Certain foot and ankle disorders are more common in patients with special needs. The panelists cover specialized interpersonal approaches to these situations, as well as common pathology, orthotic adjustments, materials, and shoe compatibility, in order to suit the unique demands of this population.
What are the most common issues that require orthotics in a patient group with special requirements, according to your experience?
“Many of the biomechanical and structural issues we see in the special needs population are very similar to those we see in everyday practice,” Timothy Dutra, DPM, FACPM explains.
Fascite plantare, medial tibial stress syndrome, patellofemoral pain syndrome, posterior tibial tendonitis, and hallux limitus/rigidus are all common injuries and pathologies in these patients, according to Dr. Dutra.
Flexible flatfoot, either alone or in conjunction with hallux valgus, hallux varus, or posterior tibial tendinitis, is the most prevalent issue she sees in her special needs patients, according to Dianne Mitchell-Pray, DPM.
David Jenkins, DPM, FACFAS, identifies hyperflexibility as a fundamental cause of many of the disease that may require orthotic therapy, stating that his experience is primarily in persons with intellectual impairments (ID) such as Down syndrome and Fragile X syndrome.
“I say’may’ because many of our Special Olympics competitors have severe pes planus, hallux valgus, and other foot problems but nonetheless function as athletes with no pain or performance limits,” Dr. Jenkins notes.
Pes planus, brachymetatarsia with metatarsalgia, capsulitis, keratomas, and/or ulceration are all common in people with intellectual disability, according to his personal research. Patients with cerebral palsy may have contractures or severe cavus foot, which is the polar opposite of the problem. 1
When evaluating a patient with particular needs for orthotics, are there any parts of the biomechanical assessment that should be highlighted? What is the most difficult aspect of gait analysis and prescription orthotics for individuals like Special Olympics athletes?
Working with elite athletes, according to Karen Langone, DPM, DABPM, requires the practitioner to be more sensitive to the patients’ demands.
“When I’m with patients, I tend to be lively,” Dr. Langone says, “but I’ve found that being calm and soft spoken is frequently received better by special needs athletes.”
Gentle reassurance, illustration of what would happen during an examination, slow examination, and verbal assistance, according to Dr. Langone, have all been useful in giving these athletes a sense of comfort throughout their appointment. She also emphasizes the importance of making the exam enjoyable, creative, and engaging.
When severe hyperflexibility is present during the biomechanical assessment for patients with special needs, Dr. Jenkins says the clinician will instantly notice it and recommends relating it to the patient’s history to determine whether it is producing symptoms or performance concerns. He also mentions that substantial contractures in some athletes, as well as circumstances where the patient may not grasp directions, can be challenging. Dr. Jenkins recommends that the physician or coach (if present) grasp the patient’s hand while walking in certain scenarios.
“Some athletes believe that this is a wonderful moment to brag and be ridiculous!” Dr. Jenkins explains, “(They) may run, skip, or otherwise not walk in their normal gait.”
According to Dr. Jenkins, some athletes will have early heel-off and substantial abduction, while others will be heavily adducted and have tripping concerns.
Dr. Mitchell-Pray says she hasn’t noticed any notable differences in her approach in this section of the evaluation.
Dr. Mitchell-Pray says, “I do a comprehensive biomechanical exam and provide a lot of knowledge to the patients and their families, caregivers, and coaches.” “I also provide a lot of shoe information, but no more than I would for any other patient or family,” she says.
She does agree with Dr. Jenkins, however, that patients may choose to act stupid at that time, making gait analysis more difficult. She tells the physician to be patient and have fun with it, suggesting that the clinician engage in the fun and then redo that section of the test.
Do you have any specific orthotic prescribing or modification pearls for this patient population?
The majority of the panelists agree that correct footwear is critical to the effectiveness of any orthotic prescription for this demographic. Dr. Mitchell points out that the cost of both shoe gear and orthotics can be an issue. However, when choosing the correct orthotic for a patient, the practitioner should take into account the patient’s footwear.
According to Dr. Mitchell-Pray, she frequently orders large orthotics with deep heel cups and minimal arch fill. She might also think about adding a medial flange and possibly a navicular’sweet spot’ to increase the surface area of contact between the orthotic and the foot, which would improve proprioception and control.
Dr. Mitchell-Pray emphasizes the need of asking patients what they think the problem is and listening to their answers.
For patient comfort, Dr. Langone prefers semi-flexible devices and will frequently employ an antimicrobial top cover to help prevent tinea. She also asks the patient what color top cover they prefer in order to get him or her involved in the strategy.
Dr. Jenkins recommends treating any extreme pronation or calcaneal eversion with a more aggressive device with a deeper heel cup, maybe adding a Blake inversion or Kirby skive modification, if the doctor feels the patient could benefit from an orthotic.
Dr. Dutra frequently concentrates on the fit of the orthotic in the shoe. If the athlete plays in numerous sports, he should be aware that varied shoe gear may necessitate the use of additional orthotics. Dr. Dutra says he commonly utilizes a Cobra-style orthotic in spikes and smaller shoes. While this orthotic fits well in these shoes, according to Dr. Dutra, the low profile may result in a loss of biomechanical control.
In older athletes, he also recommends making his orthotics more flexible and adding a cushioned topcover, as well as waiting out the break-in time before making any changes.
“I think the most important tip is to approach your orthotic prescription and recommendations (for special needs patients) in the same way that you would for your (normally developed) athletic and sports medicine populations,” Dr. Dutra says.
Is a patient’s sensory processing condition taken into account while selecting materials?
The topcover and forefoot extensions of orthotics, according to Dr. Dutra, can play an important role in proprioceptive feedback. He goes on to say that the type of sports sock, as well as the shoe itself, especially the outer sole, are important factors to consider.
Because diabetes is more common in patients with intellectual disabilities, Dr. Jenkins says he’s rethinking how he assesses sensory state in these patients, including the possibility of loss of protective sensation (LOPS). He mentions that some research on the subject is currently underway.
According to Dr. Langone, her goal is to create a gadget that the athlete will find comfortable and willing to use. According to Dr. Langone, some patient-specific accommodations on materials may be required to attain this adherence.
Dr. Dutra is an Assistant Professor of Applied Biomechanics at Samuel Merritt University’s California School of Podiatric Medicine. He is a Fellow of the American College of Sports Medicine and a Past President of the American Academy of Podiatric Medicine. He is the Vice Chair of the Joint Commission on Sports Medicine and Science and a podiatric consultant for the University of California, Berkeley’s Intercollegiate Athletics.
Dr. Jenkins is a professor at Midwestern University’s Arizona School of Podiatric Medicine in Glendale, Arizona. He is a Fellow of the American Academy of Podiatric Sports Medicine and its Past President. He also serves as the Special Olympics Fit Feet Program’s Global Clinical Advisor.
Dr. Langone is a Co-Vice President of the American Association for Women Podiatrists and a Diplomate of the American Board of Podiatric Medicine. She is a Fellow of the American Academy of Podiatric Sports Medicine and its Past President. She works as a private practitioner in Southampton, New York.
Dr. Mitchell-Pray is board certified by the American Board of Podiatric Medicine and is a Fellow of the American Academy of Podiatric Sports Medicine. Mercy Medical Group, Inc. in Sacramento, California, is her private practice.
1. DW Jenkins, K Cooper, R O’Connor, L Watanbe, and C Wills. Structure, biomechanical, and dermatological findings of podiatric problems seen in Special Olympics participants. 2011;21(1):15-25 in Foot (Edinb).