Morton’s Neuroma, Morton’s Syndrome: Different Diagnoses Require Separate Orthotic Modifications

Posted on March 1, 2012 by Rochelle B. Silberman

Few words in biomechanics cause as much confusion as the term “Morton’s”. “Morton’s” is simultaneously two different foot diagnoses – and also potentially three separate orthotic modifications! The primary misunderstanding stems from the fact that two esteemed doctors applied their names to unique foot pathologies.

Morton’s Neuroma

Thomas G. Morton studied neuralgia of the forefoot, and bequeathed his name to the entrapment neuropathy of interdigital nerves. Morton’s neuroma is a painful condition that occurs most frequently at the distal end of the third intermetatarsal space, but it can be also found in the other interspaces. The entrapped and damaged nerve causes aching and burning of the forefoot. The symptoms of Morton’s neuroma are aggravated by wearing shoes that are too tight or narrow in the forefoot.

The most conservative treatment is to apply a metatarsal pad beneath the affected webspace. By supporting the transverse arch and spreading the metatarsal heads, the pinching on the nerve will be reduced. Alternatively providing a drop or relief under the met head may be sufficient to reduce the pressure. Torpedo-shaped “Neuroma Plugs” are also sometimes used, but their placement needs to be very accurate in order to get results.

It is important that the patient wear wider shoes if a met pad or foot orthotic is provided; otherwise, the pain will only worsen as you have added bulk to an already tight fit. Other medical treatments include local injection of sclerosing solutions or surgical excision of the neoplasm.

Morton’s Syndrome

Meanwhile another physician was busy inspecting short first toes. Dudley Morton lent his name to Morton’s syndrome. This is characterized by a short first metatarsal bone causing excessive weight to be borne by the second metatarsal head. It is usually a hereditary condition and will result in callus formation under the second and third metatarsals. Pain and tenderness are usually felt at the base of the first two metatarsal bones and at the head of the second.

Conservative treatment of Morton’s syndrome consists of building a flexible platform under the first met and toe. By bringing the ground up to the first met and toe, it is assuming extra weight, and thereby relieving the second met. This addition of material to the distal end of a foot orthotic is called a flexible Morton’s extension. It can be made out of cork, EVA, or other suitable materials, and is usually 1/8″ to 1/4″ thick

Morton’s Extension

The goal of a flexible Morton’s extension, as discussed above, is to increase the range of motion (ROM) and weight bearing along the first metatarsophalangeal joint (MPJ) and hallux. However, there are other conditions that require decreasing the ROM at the first MPJ.

Hallux limitus and hallux rigidus occur due to the inflexibility of the first MPJ. The great toe is unable to dorsiflex, which may cause pain and will interfere with toe-off during gait. Patients will often shift weight to the outer border of the foot in order to prevent motion in the big toe. There are several techniques available to limit ROM in the forefoot. A rigid Morton’s extension is a foot orthotic where the rigid orthotic material extends under the first to the distal tip of the hallux. It is usually made out of a rigid thermoplastic or carbon graphite material.

This device may impede the gait cycle, and if the extension is not fully rigid, it may even exacerbate the condition! If the goal is to decrease ROM, then it is preferable to either add a sole stiffener to the shoe, or place a full-length carbon footplate under the insole of the shoe. Full-length footplates have the added advantage of being transferable between shoes. In addition, putting a rocker sole or rocker bar on the shoe will help reduce flexion.

A more conservative approach is to create a reversed Morton’s extension, which will also help decrease ROM along the first. A reversed Morton’s is a channel that allows the first MPJ and hallux to “float” while transferring weight laterally to the second, third, and fourth mets. Typically, this is an accommodative-type orthotic. It will also include a sesamoid pad (a broad met pad with a deep drop for the first met head). Other conditions such as turf toe and sesamoiditis will benefit from this style of device.

Séamus Kennedy, BEng (Mech), CPed, is president and co-owner of Hersco Orthotic Labs, New York City, New York.

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Leg-Length Discrepancies: Diagnosis and Treatment

Posted on August 3, 2011 by MosheK

Numerous studies have been conducted. All agree on the data, but the actions required are unclear. Experts weigh in with research-supported opinions, but a universal protocol is not established. Although this may sound like a discussion of the Social Security system, these statements also apply to the clinical diagnosis and treatment of leg length discrepancies (LLDs).

This is a diagnosis that appears deceptively simple. There is often more to the apparent difference in limb length than meets the eye. The symptoms can be diverse, confusing, and vague, such as complaints of lower-extremity pain or general backache. Studies have shown that true or structural LLD is less common than realized, and that most LLDs are functional in nature, i.e., they are the result of a compensation or restriction.

Structural vs. Functional

Structural LLDs are the result of an anatomic short limb. These may occur due to congenital or developmental factors. Other conditions such as post-polio syndrome, certain post-op patient conditions, or trauma cases may lead to a LLD that needs to be actively managed.

More frequently, patients will display LLDs due to a functional difference in their biomechanics. For example, spinal problems, muscular weakness, ligamentous flexibility, and restricted ranges of motion at the ankle, knee, or hip can all lead to compensations that result in LLDs. Just because these LLDs are functional in nature doesn’t mean they should be treated any differently.

Evaluating

2.5 inch Internal Heel Lift

Asymmetry is a clue that a LLD is present. The center of gravity will shift to the short limb side and patients will try to compensate, displaying indications such as pelvic tilt, lumbar scoliosis, knee flexion, or unilateral foot pronation. Asking simple questions such as, “Do you favor one leg over the other?” or, “Do you find it uncomfortable to stand?” may also provide some valuable information. Performing a gait analysis will yield some clues as to how the patient compensates during ambulation. Using plantar pressure plates can indicate load pressure differences between the feet. It is helpful if the gait analysis can be video-recorded and played back in slow motion to catch the subtle aspects of movement.

Measuring

One of the golden rules in pedorthics is that you always measure a patient’s two feet before fitting a pair of shoes. You never trust in the sizing that they tell you. Likewise, it is vital that you measure the LLD, whether structural or functional, yourself. Measuring for a LLD is not an exact science; there is no clinical consensus as to which anatomical references should be used or how the patient should be positioned. In addition, direct measurement results with a tape can be difficult to reproduce across practitioners, and they will only indicate a structural LLD. It may be best to use several methods to develop a composite picture.

Internal Heel Lifts

For a direct measurement, the method that I recommend is to measure from the anterior superior iliac spine to the medial malleolus. This measurement will give you the actual limb length difference. Other methods include palpation, frontal plane observation, X-rays, and use of a measurement screen. However, this is only a starting point for treatment. There is no agreement as to the amount of a measured difference that should trigger an intervention! Anecdotally, it appears that for LLDs greater than ¼” some form of treatment be suggested to the patient, although many cases greater than this may be asymptomatic.

My preferred course is to proceed with an indirect measurement. I am not so much concerned with what the LLD is as I am concerned with what the patient can tolerate and what makes him or her comfortable. I prefer to measure the correction.

Correcting

2 inch External Platform Lift

In order to measure for correction, use a series of blocks or sheets of firm material (cork or neoprene) of varying thickness, e.g., 1/8″, 1/4″, and 1/2″. Place them under the short limb, either under the heel or the entire foot, depending on the pathology, until the patient feels most balanced.

Usually you will not be able to correct for the full amount of the imbalance at the outset. The longer a patient has had the LLD, the less likely he or she will be able to tolerate a full correction immediately. This is a process of incremental improvements. 2 inch External Platform Lift Bear in mind that the initial lift may need to be augmented as the patient’s musculoskeletal system begins to adjust. It is often recommended that the initial buildup should be 50 percent of the total. After a suitable break-in period, one month say, another 25 percent can be added. If warranted, the final 25 percent can be added a month later.

Once you determine how much lift the patient can handle, you then need to decide how to best apply it. There are certain advantages and disadvantages to using either internal or external heel lifts.

Internal heel lifts: Putting a simple heel lift inside the shoe or onto a foot orthotic has the advantage of being transferable to many pairs of shoes. It is also aesthetically more pleasing as the lift remains hidden from view. However, there is a limit as to how high the lift can be before affecting shoe fit. Dress shoes will usually only accommodate small lifts (1/8″1/4″) before the heel starts to piston out of the shoe. Sneakers and workboots may allow higher lifts, e.g., up to 1/2″, before heel slippage problems arise.

External heel lifts: If a lift of greater than 1/2″ is required, you should consider adding to the outsole of the shoe. In this way, the shoe fit remains good. Although some patients may worry about the cosmetics of the shoe, it does ensure better overall function. Nowadays with the development of synthetic foams and crepes, such lifts do not have to be as heavy as the cork buildups of the past. External buildups are not transferable and they will wear down over time, so the patient will need to be vigilant in having them repaired. On ladies’ high-heel shoes, it may be possible to lower one heel and thereby correct the imbalance.

Compromise is always a worthy attribute, and personally I favor a blend of both internal and external lifts when more than 1/2″ is necessary. This way, shoe fit is not too affected and yet changes to the overall look are minimized. A follow-up gait analysis should reveal a more symmetric gait, more even pressure distribution across both feet, and an absence of painful symptoms.

Article written and supplied By S’eamus Kennedy, BEng (Mech), CPed

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Treating Pediatric Clubfoot and Pes Planus

Posted on March 9, 2011 by MosheK

The word orthopaedic has two ancient Greek roots:“orthos” meaning straight or right, and “paideia” referring to the rearing of children. Thus, the original term pertained to the treatment of disorders of the bones and joints and the correction of skeletal abnormalities in children. It was probably believed, and it is generally still the case, that the earlier a deformity is addressed, the better the chances for success.  

Congenital ClubfootPes Planus
This is certainly true for “talipese quinovarus” (TEV), more universally known as clubfoot, one of the most common congenital birth defects of the foot. Although the incidence varies somewhat according to race, TEV occurs in about one out of every 1,000 births, with the occurrence in boys being twice that of girls. Clubfoot is seen unilaterally and bilaterally; bilateral presentations make up approximately half of the cases. The etiology of the disease is not clearly understood, and many believe the causes to be multi-factorial, including genetic considerations, the intrauterine environment, and a variety of abnormalities related to the development and insertion of muscles, tendons, and ligaments. Regardless of the origin, it is important to identify congenital clubfoot as early as possible for two reasons: to begin immediate treatment to address and correct the deformity, and to rule out other, more serious diseases that may be masking as TEV, such as neuromuscular disorders, spinal tumors, or even trauma.  

The typical clubfoot is turned inward and down in a classic cavo-adducto-varus presentation. Radiographic analysis will confirm the diagnosis of TEV; one will often see a talar head that is deformed and irregular, a talo-calcaneal angle that is decreased, and a talo-first-metatarsal angle that is increased. In unilateral cases, the clubfoot side is often shorter, and there are deep-seated medial skin creases. If the foot is correctable, conservative measures should begin immediately—as early as neonatally—since the deformity is progressive. Left untreated, joint contractures and accommodations will develop into a rigid clubfoot. Patients with rigid clubfoot should be referred as surgical candidates.  

Flexible FlatfootFlat feet
There does not seem to be a clear consensus as to the rate of moderate-to-severe pediatric pes planus, or flatfoot, in the general population. The literature indicates a very broad range (from 3–24 percent),with several studies settling between 15–20 percent. There does appear to be a link between obese children and flat-foot, a further indication that being overweight sets the stage for more health complications later in life. The normal infant foot will not have an arch and usually displays some heel valgus. A child’s arch develops over time and should become more apparent around the age of seven.  

In addressing the disorder, it is important to determine if you are dealing with a flexible flatfoot. Rigid flatfoot, caused by tarsal coalitions, usually requires surgery and will not be helped by foot orthotics. Equinus deformity can also result in the presentation of a flatfoot and should be dealt with as the primary cause before orthotic therapy begins. Finally, be aware that other motor-neuron disorders can cause flatfoot in a child and, if suspected, necessitate further investigation.There has been an historical belief that early correction of children’s flatfoot will result in the development of an arch. This has not been scientifically tested and proven but remains a prevalent idea with some merit and considerable anecdotal evidence. Originally, pediatric pes planus was addressed using traditional Shaffer plates (high medial flange) and Whitman plates (high medial flange and lateral “clip”). These were often made from stiff sole leather, but other versions were fabricated using steel, aluminum, or Rohadur. Being flexible and correctable, a child’s foot could adapt to the rigidity and shape of these devices.  

Currently, the most commonly prescribed children’s foot orthotic is the UCBL. Named for the University of California at Berkley Laboratory, where it was first developed, the UCBL is a rigid thermoplastic foot orthotic with an extra-deep heel cup (30mm+/-) and high medial and lateral walls extending distally toward the metatarsal heads. The UCBL provides classic “arch support” as it cradles the medial column and also controls the entire rearfoot. Further correction can be achieved by adding either a medial Kirby-type heel skive to the cast or a medial extrinsic post to the shell. Extra stability in pediatric orthotics is provided by extending the heel-post trim line farther distally, and having a flatter and wider shell just behind the metatarsal heads. I prefer to dispense UCBLs without any top covers because children often and easily peel them off, and because even though their toes may outgrow a full-length top cover, the shell of the device still provides adequate functional control.  

Gait Plates with lateral extensions, to correct in-toe

Gait plates are a more specific orthotic design that is usually prescribed to correct children’s in-toeing. Originally, they were rigid flat plates inserted into the shoe to change the break point although they are now often incorporated into a regular foot orthotic. Gait plates to correct in-toe (and so induce out-toe) have a shell that ends just behind the first metatarsophalan-geal joint (MPJ) on the medial side, and then extends distally past the fifth MPJ on the lateral side. This rigid lateral extension inhibits flexion of the lesser metatarsals and encourages external rotation. Gait plates work best in shoes that flex at the ball because rigid-soled shoes block their effectiveness. Gait plates to treat out-toe can also be prescribed with the extension reversed. However, many cases of pes plano valgus can be corrected using a UCBL with good medial support, which will address the compensatory pronation.  

Conservative Clubfoot Treatment Options 

A number of conservative treatment options are available to correct flexible clubfoot. Based on the severity and duration of the condition, a practitioner may employ one or several of the following treatments: 

Serial Casting: This is the most traditional technique to treat clubfoot. The Ponseti method is considered a successful way to incrementally correct the deformity. Serial casting relies on the “stress relaxation” effect to stretch the contracted ligaments and tendons—much like a rubber band losing its tension when it is continuously overtaut.  

During casting, the clubfoot should be manipulated from distal to proximal, beginning by first correcting the forefoot adduction and varus. The equinus component is addressed later, often surgically, and care must be taken that the castings do not create a “rocker bottom” foot. To avoid slippage and address any tibial torsion, casts typically run above the knee. Casts are changed frequently, often weekly, and may continue for several months. The amount of correction is increased gradually with the goal of creating a foot that is plantargrade, functional, and stable. Progress is monitored by x-ray. 

Denis-Browne Bar: Once serial casting has achieved the correction, the correction can be maintained by using appropriate shoes and a splint such as the Denis-Browne Bar. The bar incorporates stiff leather straight-last or abducted-last shoes, which are set in an externally rotated position on the bar. The apparatus is worn for more than 20 hours a day, and extra padding or support may be added to the inside of the shoe. 

Corrective Shoes and Orthotics: As the correction takes hold and the child begins to walk, he or she can wear firm orthopedic shoes that preserve the foot position. A variety of accommodations can be considered, including supportive shoes, modified lasts, and external sole modifications. Foot orthotics will also help support the realigned position. In addition, there may be a leg-length discrepancy that should be addressed with either an internal or external lift. When using these conservative options to treat clubfoot, keep these two important ideas in mind: 

1. The earlier a program begins, the less musculoskeletal rigidity has to be overcome. 

2. To prevent a recurrence of symptoms, preventative follow up measures are essential.The use of custom foot orthotics, corrective shoes, and other physical therapies—for as long as five years—are essential to maintaining the correction. 

Article written and supplied By S’eamus Kennedy, BEng (Mech), CPed

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A Baby Helmet Story

Posted on March 1, 2011 by DanielA

baby helmetThere are a few lullabies that put your baby instantly to sleep. Greensleeves does it best and when you start humming he squirms and soon he’s sleeping with his head turned near his hand and his small baby fingers curled. But you’ve noticed that one of his ears is starting to sag. His head, still soft, is parallelogram-like.

So you go to your pediatrician and his smooth cool hands touch your baby’s skull and he says that this looks like positional plagiocephaly and your heart drops that your baby should have a medical condition. He says this isn’t too serious though, don’t be worried. And you exhale and ask what to do next.

There are times when you may want to check your baby’s head to see that all is well. And he lies there in his baby helmet like those cones they put around dogs and cats to prevent them from tearing out their stitches. But away from his crib he smiles and laughs. His positional plagiocephaly is getting better you notice when you take off his baby helmet to see a round head and ears symmetrical.

You feel good that as a parent you were able to stave off any great consequences by paying attention.

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A Closer Look at Spinal Orthoses

Posted on February 22, 2011 by KristenM

Not too long ago we mentioned how Kidi-Splints isn’t just for kids with positional plagiocephaly or brachycephaly. They also carry items for adults as well. We briefly touched upon spinal orthoses for the spine and abdomen and today I’d like to talk a little bit more about them.

A spinal orthosis is simply a brace used to hold the spine in a certain position. There are several reasons a person may need to wear one. They can be used to correct a deformity or aide in pain relief after spinal surgery or a traumatic accident. A common use for the brace is to help a person suffering from scoliosis. The brace can be used instead of surgery.

When choosing a brace, comfort and adjustability are key. You will be wearing the brace for quite some time so it needs to be lightweight, but still durable. Unless you have one custom made, ensure that the brace can be easily adjusted to fit you properly. It also needs to be easy to put on and take off so you won’t require additional help. If the brace is visible, some can feel self conscious, but it’s important to remember that these devices will reduce your pain, improve your posture, and make you feel better.

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Plagiocephaly Awareness Week Being Launched in the U.K.

Posted on February 15, 2011 by ChristineM

Over in the U.K., Technology in Motion will be raising awareness for positional plagiocephaly by dedicating a week to fund raising, free advice sessions and a launch of a new charity. Technology in Motion is the leading treatment center for plagiocephaly in the U.K. and they’ll be hosting the week from May 16th to 22nd. Of course, awareness is important all over the world and they are looking to make that a priority.

Too few parents know about the medical issue, otherwise known as flat-head syndrome, and so this week is meant for parents from all over to come and learn, ask questions and consult experts. It’s to open up parents to the idea of freely talking about the condition, since many people often feel embarrassed to do so. This way they can understand what it is and how to treat it.

And in treating the condition, you’ll want to look into baby helmets to help re-mold the head into a better shape. That’s where Kidi Splints can help.  We have helmets to suit your needs for babies anywhere from 3 to 18 months old. And in treating your own child’s positional plagiocephaly, you too can help raise awareness when others ask you what the helmet is for. It’s important for parents to be well informed so help spread the word and educate others about the condition and it’s treatments.

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Kidi-Splints: Not Just for Babies

Posted on February 14, 2011 by jessg

baby helmetsAs we’ve discussed before, Kidi Splints can help with much more than positional plagiocephaly and craniosynostosis, and we offer much more than just baby helmets. Let’s take a look at some of the other products we offer:

Spinal and Abdominal Orthoses

Whether you suffer from mechanical back pain, high thoracic or multiple fractures and instabilities, Kidi Splints can help you. We offer a number of body jackets, corsets and cervical orthoses to help relieve your pain and help you heal.

Contracture Management

We offer a number of upper extremity and lower limb orthoses, for problems with your shoulders, elbows and wrists — carpal tunnel in particular is a far too common problem, and we have plenty of braces to help with it — as well as your hips, knees, ankles and feet. Whatever’s ailing you, we’re sure to have the solution.

Of course, before you buy anything, you need to see a doctor to find out exactly what the problem is. Kidi-Splints has offices in Lynbrook, Long Island, and Crown Heights in Brooklyn. We accept most insurances, and ask that you call for an appointment, as we don’t take walk-ins.

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Crouching – Excess Knee Flexion

Posted on February 8, 2011 by MosheK

Kids with weakness in the muscle groups that control the knee position will often crouch when muscle strength is insufficient to maintain an upright posture and stand tall. For children with chronic high tone contractures of hamstrings, the knees are pulled into a flexed position, resulting in a crouched posture. This is most apparent with excessive knee flexion during weight-bearing. It can vary from mild and inconsistent to very pronounced and constant. Crouching can come from both high tone AND low tone.

Courtesy of Cascade Dafo

When strength and/or control of the plantarflexors and quadriceps are inadequate, the child cannot support or maintain a normal upright stance posture. High tone contractures of the hamstrings can constrict stance to crouched posture – associated strong plantarflexion may result in “rocker-bottom” foot. These kids may also have a pronated or supinated foot.

Depending on the level of involvement, there are many brace options. Keep in mind that these are dynamic braces, thus allowing the child flexibility while properly positioning and supporting the legs to allow for optimum ambulation.

Courtesy of Cascade DAFO

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Craniosynostosis Terminology

Posted on February 7, 2011 by jessg

craniosynostosisIf your baby has craniosynostosis, there’s going to be a lot of terminology thrown around, much of which you probably won’t recognize right away. Here’s some of it — familiarize yourself with it before the next time you visit the doctor.

Phenotype: the distinct appearance with which a child suffering from craniosynostosis is born. The exact features are determined by which of the cranial sutures is closed.

Scaphocephaly: The literal meaning of this Greek word is “boathead.” The child will have a prominent forehead (or frontal bossing) and a prominent back of the head (or coning), giving the head a boat-like shape when viewed from the side.

Trigonocephaly: The loose Greek translation of this is “triangular shaped head.” It occurs when the metopic suture* (frontal suture) closes prematurely, resulting in a narrow forehead and eyes that are closer together than average.

*Other sutures are the coronal and sagittal sutures — ”dense, fibrous connective tissue joints that separates the frontal and parietal bones of the skull” — and lamboid sutures, which are located at the posterior of the skull. At the time of birth, the bones of the skull are not yet supposed to meet — when they do, the result is craniosynostosis.

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Positional Plagiocephaly and Craniosynostosis: What’s the Difference?

Posted on January 24, 2011 by jessg

craniosynostosisPeople often confuse positional plagiocephaly and craniosynostosis. It’s a fairly easy mistake to make — they’re quite similar to one another — so we’ve compiled a list of the differences:

Positional plagiocephaly

The ear on the affected side is typically pushed forward toward the face.

 Craniosynostosis

The ear on the side of a prematurely fused lambdoid suture is pulled toward the back of the head.
There is usually compensatory bulging of the forehead on the side of the “flat spot.” There is typically no bulging (if no other suture is involved).
The skull is more in the shape of a parallelogram (like a crooked rectangle). Because of this, positional plagiocephaly is called “parallelism”. The skull is shaped more like a trapezoid shape (wider in front, narrower in back).

Now that you know these differences, you should have no trouble at all deducing whether your baby has positional plagiocephaly or craniosynostosis. Of course, as we’ve stressed before, the only way to know for sure is by bringing him or her to the doctor for a professional evaluation. Once it’s been confirmed that your baby has one of these, you can move forward and start discussing treatment plans.

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