The Travelling Pod | Improving mobility in a patient with Spina Bifida

One of the projects I am involved in is volunteering for podiatry service once a week at a male drug rehabilitation centre in Irapuato Mexico. At this centre, 150 males live on campus and I have enjoyed serving these men. I have a Mexican friend who has a big heart for people and she accompanies me to the centre as my translator. I work on their feet while she talks to them and assists in my treatment.

 

One of the men I treated was a 15-year-old boy who had spent months in the rehabilitation centre without mostly older men. He reported that he had Spina Bifida.

 

Initial presentation

He complained of heel pain, and once I palpated his feet he had pain in bilateral tibialis posterior tendons. His ankle range of movement was abnormally flexible and his non-weight-bearing calf strength was minimal to none. He was unable to complete heel raises and it affected his gait by the inability to propel forward. His gait finished on a flatfoot/ midstance position using more hip flexor strength to initiate the swing phase.

 

Unfortunately, the men were not allowed to wear normal shoes and he was wearing Croc-style shoes. I was not prepared for this type of problem at the centre, but I could use what I had, and I glued a heel lift into his Croc-style shoes after he reported that it was more comfortable.

 

A few weeks later

Thankfully, the boy left the centre two weeks later and lived at home with his family while working in a paid job during the day. We received permission from his mother to visit the boy a few weeks later and we brought him brand new supportive shoes that had a rocker bottom to help with his propulsion.

 

The shoes were bought from a fundraiser we did on social media (a massive thank you to those generous donors), and the boy felt comfortable in the shoes.

 

After having dinner with his family, the boy showed me a pair of orthotics that were made for him previously by another professional. He reported that he does not use them because they are uncomfortable. The mother seems to think they were not made for him and given to him by accident.

 

After looking at the previous orthotic, seeing it had a rearfoot valgus wedge also made me question if they were made for the boy. I wanted to make him some semi-customised orthotics from recycled flip-flops, and the boy was happy for me to make it for him.

 

Making semi-customised orthotics

I used the innersoles of the new shoes to make a stencil of the orthotic and marked the bony landmarks of his heel, navicular, lateral arch, and 1^st metatarsal joint (MPJ). I observed that his arch was minimal during weight bearing which would influence how thick I would make the arch cookie on his orthotics.

 

One week later

We returned a week later to fit his orthotics into his shoes and make sure that they were comfortable.

 

As previously mentioned, I used an unwanted pair of flip-flops as the arch cookie in the marked location on the material. I used my Dremel to shape the arch cookie with the navicular landmark to be the peak height of the arch and gradually declining before the start of the 1^st MPJ. Moreover, keeping in mind that I wanted the peak height to be lower than usual.

 

Also, I created a small support for the lateral arch with a similar material to prevent the foot from moving off the orthotic. Then, I glued a 5mm EVA cover because his shoe had plenty of depth, and I thought the extra padding would give him more comfort from his heel pain (as he was used to wearing cushioned footwear). Lastly, I created a rearfoot varus wedge using my Dremel using a firm 4mm material.

 

On our return visit, we provided dinner again and ate with his family. The boy reported that he had been liking his new shoes, and seemed very grateful. After dinner, we fitted his new semi-customised orthotics into his shoes and got the boy to walk around the house including moving up and down their staircase. He reported that they were comfortable and that he thought he could wear them all day.

 

Six months later

It was six months later when I caught up with him to see how he was doing with the orthotics and donated shoes. It turned out he was not wearing them. He reported that his orthotics after four months started to become a bit uncomfortable on the rear foot.

 

I originally added a firm 4mm heel lift with a 4mm varus wedge in the hope of reducing the force loading to his planter fascia and tibialis posterior but also assisting his inability to propel due to significant muscle weakness. Unfortunately, the wedge was too much and by the wear patterns on his shoe, he was significantly loading the lateral aspect of the heel. Therefore, the varus wedge rearfoot was too much invasive for his high mobility in his rearfoot.

 

I palpated his foot and he still presented with tenderness in in the planter fascia and tibialis posterior bilaterally and decided to make him some customised orthotics from recycled plastic bottle caps.

 

Making customised orthotics

I took his mould by weight-bearing on a firm wood plank and used wet sand to mould around his manipulated foot. I held his 1^st toe in a dorsiflexed position, basically activating the windlass mechanism which increased his arch profile and naturally slightly inverted the rearfoot.

 

Carefully, I removed his foot from the sand mould, but this time I modified the lateral part of the sand. I knew that his foot was slightly deformed and if I moulded the width of his foot, then the plastic orthotic would not fit in his shoes. Therefore, I carefully pushed the moulded sand on the lateral side closer by a few millimeters without losing its natural mould.

 

Once the plaster was set, I had the shape of his foot and used extra plaster to smoothen the edges and fill the gaps where it did not mould correctly.

 

I melted the plastic bottle caps of the plaster molds. I used my Dremel to remove the access plastic and form the shape whilst smoothing the edges. I added a 5mm EVA soft cover with a medium firm 2mm back cover.

 

Fitting the new orthotics

When fitting his orthotics to his shoes, I ran into a lot of problems, and as predicted his shoes were slightly small for him. I spent a lot of time grinding the heel cup and mostly the lateral column to tightly fit into his shoes.

 

The boy’s feedback was positive straight away, after a few minutes of walking around. I pushed for honest feedback and he felt like he could wear the orthotics all day.

 

Nevertheless, I left 5mm adhesive heel lifts with his mom and told her to contact me if the orthotics were too uncomfortable. The idea is to instruct her on how to apply the heel lifts to his orthotics (reduce the Achilles tendon plantar flexion moment on the calcaneus) since I won’t be seeing the boy for a long time.