Case Study

By Cidny Fox, CPO

MF is a 4-year-old boy with cerebral palsy quadriplegia as a result of complications during delivery. He previously wore DAFO 3s, but had not tolerated any orthoses for the 6 months before I first met him. He is not ambulatory. Functional goals included improved alignment so he could resume standing in a stander. He presented with clonus at ankles, hindfoot varus deformity left much worse than right, left 24 degree plantarflexion contracture and right dorsiflexion just to 90 degrees.

I had to begin with serial casting (Fig 2) to correct the equinovarus deformity prior to molding for DAFOs. After casting, MF’s right foot was easily positioned in neutral and he had 25 degrees dorsiflexion ROM. His left ankle could be positioned close to neutral and dorsiflexion was just past 90 degrees. His feet still assumed an equinovarus position (Fig 1). It was anticipated that the DAFOs would need to be worn 23 hours a day to prevent recurrence of the deformity and contractures.

If I had planned to position MFs feet in neutral alignment (hindfoot vertical, forefoot level), he would be able to supinate within the orthoses. His ankles were positioned in one degree dorsiflexion (his most corrected position on the left) and I requested foam calf shims be sent with the order to increase dorsiflexion later if his ROM increased.

His feet and ankles required aggressive molding to try to “pronate” him out of his supinated position. A corrective force was applied with the thumb of one hand over the lateral head of the talus while a counterforce was applied with the other hand over the medial aspect of the first metatarsal head to abduct the forefoot. A second set of hands was required to stabilize the knee while the feet were molded using otherwise standard DAFO casting techniques.

The more rigid left foot required 3/8” lateral forefoot (valgus) posting to maintain a vertical calcaneus. On the order form, I requested that the forefoot abduction not be corrected. I also asked that no build-ups be added over the lateral malleolus and instead, additional foam added to provide the precise control without hard pressure over boney prominences.

DAFO 8s were chosen because of the more flexible nature of the plastic. It is not strong enough for walking, but is fine for supported standing. MF had a history of skin breakdown over the cuboid and lateral malleolus, so he needed strong control of his equinovarus position by applying pressure where he could tolerate it. The softer plastic is a good choice when there is rigid deformity that may or may not be fully correctable, as is the case with MF’s left foot. If a patient has very high tone, a Softy^TM version of a DAFO 3 or Turbo would be a better choice because they can overpower the soft plastic.

After fitting the DAFOs, there was redness over the left cuboid bone. I find it is better to try to increase correction by adding additional padding, rather than heating and relieving over pressure areas. Foam was added over the medial aspect of the left first metatarsal bone to further increase forefoot abduction and better control supination. A small pad was also added at the inferior border of the left lateral malleolus to increase the corrective force that prevents supination. MF wears his DAFOs 23 hours a day and is tolerating them well (Fig 3).

Editors Note: The standard plastic for DAFO 8 has been switched from TPE to MPE. This plastic is softer and more comfortable for the patient to wear than the TPE. It is also easier for the practitioner to adjust. 

Fig. 1 Fig. 2 Fig. 3