Patient Case History | Kelly

Kelly is an 8-year-old girl with cerebral palsy spastic quadriplegia as a result of complications from prematurity. She uses a prone stander and gait trainer at home and at school. After her family moved to our area, they had to wait on insurance authorizations for new services. During that time, Kelly outgrew her solid AFOs and she regressed functionally without treatment. Kelly developed rapidly progressing contractures and deformity while out of braces, due primarily to her extremely high tone. Her increased muscle tone prohibits volitional movements, even though she takes an oral medication to reduce tone.

I began seeing Kelly as a patient 10 months ago, at which time, she had been without braces for a year. Her physician called me before writing a prescription to see if I would try serial casting without Botox, so that Kelly could get back into braces as quickly as possible. I tried one cast and had to remove it after two days because she couldn’t tolerate it. So, we waited for the Botox.

Functional goals included improving alignment of the foot and ankle to help reduce tone and to facilitate active movements for reduced support when sitting, to improve standing and balancing, and to use in her gait trainer. Kelly had severely pronated feet with calcaneal valgus, forefoot abduction, and hallux valgus (Fig 1).

The right foot had considerably more deformity than the left. She appeared to have good dorsiflexion range of motion (ROM) bilaterally, but the right heel cord was tight and all dorsiflexion was occurring through midfoot pronation. Her calcaneus was plantarflexed and forefoot dorsiflexed, resulting in a rocker bottom deformity.

Kelly had Botox to the right peroneal m., gastrocnemius m., and hamstrings mm. followed by serial casting to improve her foot and ankle alignment. She wore a knee immobilizer at night to stretch the gastrocnemius m. and hamstring mm.

While the serial casting produced some improvement, Kelly still had significant pronation with forefoot abduction (Fig 2). Posterior views of first and final serial casts dramatize this improvement (Fig. 3). Because of her deformity, no footplates fit her feet. She was molded for her DAFOs non weight bearing so all arches could be accentuated by hand. Her hindfoot valgus was reduced by supinating and adducting the forefoot with one hand and applying a corrective force in the ST area of the calcaneus with the thumb of the other hand.

Kelly had dorsiflexion range just to 90 degrees when her subtalar joint was in neutral, so this would be her ankle position in her DAFOs. I requested heel wedging to simulate 3-4 degrees of dorsiflexion which would be required for full heel contact when standing. On the order form, I requested no build-ups over the medial malleolus and navicular; instead, additional foam was added over these areas to provide maximum control without pressure problems. Toe abduction loops were requested to control hallux valgus and to help control her forefoot abduction. I requested strong Type 2 ST support and ¼ inch medial forefoot (varus) posting to help control the calcaneal valgus.

DAFO Turbos were chosen because the two-piece design makes donning the orthoses easier and a strong outer shell provides maximum control even for a very high tone foot. The inner SMO of the Turbo can also be worn alone when using a gait trainer. I usually request that bottom stabilization be added to the inner shell when it will be worn alone.

Kelly began her adjustment period with several wearing periods each day and short breaks to check for excessive pressure. She had redness over her right medial malleolus once she reached four hours wearing time, so I heated and relieved slightly over this area and added a layer of 3/16 inch foam over the ST padding and in the medial longitudinal arch. I also added a layer of 1/8 inch foam over the lateral border of the fifth metatarsal and toe to better control forefoot abduction and hindfoot valgus. Inhibition of tone appears to take place when her feet are properly aligned (though this outcome has not been proven in a controlled study). The DAFOs are holding Kelly’s feet in good alignment (Fig 4) and her feet are tolerating the braces well.

-- Cidny Fox, CPO, FAAOP

Cidny Fox graduated from the University of Washington in 1982 with a BS in Prosthetics and Orthotics. She is certified through The American Board for Certification in Orhtotics and Prosthetics, and is a Fellow of AAOP. Cidny has specialized in pediatric orthotics since 1986, and works at Orthotic Solutions LLC, in Fairfax, Virginia.

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