Guest Blog: Rich Griffin
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Objective: In gait the patient walks in an excessive supinated position throughout the gait cycle, on passive range of motion there is 10 degrees of dorsiflexion.
There is a 1.5 size difference in footwear common with talipes and signs of gastrocnemius/soleus wastage another symptom of talipes. On encouraged eversion the patient could move the foot into a corrected position however in walking, fatigue or lack of innovation of peroneals was demonstrated immediately. The overall aim at such a young age and this stage was to stimulate and encourage active firing of peroneals in function.
In a CPD session in 2011 a presentation was delivered on the use of Compex Neuromuscular stimulators (NEMS) in sports rehabilitation facility I was employed in. Clinical reasoning would suggest this type of machine would benefit the patient with his rehabilitation. Contact was made with a former colleague in a clinic were the patient could be taken, this would allow a trial on the Compex NMES machine to see if it was a valid option.
Two small metal rods were placed in the approx area of peroneal’s origin and insertion then a electrical charge was sent through this area, immediately the foot moved into eversion and the peroneal muscle group carried out there functional action.
The electrode pads were then placed in the same area and the Compex NMES machine was used on a strength cycle set to a signal which would innovate the peroneals, the patient at such a young age was upset initially so distractions were used, once settled I then got the patient to walk around the clinic, the machine enabled the patient to produce small but definite improvements to the foot position during gait.
For 8/52 the NMES machine was used on the patient for 20 minutes each evening prior to putting boots and bar on before bed, increases in stimulation was made as the patient adjusted to the use of the NMES machine. Often walking around the house with it on or favourite films/cartoons were used to distract the patient.
The surgeon reviewed the patient after using the NMES machine for 8 weeks and stated that he felt there was an improvement in the patients gait and active eversion. This appointment was purely coincidental regarding time frame of use of NMES machine. Due to this a delay was put on surgery, the patient has another review in 3/12.
Only time will tell if further surgery will be required but at this stage the NMES protocol is assisting in the rehabilitation of talipes for this young patient.
Point of interest
In 19525 it was suggested the best age for tibialis transfer was between 3 and 6 years, as after the age of six years secondary changes in the soft tissues and bones prevent adequate correction. In a follow up paper of patients with clubfeet treated with extensive soft tissue release, a correlation was found between the extent of the soft-tissue release and the degree of functional impairment. Repeated soft tissue releases can result in a stiff, painful and arthritic foot and significantly hinder quality of life.7
- Miedzybrodzka Z, Congenital talipes equinovarus (clubfoot): a disorder of the foot but not the hand. 2003
- Morcuende J, Lori A, At El, Radical Reduction in the rate of extensive corrective surgery for clubfoot using the ponseti method. Pediatrics Vol.113. 2004.
- Dobbs M, Nunley R, Schoenecker M, Long-term follow-up of patients with clubfeet treated with extensive soft-tissue release. 2006.
- Critchley J, Taylor R, Transfer of the tibialis anterior tendon for relapsed club-foot. 1952.
- Haasbeek JF, Wright IG, A comparision of the long term results of posterior and comprehensive release in the treatment of club foot. J Pediatr Orthop, 17: 29-35. 1997
- Templeton P, Flowers M, Et Al, Factors predicting the outcome of primary clubfoot surgery. 2005.