fold over.
Pt will let writer know in two weeks how the support is going.

Visit 4
26.8.20
Phone call with Pt, she reports the boot is great though she does get some pain on the plantar surface but thinks it is her foot letting her know that she has done too much.

Pt also reports that Specialist has declined her access to an Orthopaedic appointment even though she had suggested she refer her to the hospital as ACC not covering the injury. She feels she was discharged without support some two years ago without diagnosis of fracture which only came later. Pt is going to go to the HDC with regard to the management of her case as feels like this has been a medical misadventure.

Would like to access footwear to fit the anklet as has only been able to find the one shoe. Appointment booked for 17th September to review options.

Visit 5
17.9.20
Met with Pt and her husband today with regard to footwear, Pt has had difficulty in finding footwear that will accommodate the Arizona brace.
Discussed options – Pt will Email case manager name so preapproval can be sought.
Looked at all footwear options available for summer wear – so other foot is not fully enclosed in a shoe
Likes to walk on the beach so look at sandal option
Propet Farrah WSX113L size 9 4E to get up for trial.
Contact Pt when arrived

Visit 6
29.9.20
Met with Pt and her husband today for the trial fitting of footwear to accommodate the Ankle brace. Fits well on the right – needs addition of arch support and trim toe if possible, on left lengthen instep and posterior ankle straps as marked. To be collected when completed.

Critical Appraisal of Case Study

What have you learned from this case?

Sometimes that the majority of the factors surrounding the patient condition are not about the physical pt condition but about their cuircumstances and role they play in the family dynamics.
We do not always know what is going on in a family. Some patients are very up front and others you need to dig deeper

What could have been done better?
Planning was good so I think that patient was informed well on the process and time for longer term delivery.
May be should have looked at sandal option earlier for summer wear.

Does this study contribute to orthotic research/evidence?
No I do not think so

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