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CLUBFOOT RESEARCH FOUNDATION

BRACE TIPS

FACT: FIT IS IMPORTANT FOR ALL BRACE TYPES

REASONS WHY BRACES MAY SLIP OR GET KICKED OFF

There are really several reasons why bar braces may require adjustments or replacement, and these are also reasons, the shoes may slip or get kicked off while the baby is kicking. Slipping is less prevalent in single-leg braces but we may address these later.

  1. Undercorrection – per literature 99% of true clubfeet are under-corrected which makes sense since a genetic disorder cannot be fixed with an external fix. the heel has a deep crease, and the Achilles tendon has not dropped due to casting slippage before bracing starts or due to the type of clubfoot (genetic, neuro causes). Some heels can drop gradually provided the crease is not too deep, which indicates suboptimal healing length of the Achilles tendon. However, per Dr. Matthew B Dobbs, if the heel has not dropped at all after 6 weeks of trying, you probably need a second opinion on the correction of the foot or feet.  Please note that positional clubfoot does not involve any bone displacement or malformation, so bracing experiences vary per case type and generalization should not be applied to all case types.

  2. Initial Severity/Stiff Feet – Stiff feet are more likely to slip because the full correction was never a possibility, leading to slipping and sores – see Dobbs, Frick, Mosca et al:2017

  3. Shoes too big – The shoes may be a little bit, but the last strap should still end behind the toes, not over the toes. Bigger shoes are also wider in the back part of the shoe to accommodate a larger foot, so the foot will slip if too slim for the larger shoe.

  4. Shoes too wide – The size is probably too big, but if there is a lot of room between the edges of the foot and the white liner it can slip.

  5. Shoes too small – Foot is bulging between the straps may be a sign of a too-small fit. Straps running out of holes etc. Some feet are born too wide for the standard sandal fit, in a very low percentage of cases. Sores on the side of the feet are usually a sign the liner is not wide enough anymore.

  6. Prominent heel bone – sometimes a problem even on the unaffected foot and this situation is just more prone to sores, resulting in suboptimal time in the braces. In the words of Hanger Orthotics distributes all brace types:  Find what works and that you can use all the time! None of the products they issued according to them ever causes a relapse and it does not matter which product you use if you get those hours in - what makes bracing successful is the duration of use and if it cannot be used due to sores and time out of the brace, then it is not effective bracing.  

  7. Leg Length Difference if significant – some more complex cases and especially Unilateral cases have larger leg length differences to start with. This causes one side to slip out even if fastened snugly when the baby kicks the longer leg straight. One that has not worked with fibular hemimelia cases or lots of differences cannot claim that this situation does not exist, and it reflects the lack of experience in some places. Some orthotists have engineering degrees also and can testify to the issue of leverage, so do adult patients.

  8. Combined Issues - Leg Length Difference combined with an Under corrected Heel/Foot - At TSRH a slight difference of 0.5 cm and under-corrected heel caused slipping upwards in the braces numerous times, forcing the hospital to design a single combination from a Mitchell shoe combined with a KAFO brace to address such issues and to keep adduction that was achieved until further treatment could be provided. Hip Dysplasia and Clubfoot are other combinations that is more complex to brace.

  9. Severe Blount’s Disease – With tibial bowing that is severe and present from birth, there may be issues regarding bar bracing which Dr. Ponseti admitted at a conference in Australia - In such incidences a KAFO type or single leg product brace is better to use.

  10. Other Co-Morbidities may influence brace application from the beginning or over time.

  11. Skin/Tissue Differences – some types are so prone to sores they never get to brace many hours from the get-go and then they start to lose dorsiflexion – such a situation is not optimal bracing. If a product that is less common results in increased hours, it is usually a more effective form of bracing. Skin problems are often in Spina Bifida case types and other more complex cases.

 
HOW TO TEST THE DORSIFLEXION

Bend the knee and place your hand from the heel to the toes with the heel of your palm starting at the heel. Now push upward only as far as it will go without resistance. This is what most physical therapists would do. Doing it on a sleeping child is best because they would not typically put in their own resistance to the stretch to confuse you. Check to see if the dorsiflexion is going beyond 90% and estimate how much. Some physical therapists will teach you how to measure it with their measuring tool also, therefore the Clubfoot Research Foundation.org has been recommending that every CTEV child should see a physical therapist often in their life for gait assessments and review.

The Clubfoot Research Foundation has hundreds of pictures that is deemed under corrected or not corrected for you to peruse. https://www.facebook.com/groups/490115561095206. This collection goes back 11 years. All has been confirmed by an Orthopedic specialist as not corrected.

Despite measuring this way, please note the whole concept of dorsiflexion and the degree which should be considered ‘normal’ is still controversial in literature. Please review https://journals.lww.com/jbjsjournal/fulltext/2021/10200/measuring_ankle_dorsiflexion__not_as_simple_as_you.14.aspx

TEST THE SHOE SIZING

If the shoes are too big or too small or too narrow or wide, measure your baby’s feet (width and length) and compare the sizing charts found on the manufacturer’s website. Follow the manufacturer’s recommendations for these measurements. Hanger Orthotics or other general orthotists servicing a wide variety of products may not have the best orthotist in place to provide this kind of technical advice. Regional areas that are more remote also do not have expert fitters per se.

SIZING CHARTS
1.MD Orthopaedics sizing chart:

You must fill the measurements of width and length in on the company's application form.

2.ADM SIZING CHART

https://c-prodirect.com/adm-non-ambulatorysizing

3.IOWA BRACE SIZING CHART

https://www.clubfootsolutions.org/education/iowa-sizing-chart/

4.MARKELL SHOES SIZING CHART:

https://markellshoe.com/Tarso-Open-Toe-Boot-Sizing.pdf

 

SCOPE OF CO-MORBIDITIES

See our website blog at www.clubfootresearch.org/blog

 

REFERENCES

  1. Sussman, Michael D. MD1, A Measuring Ankle Dorsiflexion: Not as Simple as You Might Think, The Journal of Bone and Joint Surgery: October 20, 2021 - Volume 103 - Issue 20 - p e83 doi: 10.2106/JBJS.21.00742

  2. Dobbs, M.B., Frick, S.L., Mosca, V.S., et al:2017, “Design and descriptive data of the randomized Clubfoot Afduction Brace Length of Treatment Study (FAB24)”, Wolters Kluwer Health, Journal of Pediatrix Orthopedics, B 2017, 26:101-107.