Hi All,
41 years old (nearly). Born with talipes in my right foot. Had two operations (at 18 months and 5 years) to lengthen the achilles tendon. Fast forward to now. Generally the foot is good until I've been on my for a few hours then it gets progressively stiffer and more painful. I play cricket (I'm from England!) and the day after a game I can't walk at all. I wear a specifically designed orthotic shoe on my right foot. The doctor has put me on Oxycontin and Tramadol for the pain and this seems to work fine. I'm also due for an ultrasound guided injection into the Sinus Tarsi on Friday.

Two points:
1) What should I expect from the injection? I've heard that it is really painful to have and this, combined with a fear of needles, means I'm not looking forward to Friday!

2) For years I've suffered with intermittant severe pain in my side (lower side just above the hip). It's normally on the right hand side but can also happen on the left, but never both at the same time. The pain is a deep internal ache that can get so severe that I'm doubled over. I have ignored it up until the last few months when it has become truly unbearable. I've had numerous tests that have found nothing wrong and I think now that the general idea is that this is referred pain brought about by the difference in strength between the the two legs and my body's attempt at compensation to cope with this difference. Is this something that happens in adults with clubfoot?

I'm also quite surprised about the lack of information available to patients on the internet regarding this issue. There seem to be many medical articles that are only accessible to medical people (or to paid subscribers). Is there anywhere on the net that deals specifically with adults coping with life after clubfoot surgery? All the sites I can find seem to deal with the issue from a parents point of view and with pediatrics in mind.

Thanks in advance...
Mark P.

Hi and welcome.

Good point about the lack of information of the web. It's likely that we see most of the treatment of talipes equino varus (TEV) in the peds setting. Most adults with residual clubfoot deformity just decrease their activity level and take a back seat to others who are more active. and I think most adults with TEV are so accustom to their limitations that they just assume that they got dealt a set of cards that they have to play out.

Ironically, I too was born with bilateral clubfeet. I had serial casting as an infant with no surgery. But my feet do limit me in what I can and cannot do. I love to backpack and I'm limited to just 8 miles a day. Some would say I shouldn't complain, but backpacking 8 miles a day isn't going to get one very far in the wilderness.

You have to look at adult clubfoot deformities as three separate issues. First is the forefoot adduction, second, a tight posterior ankle and third, rearfoot pain secondary to osteoarthritis.

I just started working with an adult clubfoot patient this spring. We did the first of several surgical procedures about 2 weeks ago. The first step was to straighten the foot with something called a Berman-Gartland procedure. The Berman-Gartland addresses the adduction of the forefoot by placing wedges (osteotomies) in the bases of the metatarsals. I also transferred the tibialis anterior tendon from the medial foot to the lateral foot. This tendon transfer will also help to evert the foot.

Stage 2 will be a triple arthrodesis that we'll do in about 12-18 months down the road.

Sounds like what your doc is doing is to assess the location of the rearfoot pain with an injection. If the injection blocks the pain, you know exactly where the problem lies. So think of the injection as a diagnostic tool.

How'd the injection go?

I don't think I can comment on the flank pain. I can say that it's not a common finding with TEV.

So when you compare yourself to me or the patient that I've described, where do yu seem to fit in?

Jeff

I am a 33-year old woman born with bi-lateral club feet. My doctors used casts to try to fix my feet as an infant, but I ended up, for better or worse, getting surgery when I was 2. I have pretty much no flexibility in my feet and no calf muscles, but I manage to live a relatively active life and I do go on bike-rides and hikes, but nothing too strenous or my feet will hurt. Certainly no high heels, which I've always wanted to wear.

At any rate, I am very interested in hearing more about the surgeries you are trying, Doctor Oster, and the injections that Mark has posted about. Have any of these things worked at all? What was the outcome? I am looking for anything out there that might help decrease pain and improve flexibility and strength. Also, which products on this site would be good for this? Any specific supports or braces? I have a had a very difficult time not only finding info on the web but just finding a doctor that has experience with this.

Thank you in advance
-AA

Hi AA and welcome.

Ah, we share the same calves, eh? Clubfeet always have those slim calves.

For the past several years I've been studying the way that the foot and ankle interact. The foot ankle and leg are a lever. the calf fires and the force generated by the calf is delivered to the ball of the foot. Levers are uni-planar. Let me give you an example of a common lever to explain that. Let's say you're going to use a pry bar to move a big rock. You'd get a small rock and a pry bar, right? The pry bar is a lever. And a lever is a tool that is used to gain a mechanical advantage. Now let's say for some odd reason that the pry bar that you have is bent in a 'U' shape. It's obvious that the pry bar will only work in one way. The pry bar will rotate to function in the plane where it is most effective.

And that's true of the lever we call the leg, ankle and foot. Any deviation of the leg, ankle or foot in that one plane will create eccentric force and poor biomechanics.

I didn't forget about your clubfoot....the clubfoot is what creates the bend in the lever. A clubfoot will behave like the bent pry bar. The deviation from the single plane will result in eccentric load and eventual failure of the leg, ankle and foot to function well.

So the goal then of treating a clubfoot is to realign the force that is generated by the calf and to be sure that that force is carried to the ball of the foot with as little deviation from that single plane.

Each case is going to vary a little based upon the primary location of the deformity of the clubfoot. Braces can be used, but so often, treatment of a clubfoot can be treated by simply using a traditional Oxford shoe. The virtues of the Oxford are really significant in that it acts as a brace more than a shoe. Slight heel, rigid shank, still leather sides and a laced upper will act to brace the foot and realign the direction of force.

Make sense?

Jeff

Doctor Oster,

Are you suggesting I get an Oxford shoe? I suppose I can do that.

I am still wondering how the surgeries you mentioned earlier in the thread worked out?

Thank you,
-AA

I saw my patient yesterday. He's not the most compliant patient so I'm a bit concerned about the tendon transfer holding. But other than that, he's doing well so far. Each foot is going to require two separate surgeries, so it's going to be a year or so for each foot...long time for sure.

Right, and Oxford would really do the job for you. the humble Oxford is one of the most overlooked assets in foot care. And here's a good example. I saw a school superintendent yesterday who felt a pop in the outside of his foot while walking through the sand on the beach while on vacation 2 weeks ago. X-rays showed 2 non-displaced metatarsal fractures of the 4,5 mets, left. He wore into the office a pair of leather lace up Oxfords. Rather than using a cast, we chose to make a compromise and have him decrease activities and use the Oxfords everyday.

Now the primary reason that he sustained the fractures was that he has a 'c' shaped foot, a bit like a club foot. What I mean by a 'c' shape is that when you're standing and look down on the foot you see a 'c' on the left and a reverse 'c' shape on the right. The turning in of the forefoot (called metatarsus adductus) is one of the three components of a clubfoot. And this fellow had a high degree of met adductus. The met adductus rolls him to the outside of the foot making him prone to lateral foot fractures. So the Oxford is simply used to straighten the 'c' shape of the foot.

Make sense?

Jeff