SMOs vs. Orthotics!

When to Brace OVER and When to Brace UNDER the Ankle

By Dr. Louis J DeCaro, DPM

My patient comes in with SMOs. The patient has “apparent” ankle collapse as well as significant ligamentous laxity of the ankle. However, on examination today it is seen that the “ankle collapse” is heavily dependent on the foot needing to pronate from its neutral position, not the ankle collapsing itself.  The heel eversion, forefoot abduction, combined with Sub talar joint collapse and significant forefoot varus all contribute to seemingly “dragging down the ankle”. To illustrate this to the parent the patient is seen standing in both RCSP (relaxed stance) and then sub talar neutral (the natural structural position of the foot relative to the leg-holding the patient in by inverting the foot to mimic what a UCBL would do) stance. In STN stance it is seen that the ankle is much more erect illustrating the imperativeness of good FOOT control, not necessarily ankle control. Standing in the littleSTEPS orthotic (which offers 30mm depth heel cup for calcaneus and rear foot control, along with lateral clips ((decreasing abduction)) and medial skiff ((holding up the sustentaculum tali))) from my fitting kit reveals that the FOOT is actually controlling the collapse of the ankle, not the ankle collapsing itself. Often SMOs are uncomfortable or “rub” medially around the ankle due to lack of foot control. Focus is often placed on “trapping down” the ankle and ignoring what is actually controlling the ankle drop – the foot position. Many times multiple adjustments” and padding are tried to counter this but without foot control the device remains uncomfortable.  Sometimes (in this case) adequate foot control can actually allow the patient to not have to wear a device over the ankle. This allows much more freedom for the patient in gait as well as many more options for shoe fit and ease of wear.  Going forward littleSTEPS deep UCBL orthotic devices will be provided, which places the foot in a position of maximum efficiency for ambulation with the subtalar joint in neutral position and the mid-tarsal joint locked.  

Before and After child standing on littleSTEPS

Functional littleSTEPS UCBL orthotic devices help compensate for the underlying biomechanical abnormalities which lead to the structural deformities and their resulting symptoms.  To the parent, I explained how deep functional custom UCBL’s will help control the biomechanical abnormalities and reduce the progression of the multiple foot problems which could occur in the future and also continuation and furthering of all other involved upper extremity issues and systems. A more normal gait and ankle motion will allow upper kinetic chain muscles to fire more readily and symmetrically. Orthoses also can help prevent the potential need for surgical intervention possibly needed in the future by preventing unnecessary chronic foot collapse that can lead to a rigid flatfoot deformity.

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