Re: unsure of next step-a little confused

March 3, 2006

Oh, Halley I am so sorry you are going through this. Do you believe

her feet are corrected or over corrected? I just think that if you

believe everything is fine you wouldn't have emailed Dr. Ponseti.

We stayed with our first Dr. for 14 months not knowing if things

were being done right, they were not. I don't think I will be much

help, but I would say follow your motherly insict. Do you have the

pics you sent to Dr. Ponseti? Would like to see them. You can send

them to me directly if needed. Well take care and let us know what

you decide.

Tabitha

Brittanie 6 years

Karter 19 months blcf

>

> Hello,

>

> I posted a few weeks ago about how I had e-mailed both Dr.

Morcuende and Dr.

> Ponseti pictures of Keira's foot. Dr. Morcuende said they

looked " nicely

> corrected " while Dr. Ponseti said that he thinks that they may be

atypical

> and that he believes that her forefoot is too hyperabducted. He

couldn't

> confirm if they were atypical as I didn't have a picture of the

sole of her

> foot prior to treatment for his reference. He recommended getting

the

> brace (we just ordered this) and reducing degree of

abduction to no

> more than 30 degrees.

>

> I send him a follow up e-mail to ask about the impact of reducing

abduction

> as it relates to maintaining a full range of motion as well as

allowing for

> some natural regression of the foot. I will post the last two

replies from

> Dr. Ponseti below. I don't know if it's just me, but they seem a

bit

> contradictory with the first saying that no casting should be done

until we

> see how she responds to brace and the next one saying one or two

more casts

> needed before the brace. I know it's hard for Dr. Ponseti to see

what is

> going on with a foot via pictures over the internet especially

since I'm not

> a great photographer. I will also post the e-mail from Keira's

doctor, Dr.

> in response to the first e-mail from Dr. Ponseti.

>

> February 13, 006

>

> Yes, I would like to see photos of Keira's foot at birth. In the

atypical

> clubfoot at birth there is involvement mostly in the calf muscle

and the

> deep plantar intrinsic muscles of the foot. Only about 3-4% of

all clubfeet

> are atypical. Possibly your doctor has never treated one before.

The

> turning in of the foot and ankle tends to correct fairly easily

but then the

> forefoot goes into excessive abduction because the metatarsals are

bent

> downwards and the ligaments and joints in the middle of the foot

are loose.

> The tendo Achilles is tight and this was probably corrected with

the

> tenotomy performed by your doctor. If there is persistent

tightness of this

> tendon, it usually improves with time and the foot hyperabduction

also

> improves in time with the use of the brace.

>

> We have written a paper outlining the proper treatment for the

atypical

> clubfoot which we hope will be published in Clinical Orthopaedics

and

> Related Research.

> Last year when I talked to Dr. Pirani about this, he had not yet

been called

> upon to treat one. I think you should see Dr. . When you

get the

> shoes, the right shoe should be turned out 20-30 degrees

but no

> more. The foot will be nearly straight on the bar so the

metatarsus

> adductus will improve. The left shoe should be in about 30

degrees of

> abduction as well. It would be best not to apply another cast

until you see

> how the foot responds to the brace.

>

> Please encourage Dr. to contact me by phone (319 356-

3469) or

> e-mail if he would like to discuss Keira's treatment.

>

> I.V. Ponseti, M.D.

>

> March 1, 2006

>

> The picture shows this is an atypical clubfoot. These feet have

very tight,

> shortened plantar intrinsic muscles which cause the crease on the

sole of

> the foot and they also have a tight heelcord. The muscles on the

inner side

> of the leg, the posterior tib and flexors of the toes, are easily

stretched

> so the foot should not be overabducted. The hindfoot is already

in 10

> degrees of valgus. The child needs another cast or two in 20

degrees of

> abduction and dorsiflexing all of the metatarsals with both thumbs

with

> counterpressure applied by firmly holding the knee in 90 degrees

of flexion.

> The foot should be dorsiflexed simultaneously both at the midfoot

(Lisfranc

> line) and at the heel to correct the cavus and equinus. A

heelcord tenotomy

> may be necessary before the last cast is applied dorsiflexion is

limited to

> less than 10 degrees. These feet tend to improve with time and

the calf

> muscles become more relaxed when the child begins walking in the

> brace. The shoes should be in about 20 (and not more than 30)

degrees of

> outward rotation and the bar should be straight, not bent up at

the ends.

> The child should be encouraged to stand in the brace.

>

> If you put the foot at 70 degrees of abduction, the crease on the

outside

> border of the foot will not go away. This crease indicates the

metatarsals

> are overabducted at the Lisfranc line. This is why the shoes

should only be

> at 20-30 degrees of outward rotatiion.

>

> I.V. Ponseti

>

> Hi Ms Prestage

>

> Thanks for your email. I am always interested to hear comments

from others,

> especially Dr. Ponseti.

>

> I believe Keira's foot is well corrected now a Pirani 0 versus 6

when we

> started. As well it is very flexible and achieves ankle flexion

towards the

> leg of about 15 - 20 degrees (dorsiflexion) after the heel cord

tenotomy

> which I am happy with. It is sometimes difficult to get a full

appreciation

> of the foot from non-standardized pictures over email.

>

> As for the comments regarding too much outward rotation of the

foot, I would

> not be against decreasing the outward rotation somewhat as per Dr.

Ponseti's

> suggestion. I am also happy for you to choose the shoes as

> mentioned. We at the Alberta Children's Hospital have had great

success with

> the shoes as you have now but it can be your choice.

>

> Just as an aside, Dr. Ponseti would be happy to know I trained

with one of

> his former fellows, Dr. Haemish Crawford, who performs his

technique

> exactly. I also try to do this.

>

> Try not to worry. The foot is well corrected and we should have

good results

> in the long term if we stick with the foot abduction orthosis. If

you would

> like, I could see you sooner than our scheduled appointment to

discuss the

> shoes.

>

> Yours sincerely,

>

> So, I was thinking of forwarding the last e-mail from Dr. Ponseti

to Dr.

> to see what he thinks of this. Dr. seems to think

her foot

> looks great but then maybe he hasn't dealt with an atypical foot

before.

> Speaking of atypical, I am not sure anyone knows if Keira's foot

was

> atypical or not..even Dr. Ponseti said that he would need to see

pictures of

> the plantar surface of her foot to determine this.

>

> Sorry this is so long..but I am sort of vexed by all of this.

Maybe I should

> just go to Iowa and call it a day! Should I let Dr. have

another go?

> Ultimately, I'd like Dr. to phone/e-mail Dr. Ponseti but I

don't want

> to appear to impugn his expertise in this either kwim?

>

> Anyway, I would love to hear some feedback if you have time to

read this

> long e-mail!

>

> Thanks!

>

> Halley

>

March 3, 2006

Halley,

This is my impression based on what you've shared with us...

It seems like Dr. is very caring and supportive of

you...understanding your concerns and trying to work with you as

a " partner " not dictating to you at all.

I think that he would probably be happy to call Dr. Ponseti and

discuss Keira's foot (what he sees and physically feels) with Dr.

Ponseti directly if you'd ask him to. It is hard to make

recommendations and diagnose via photographs...so perhaps if Dr. P

is able to talk with Dr. and tell him what to look for, it

will be the quickest route to giving you that peace of mind......or

helping you decide if you should take a trip to see Pirani or

Ponseti!

Tell Dr. that you would be grateful if he would call Dr.

Ponseti directly to discuss Keira's case. He seems to be very

sincere and would probably be willing to do this for you! The best

time to reach Dr. P is 2:30-3pm Central time on M, W, & F.

Hugs!

>

> Hello,

>

> I posted a few weeks ago about how I had e-mailed both Dr.

Morcuende and Dr.

> Ponseti pictures of Keira's foot. Dr. Morcuende said they

looked " nicely

> corrected " while Dr. Ponseti said that he thinks that they may be

atypical

> and that he believes that her forefoot is too hyperabducted. He

couldn't

> confirm if they were atypical as I didn't have a picture of the

sole of her

> foot prior to treatment for his reference. He recommended getting

the

> brace (we just ordered this) and reducing degree of

abduction to no

> more than 30 degrees.

>

> I send him a follow up e-mail to ask about the impact of reducing

abduction

> as it relates to maintaining a full range of motion as well as

allowing for

> some natural regression of the foot. I will post the last two

replies from

> Dr. Ponseti below. I don't know if it's just me, but they seem a

bit

> contradictory with the first saying that no casting should be done

until we

> see how she responds to brace and the next one saying one or two

more casts

> needed before the brace. I know it's hard for Dr. Ponseti to see

what is

> going on with a foot via pictures over the internet especially

since I'm not

> a great photographer. I will also post the e-mail from Keira's

doctor, Dr.

> in response to the first e-mail from Dr. Ponseti.

>

> February 13, 006

>

> Yes, I would like to see photos of Keira's foot at birth. In the

atypical

> clubfoot at birth there is involvement mostly in the calf muscle

and the

> deep plantar intrinsic muscles of the foot. Only about 3-4% of

all clubfeet

> are atypical. Possibly your doctor has never treated one before.

The

> turning in of the foot and ankle tends to correct fairly easily

but then the

> forefoot goes into excessive abduction because the metatarsals are

bent

> downwards and the ligaments and joints in the middle of the foot

are loose.

> The tendo Achilles is tight and this was probably corrected with

the

> tenotomy performed by your doctor. If there is persistent

tightness of this

> tendon, it usually improves with time and the foot hyperabduction

also

> improves in time with the use of the brace.

>

> We have written a paper outlining the proper treatment for the

atypical

> clubfoot which we hope will be published in Clinical Orthopaedics

and

> Related Research.

> Last year when I talked to Dr. Pirani about this, he had not yet

been called

> upon to treat one. I think you should see Dr. . When you

get the

> shoes, the right shoe should be turned out 20-30 degrees

but no

> more. The foot will be nearly straight on the bar so the

metatarsus

> adductus will improve. The left shoe should be in about 30

degrees of

> abduction as well. It would be best not to apply another cast

until you see

> how the foot responds to the brace.

>

> Please encourage Dr. to contact me by phone (319 356-

3469) or

> e-mail if he would like to discuss Keira's treatment.

>

> I.V. Ponseti, M.D.

>

> March 1, 2006

>

> The picture shows this is an atypical clubfoot. These feet have

very tight,

> shortened plantar intrinsic muscles which cause the crease on the

sole of

> the foot and they also have a tight heelcord. The muscles on the

inner side

> of the leg, the posterior tib and flexors of the toes, are easily

stretched

> so the foot should not be overabducted. The hindfoot is already

in 10

> degrees of valgus. The child needs another cast or two in 20

degrees of

> abduction and dorsiflexing all of the metatarsals with both thumbs

with

> counterpressure applied by firmly holding the knee in 90 degrees

of flexion.

> The foot should be dorsiflexed simultaneously both at the midfoot

(Lisfranc

> line) and at the heel to correct the cavus and equinus. A

heelcord tenotomy

> may be necessary before the last cast is applied dorsiflexion is

limited to

> less than 10 degrees. These feet tend to improve with time and

the calf

> muscles become more relaxed when the child begins walking in the

> brace. The shoes should be in about 20 (and not more than 30)

degrees of

> outward rotation and the bar should be straight, not bent up at

the ends.

> The child should be encouraged to stand in the brace.

>

> If you put the foot at 70 degrees of abduction, the crease on the

outside

> border of the foot will not go away. This crease indicates the

metatarsals

> are overabducted at the Lisfranc line. This is why the shoes

should only be

> at 20-30 degrees of outward rotatiion.

>

> I.V. Ponseti

>

> Hi Ms Prestage

>

> Thanks for your email. I am always interested to hear comments

from others,

> especially Dr. Ponseti.

>

> I believe Keira's foot is well corrected now a Pirani 0 versus 6

when we

> started. As well it is very flexible and achieves ankle flexion

towards the

> leg of about 15 - 20 degrees (dorsiflexion) after the heel cord

tenotomy

> which I am happy with. It is sometimes difficult to get a full

appreciation

> of the foot from non-standardized pictures over email.

>

> As for the comments regarding too much outward rotation of the

foot, I would

> not be against decreasing the outward rotation somewhat as per Dr.

Ponseti's

> suggestion. I am also happy for you to choose the shoes as

> mentioned. We at the Alberta Children's Hospital have had great

success with

> the shoes as you have now but it can be your choice.

>

> Just as an aside, Dr. Ponseti would be happy to know I trained

with one of

> his former fellows, Dr. Haemish Crawford, who performs his

technique

> exactly. I also try to do this.

>

> Try not to worry. The foot is well corrected and we should have

good results

> in the long term if we stick with the foot abduction orthosis. If

you would

> like, I could see you sooner than our scheduled appointment to

discuss the

> shoes.

>

> Yours sincerely,

>

> So, I was thinking of forwarding the last e-mail from Dr. Ponseti

to Dr.

> to see what he thinks of this. Dr. seems to think

her foot

> looks great but then maybe he hasn't dealt with an atypical foot

before.

> Speaking of atypical, I am not sure anyone knows if Keira's foot

was

> atypical or not..even Dr. Ponseti said that he would need to see

pictures of

> the plantar surface of her foot to determine this.

>

> Sorry this is so long..but I am sort of vexed by all of this.

Maybe I should

> just go to Iowa and call it a day! Should I let Dr. have

another go?

> Ultimately, I'd like Dr. to phone/e-mail Dr. Ponseti but I

don't want

> to appear to impugn his expertise in this either kwim?

>

> Anyway, I would love to hear some feedback if you have time to

read this

> long e-mail!

>

> Thanks!

>

> Halley

>

March 3, 2006

Halley,

Agreeing with here, I would probably share Dr. Ponseti's email

with Dr. and tell him you understand it is difficult to

diagnose via pictures but you still have some nagging questions based

on Dr. Ponseti's comments. And just ask him if he would mind calling

Dr. Ponseti and discussing Kiera's foot directly, just to put your

mind at ease. Sounds like Dr. is really dedicated and caring

and should not be put out by this if you approach him sensitively.

He is probably fully capable of correcting the issues that Dr. P sees

based on what is in this email, and I'm sure he will do so if the

diagnosis based on the photos is correct. He does seem to feel that

her foot is corrected properly but he might be able to reassess after

hearing exactly what Dr. P had to say.

Hope this helps,

> >

> > Hello,

> >

> > I posted a few weeks ago about how I had e-mailed both Dr.

> Morcuende and Dr.

> > Ponseti pictures of Keira's foot. Dr. Morcuende said they

> looked " nicely

> > corrected " while Dr. Ponseti said that he thinks that they may be

> atypical

> > and that he believes that her forefoot is too hyperabducted. He

> couldn't

> > confirm if they were atypical as I didn't have a picture of the

> sole of her

> > foot prior to treatment for his reference. He recommended

getting

> the

> > brace (we just ordered this) and reducing degree of

> abduction to no

> > more than 30 degrees.

> >

> > I send him a follow up e-mail to ask about the impact of reducing

> abduction

> > as it relates to maintaining a full range of motion as well as

> allowing for

> > some natural regression of the foot. I will post the last two

> replies from

> > Dr. Ponseti below. I don't know if it's just me, but they seem a

> bit

> > contradictory with the first saying that no casting should be

done

> until we

> > see how she responds to brace and the next one saying one or two

> more casts

> > needed before the brace. I know it's hard for Dr. Ponseti to see

> what is

> > going on with a foot via pictures over the internet especially

> since I'm not

> > a great photographer. I will also post the e-mail from Keira's

> doctor, Dr.

> > in response to the first e-mail from Dr. Ponseti.

> >

> > February 13, 006

> >

> > Yes, I would like to see photos of Keira's foot at birth. In the

> atypical

> > clubfoot at birth there is involvement mostly in the calf muscle

> and the

> > deep plantar intrinsic muscles of the foot. Only about 3-4% of

> all clubfeet

> > are atypical. Possibly your doctor has never treated one

before.

> The

> > turning in of the foot and ankle tends to correct fairly easily

> but then the

> > forefoot goes into excessive abduction because the metatarsals

are

> bent

> > downwards and the ligaments and joints in the middle of the foot

> are loose.

> > The tendo Achilles is tight and this was probably corrected with

> the

> > tenotomy performed by your doctor. If there is persistent

> tightness of this

> > tendon, it usually improves with time and the foot hyperabduction

> also

> > improves in time with the use of the brace.

> >

> > We have written a paper outlining the proper treatment for the

> atypical

> > clubfoot which we hope will be published in Clinical Orthopaedics

> and

> > Related Research.

> > Last year when I talked to Dr. Pirani about this, he had not yet

> been called

> > upon to treat one. I think you should see Dr. . When you

> get the

> > shoes, the right shoe should be turned out 20-30 degrees

> but no

> > more. The foot will be nearly straight on the bar so the

> metatarsus

> > adductus will improve. The left shoe should be in about 30

> degrees of

> > abduction as well. It would be best not to apply another cast

> until you see

> > how the foot responds to the brace.

> >

> > Please encourage Dr. to contact me by phone (319 356-

> 3469) or

> > e-mail if he would like to discuss Keira's treatment.

> >

> > I.V. Ponseti, M.D.

> >

> > March 1, 2006

> >

> > The picture shows this is an atypical clubfoot. These feet have

> very tight,

> > shortened plantar intrinsic muscles which cause the crease on the

> sole of

> > the foot and they also have a tight heelcord. The muscles on the

> inner side

> > of the leg, the posterior tib and flexors of the toes, are easily

> stretched

> > so the foot should not be overabducted. The hindfoot is already

> in 10

> > degrees of valgus. The child needs another cast or two in 20

> degrees of

> > abduction and dorsiflexing all of the metatarsals with both

thumbs

> with

> > counterpressure applied by firmly holding the knee in 90 degrees

> of flexion.

> > The foot should be dorsiflexed simultaneously both at the midfoot

> (Lisfranc

> > line) and at the heel to correct the cavus and equinus. A

> heelcord tenotomy

> > may be necessary before the last cast is applied dorsiflexion is

> limited to

> > less than 10 degrees. These feet tend to improve with time and

> the calf

> > muscles become more relaxed when the child begins walking in the

>

> > brace. The shoes should be in about 20 (and not more than 30)

> degrees of

> > outward rotation and the bar should be straight, not bent up at

> the ends.

> > The child should be encouraged to stand in the brace.

> >

> > If you put the foot at 70 degrees of abduction, the crease on the

> outside

> > border of the foot will not go away. This crease indicates the

> metatarsals

> > are overabducted at the Lisfranc line. This is why the shoes

> should only be

> > at 20-30 degrees of outward rotatiion.

> >

> > I.V. Ponseti

> >

> > Hi Ms Prestage

> >

> > Thanks for your email. I am always interested to hear comments

> from others,

> > especially Dr. Ponseti.

> >

> > I believe Keira's foot is well corrected now a Pirani 0 versus 6

> when we

> > started. As well it is very flexible and achieves ankle flexion

> towards the

> > leg of about 15 - 20 degrees (dorsiflexion) after the heel cord

> tenotomy

> > which I am happy with. It is sometimes difficult to get a full

> appreciation

> > of the foot from non-standardized pictures over email.

> >

> > As for the comments regarding too much outward rotation of the

> foot, I would

> > not be against decreasing the outward rotation somewhat as per

Dr.

> Ponseti's

> > suggestion. I am also happy for you to choose the shoes

as

> > mentioned. We at the Alberta Children's Hospital have had great

> success with

> > the shoes as you have now but it can be your choice.

> >

> > Just as an aside, Dr. Ponseti would be happy to know I trained

> with one of

> > his former fellows, Dr. Haemish Crawford, who performs his

> technique

> > exactly. I also try to do this.

> >

> > Try not to worry. The foot is well corrected and we should have

> good results

> > in the long term if we stick with the foot abduction orthosis. If

> you would

> > like, I could see you sooner than our scheduled appointment to

> discuss the

> > shoes.

> >

> > Yours sincerely,

> >

> > So, I was thinking of forwarding the last e-mail from Dr. Ponseti

> to Dr.

> > to see what he thinks of this. Dr. seems to think

> her foot

> > looks great but then maybe he hasn't dealt with an atypical foot

> before.

> > Speaking of atypical, I am not sure anyone knows if Keira's foot

> was

> > atypical or not..even Dr. Ponseti said that he would need to see

> pictures of

> > the plantar surface of her foot to determine this.

> >

> > Sorry this is so long..but I am sort of vexed by all of this.

> Maybe I should

> > just go to Iowa and call it a day! Should I let Dr. have

> another go?

> > Ultimately, I'd like Dr. to phone/e-mail Dr. Ponseti but I

> don't want

> > to appear to impugn his expertise in this either kwim?

> >

> > Anyway, I would love to hear some feedback if you have time to

> read this

> > long e-mail!

> >

> > Thanks!

> >

> > Halley

> >

March 4, 2006

Hi Tabitha,

I can't really tell if her feet look the way they should, to be honest. I do

see the small lateral crease but Dr. Morcuende said it should go away over

time and Dr. has seen it and didn't say anything about it. I e-mailed

Dr. Ponseti because I want to make sure it is correct and thought I might as

well see what the expert has to say. I will send you some pictures of

Keira's foot. I am embarrassed to say that after several attempts to shrink

them, I still haven't figured it out. I thought I was shrinking them and

then when I sent the test e-mail to myself, the pictures were GIANT!

I'll try to send them a little later.

Thanks!

Halley