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PES EQUINO VARUS --------------------------------------------
Pes Equino Varus basically means horse foot. Most of you will know it as club foot. It is found in newborns and created by the way the baby was carried. The legs were folded and the muscles on the inside of the leg tightened and the external or lateral sets of muscles stretched. Normally your muscle sets are in balance. This gives you a range of motion to walk and do other functions. For every set of muscles that pull one way, there is another set that pulls the opposite direction.
When one set muscles is too tight, it pulls everything out of balance. When babies are born with the medial or inside set of muscles shortened by the way they were carried, once born and stretching out the muscles and other soft tissues prevent the foot and leg from straightening. If the foot is contracted, it may turn medially (to the inside) at the choparts or Composite joint.
The legs may also be involved and generally the leg and foot both twist down and to the inside like a corkscrew. In extreme cases the foot may even point posterior (almost backwards).
SOLUTIONS
In mild cases the doctor may give the parents exercises. Rotating the feet and legs to the out side, and forming three points of pressure on the foot itself. Inside of the ball of the foot, heel and in the middle on the outside. Then applying pressure on the three points to straighten the foot.
In more severe cases, there are special open toe shoes made to help correct the foot. The first are straight last. They have no rights or lefts and the baby is tied securely into the shoe and it squeezes the foot straight and holds it straight. The second are called pronators, reverse last, outflair or abductors. All terms refer to the same shoes, just depends where your doctor learned his profession. These shoes have a steel plate between the sole and inner-sole, a hard counter in the middle of the outside of the shoe and the shoe forms a mild C over this pivot point. It thus forms a three point pressure system to correct the foot. The shoes are worn with heavy sox and are kept on the baby 20 hours a day. The toes are open to allow for perspiration to evaporate and keep the foot dry. It also allows the baby to grow through the end of the shoe and still keep the correction on the foot without having to purchase another pair of shoes.
The shoes can be worn separate or if the legs are involved, they can be used with a Dennis Browne Orthosis or Splint. This is a metal bar that the shoes are clamped to. The shoes are set in an external rotational position. Usually 45 to 60 degrees of external rotation. The shoes may be mismated, straight last and outflair or even in sizes. The cost of mismates is usually $5 more than just the shoes. A factory charge that is passed on by most stores.
When in doubt, treat! Babies are extremely flexible. Much of their bodies are cartilage. No bone yet. Bone will begin to form over the coming months. So when in doubt, it is best to treat as the process will take weeks rather than months or years. A month old baby may take one to two months to correct. A three month old baby may take six months to correct and a year old baby my not completely correct over several years.
Babies have no expectations. You are new, grandparents, clothes, house, car, pets, other children, toys, food, everything is new. They accept new easily. At a year, children have learned to have patterns and expectations. New motion limiting gadgets like braces may not be taken to easily at a year or later. So again, when in doubt, treat and treat early. If suspicious that the feet are twisting in too much, make sure your pediatrician checks it out. If they ignore the problem, get a second opinion form an orthopaedic surgeon. If both agree to wait and see, do the exercises daily. They do help.
In severe cases surgery is used. Again the shoes and perhaps the brace can then help to maintain and retrain the tissues. The body has a memory and if you get things corrected and then put on a cheap shoe with an inward curve, you may soon see the foot return to it's previous position. The straighter the shoes, the better. Then as the child grows forward in the shoe, there is no curve to hit to turn the foot inward. It is very important to watch the children's shoes for the first six years. Adult shoes with forefoot adduction (turn in) scaled down to children's sizes will make many normal children toe in. On children with pes equino varus, it can be much worse. You an undo years of correction with one bad shoe worn for a few months.
Watch sleeping positions. Do not let children sleep on their tummy's with their feet twisted to the inside. Leg weight against a hard bed is like a brace to hold the foot in. If necessary wait until they fall asleep, then roll them to their side and place a small pillow under the hip so they can not roll back to their tummy. Also watch sitting positions. Do not let them crawl around and then rock back to sit on the feet pressed against the floor to the inside. Again it is like putting them in a brace to turn in. Help them to sit with their feet and legs in front on them when they play. This is the most sever form of a varus foot.
VARUS ----------------------------------------------------------------------------------------------------------------------
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-Varus can come in degrees like pronation. A varus foot tends to adduct or curve inward. If you look from behind the Achilles tendon may look like a c with the open space facing the midline. This curve shows that the calaneum is inverted. Weight is shifted to even more to the outside of the foot. The knife's edge that normally bears weight is then also inverted and the weight shifts lateral. Excess pressure is put on the 5th metatarsal and a bunion may begin to form there from the driving on the joint laterally. The arch of the foot will normally be pronounced and excessive. In extreme situations the outside of the knee may also be come involved.
SOLUTIONS
Strong shoes with extended lateral counters help. Straight last shoes can also help straighten younger feet. The doctor may want to use lateral heel wedges and medial toe wedges to pivot the foot straighter with every step. Arch supports may be required. Varus feet are more rare than pronated valgus feet. Skeletal structure favors medial collapses not lateral collapses. So pronation is more common. In extreme cases a sole may be extended laterally and a wedge built up the whole length of the shoe. It is all a matter of balance. If you are having problems, see your orthopaedic surgeon.
PES CAVUS ----------------------------------------------------------
Pronation is caused by the longitudinal ligament stretching and allowing the talus to drop medially (inside) off the calcaneum bone. The bow created by the longitudinal ligament allows the arch to collapse. In a Pes Cavus foot, the ligament is too tight and actually pulls the ball of the foot back into the heel. This can be quite painful and the instep is pushed up and metatarsals are on edge and tend to get irritated. The exaggerated arch is a problem because the normal ratio of ball of foot distance to heel is shortened, so shoes do not fit. The instep is so high that slip on shoes are impossible to fit. Everything is too rigid, so there is not the normal amount of shock absorption in the foot. By the time the heel and instep are comfortable, the ball of the foot is somewhere in the arch, rather than in the widest part of the shoe. The feet tend to be very wide as volume is the measurement of width, not how far across.
SOLUTIONS
Generally, a tie oxford that is wide enough to accommodate the mass works best. Cushion innersoles to cushion the metatarsal heads will help. In some cases, the doctor may make a custom orthotic to relieve arch pressure on the ligament, as the tightness often causes inflammation in the plantar (bottom of the foot) soft tissues.
- HAMMER TOES, METATARSAL PROBLEMS ----- --------------------------------
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Metatarsal problems and hammer toes are often associated. Hammer toes are caused when the plantar ligaments of the toes contract. This can be caused by shoes that are too short, hose that double up the toes, arthritic changes and other factors that end up allowing the ligaments on the bottom of the toes to contract. Hammer toes can cause multiple problems. Inflammation and pair are just the start. Because the inter phalangeal joint is elevated by the contraction, the joint rubs on the toe box in most shoes. This can cause callous formations, corns, enlarged joints and other problems.
Because the metatarsal phalangeal joint is depressed into the bottom of the shoe, huge callous formation are common. This then presses back on the joint and pinches the nerves.
SOLUTIONS
Accommodate the problems! Wide oblique toe shoes, give extra height, and room for the toes. In some patients, a pinch pad (a felt pad with an adhesive back like a Band-Aid, can be placed in the toe to put soft pressure on the joint to straighten and thus take away some of the pressure. The thicker inner-soles also cushion the metatarsal heels. A metatarsal pad can be placed in the the shoes just before the metatarsal phalangeal heads to bare your weight on the tarsals. This takes weight off the heads. Your doctor may also make a custom arch support to take off pressure also. Some of the new thermo plastics are very moldable and have much cushion to relieve pressure. Believe it or not, exercise can help the toes. If you put pressure on the proximal phalange ( toe bone in front of the ball of your foot) and press down while you lift up the tip of your toe, it straightens the toe. This stretches the soft tissues that have contracted, much like doing physical therapy on a stroke victim to stretch out contractures. If you stretch the toes daily for some weeks, they often respond by slowly straightening more every day. I have seen women where the joints were still not locked, but had severe callus formations from their hammer toes, do the exercises and find a few weeks later that the toes were almost straight and the callus formations were going away. Faster, easier and cheaper than surgery. You have nothing to lose but some time and every degree of correction is less pressure, pain and problems.
In cases where arthritis has caused bone changes in the joints allowing the joint capsules to collapse or change their seating, the shortened ligaments may also contribute to the joints fusing and becoming rigid. As in bunions, the solution may be to go to the deepest shoes possible. Then use the ball stretch tool to make pockets over the toes to take off the pressure. P W Minor has a new set of shoes out for arthritis with elastic uppers which can easily stretch to conform to any deformity. For severe rheumatoid and other arthritis patients without hope for a good result from surgery, these shoes can make a major comfort difference.
In severe cases the doctor may do surgery. If the joint is involved and enlarged, they may remove the joint capsule and pin it straight. Another method is to open the toe and make small serrations on the ligaments and then pull the toes straight and cast. As the scar tissue forms it fills in the cuts making the tendon longer and allowing the toes to again lay flat. As in most surgical solutions, it is the last treatment, not the first. Shoes, arch supports, pads and stretching for deformities come first and if nothing works and you can not live a normal life, you resort to surgery. Again, after surgery, the best results are to be gained by wearing the oblique toe shoes for a year so that everything heals straight.
Callous or Callus formations are caused by pressure on the skin from the underlying bone. This may be caused by the bones having shifted, excessive weight, friction or pressure. The body to protect itself, allows the skin to thicken to protect the area. This additional thickness then tends to increase pressure and cause more thickening. In some cases it presses on the bone or nerves and causes pain.
SOLUTIONS
First you must identify the cause of the problem. If it is friction from sliding around in shoes that have stretched out or are too loose, then you only need to replace the shoes. If the problem is caused by an arthritic spur, a bone shift or enlargement of bone, a cushion innersole like Spenco may help. A worse problem may take a gel innersole or even a custom arch support made or prescribed by your doctor. In the ball of the foot area, a metatarsal pad may help. In the heel, orthotic heel supports, cushion heel pads or even a felt heel pad may help. Like so many foot problems, it is trial and error.
Generally you want to support the foot, cushion the bottom and have a sole that absorbs shock well. Repetitive blows from hard heel, thin soled shoes can cause bone bruises, bone spurs and callous to form. So can friction from sliding around in an ill fitting shoe or a shoe that does not control your foot. Walking shoes, shoes with thicker cushion soles, shoes with cushion innersoles and any in-depth orthopaedic shoe will help callous formation problems.
Soaking the feet until the callous softens enough to sluff off, is another partial solution. You can also help the problem by wearing thick cotton sox. They then absorb the friction and blow and can reduce the callous. There are a number of pads etc. on the market. They cover the area, make it sweat and soften so it may be removed. In severe cases your doctor can cut them off, but they tend to come back. Removing them takes care of the symptom, but not the skeletal cause of the problem. For most people it is not a problem and the dead skin tissue just comes off in the shower over time if you change to better shoes or cushion innersoles.
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BAREFOOT FREEDOM SHOES - P W MINOR SHOES - INTRODUCTION
RELATED ARTICLE - ARTHRITIS