The Travelling Pod in Mexico | Part 3

Working on the street at the underpass next to the train tracks known as the vias, I saw a man amongst all the passing migrants, sitting down and wearing a bandage. At this time, I had Spike a Mexican volunteer of Amigos del Tren organisation, helping me to translate. Spike told me that this man from Honduras had a horse accident four years ago, injuring his left hip.

Initial impressions

The man’s gait was significantly affected, with an obvious weakness to his left leg to the foot causing a noticeable drop foot as if it were dead weight. He would load his body weight to his non-affected right hip and leg muscles to be able to complete the swing phase of his affected foot. He complained of muscle pain in his non-affected right gluteal muscles and feels unstable when he walks.

On observation and palpation when I rolled up his jean pants, he had significant muscle atrophy from his left leg down to his foot. He was unable to move his left affected foot into dorsiflexion compared to his normal moving right foot. His right foot presented with crawled toes in an attempt to grip the ground for stability compensating for his unstable left leg and foot. He had a significantly thick callus on his right lateral heel, complaining that it gets sore when he walks for a long time. Also, callus build-up on his right medial 1^st inter-phalangeal joint because he pushing with medial angular propulsion due to a weak propulsive lever.

It was clear he had significant nerve damage as a result of his hip injury, also I was not able to detect 10 grams of pressure on his distal toes. Situations like this are sad because there is not much I can do for him to solve his problem; he needs to see a specialist for further investigation. However, I CAN DO SOMETHING to make his experience more comfortable.

Initial interventions

He was wearing flexible running shoes that were not broken thankfully (which is uncommon amongst passing migrants) but not suitable for his unstable foot. Unfortunately, I did not have any donated supportive shoes available to trade him, but at least he found his shoes comfortable to wear. I decided to use prefabricated orthotics that were donated generously and organised by Mona from Club Warehouse in Sydney Australia.

Also, I added an arch cookie slightly grinded down with my Dremel for extra support since the man had a high arch in his non-affected right foot during weight bearing. I recycled thongs/flip-flops to use the material as a minimal varus wedge to offload the 1^st IPJ loading. I covered the orthotic with a 2mm EVA covering for comfort.

Since his left affected hip level was higher anteriorly and posteriorly during weight bearing, I felt comfortable adding a valgus lateral wedge to his heel to offload his high-impact area. I removed a lot of his thick callus to make his walking experience more comfortable. He felt comfortable and more stable in his walking, and he appreciated my efforts by giving me a hug.

Further intervention

Two mornings later, I woke up with an idea that interrupted my sleep.

I had an idea of making the man an ankle-foot-orthotic (AFO) out of recycled plastic Coke bottle caps. He needed an AFO to help his walking to avoid dragging his foot and significantly loading his right hip and leg muscles. I had never done this but it was an experiment that I was excited to try to hopefully bring him greater comfort and mobility. I brought the man into the Amigos del Tren center earlier than their operating hours (unfortunately, I got in trouble for it).

I cast his foot with his orthotic held in place with a bandage using plaster, and his foot held into a 90-degree dorsiflexed position. Then, I used my sandwich press to melt Coke bottle caps and laid the hot plastic over the cast. I continued this process until I had covered the majority of the plaster. As you can imagine, it was hard to mold without suitable gloves or the correct equipment.

I was able to make the desired shape and used my Dremel to shape it and flatten it so it could fit into his shoe appropriately. This project took half a day to complete, and continual trials on his foot. Lastly, I had glued 2mm EVA on the inside of the AFO where his Achilles tendon is.

The AFO was definitely not perfect, the biggest problem was the posterior shape not fitting inside his shoe. I had to continue to grind and fill weak spots with melted plastic bottle caps to provide more durability. I had to provide a 4mm hard EVA innersole under his orthotic for his non-affected right foot because the AFO raised him higher. He felt comfortable walking with the AFO and extra innersole (right foot), also using a bandage to lock his leg to the AFO.

The next day he was not using the AFO and I asked why. He had changed shoes (thrown out his previous pair) for a more supportive casual shoe (donated by a visiting church group) but the toe box was too shallow for the AFO and orthotic.

Patient feedback

I cut the orthotic to make it a ¾ length and that fitted better, and with a little more grinding, the AFO and orthotic felt comfortable. Using a translator, I asked for his honest feedback reassuring him that he would not offend me with my first AFO trial. He complimented the device and saw him wearing it for the day, and other days he has not worn it. He knows he can just use the prefabricated orthotics if the AFO bothers him, but he said he uses it when he walks a lot –  honestly, I am not too sure but I did give him my best.