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Re: Brace after 6 months for 14 year old -- Genu valgum, gait, foot orthotics...

Posted By: Michael Frind
Date: Tuesday, 25 March 2008, at 9:47 p.m.

In Response To: Re: Brace after 6 months for 14 year old -- Female soccer player, genu valgum... (Chris Fleetwood)

Dear Chris,

Your daughter's brace would be a Defiance, given that this is the only custom-made carbon-fibre brace from DonJoy (now known as DJ Orthopedics or simply DJO). It is good that the brace fits well. As you noted, the problem is the genu valgum (knockkneedness).

When wearing the brace, please make certain that the strap that encircles the leg just below the knee is tightest. This is an essential component of anchoring any brace to a leg, but it is especially important with the Defiance, given how its frame design (posterior tibial cuff) interfaces with the leg. DonJoy provides a unique strap-tightening procedure, but the end result should always be that the brace hinges align with the knee, and that the strap immediately below the knee is tightest. Meanwhile, the topmost strap should be only gently tight.

You asked about shoe inserts. There are many kinds of off-the-shelf inserts available, ranging from simple insoles with thickened arch sections (similar to what most shoes are sold with) to dedicated arch supports (e.g. viscoelastic wedges) and even heat-mouldable plastic insoles. Custom-made insoles (prescription foot orthotics) are available too.

I think that anything more elaborate than a simple foam-type insole (with a thickened foam arch section, such as those from Spenco) should be fitted only by someone experienced in this sort of work (for example an orthotist, pedorthist, or person of similar background). Foot biomechanics is a very complex topic, and even a small insert can significantly affect the person's gait (walking pattern). It is also helpful to discuss orthotics with a physiotherapist, given the gait implications.

Improperly chosen or inappropriately used arch supports and other off-the-shelf orthotic devices can, over time, cause considerable harm to feet, to knees, or to other musculoskeletal components such as the spine. The complexity of designing, fabricating and fitting foot orthotics is made even more involved by the daunting intricacy and continual evolution of modern footwear. In other words, a given arch support (or orthotic) will work differently in one type of shoe than in another. This is another reason why the services of a foot-orthotic professional are so valuable. (Custom-made insoles, as made by a professional, can be slightly different from side to side because most people's feet are not quite identical. But for someone whose foot shape and general leg alignment were symmetrical before a knee injury, it is safe to expect that a set of custom-made orthotics will be essentially symmetrical. The goal of prescription foot orthotics is to restore normal gait, and also to relieve pain resulting from gait abnormalities that could be the result of an injury history [such as ACL tearing and reconstruction, as in the case of your daughter].)

It is not feasible to remove genu valgum with the use of foot orthotics, since genu valgum is rooted in bone shape and bone alignment. However, if your daughter has a gait problem (which could easily be exacerbated by the knockkneedness), or if she has fallen arches or is flat footed, then foot orthotics can be enormously helpful. Therefore, I strongly recommend consulting a foot-orthotics expert. Foot orthotics can also be very helpful with certain knee-function problems in general, particularly if the problems are a lingering consequence of a ligament-injury history. (Knee Library resources on this topic include Donatelli-EKLR-Ch23-2000 and Butler-AJSM-Dec06, along with some other articles in the Biomechanics/Gait Dynamics/Knee Alignment section and also the Textbook Chapters and Female-Athlete sections.)

In addition to consulting a specialist in foot orthotics, it may be helpful to have your daughter's gait analyzed in a biomechanics laboratory (as some orthopedic-research-intensive hospitals and university kinesiology departments have). Such a computerized analysis would involve walking across force plates (pedobarographs, which record pressure of the each part of the foot during walking) and a three-dimensional video analysis of body movement (using infra-red markers at each joint, which are viewed by special infra-red cameras). Unfortunately, because the cost of such high-tech equipment is high, such gait-and-posture labs can be hard to find.

Yours truly,
Michael Frind.
Knee Library http://factotem.org/library

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