Bracing with 

BOOTS & BAR

Congratulations on starting BNB! Wearing BNB is critical for treatment to be successful. Clubfoot will relapse, or come back, if a foot-abduction brace (FAB) is not implemented. A brace does not correct clubfoot. It  maintains the correction that was completed during the casting phase of treatment. Think about it like wearing a retainer after braces are worn. Not wearing BNB will compromise treatment. The boots, also referred to as AFOs, (ankle-foot orthoses) are only effective when attached to the bar.

INSURANCE

Iron out any possible insurance issues that may delay the start of BNB. 

Call your insurance directly and have them run the proper insurance billing codes to see what portion, if any, is covered. 

Codes:

Mitchell Boots: L 1930 (times two) | Ponseti Bar: L 2768, L 3150 | Dobbs Bar: L 2300, L 3150, L 2210

 

TUTORIALS

TUTORIALS

These tutorials are designed to assist you during the Boots and Bar phase

 

tips

 

Bar Width

The bar width (the distance between the inside edges of the heels of the boots) should be the width of the child’s shoulders. This distance is what is comfortable for the child and prevents knee or hip problems. If you lay the brace on the floor with the boots facing upward, the child’s shoulders should fit snugly in between the boots.

Sizing

Boots should fit in both length and width like shoes.  Boots that are too big or too small can cause skin issues.  A little room to grow is appropriate, but boots that are too big may cause friction and sores. The toes should meet or extend past the toe strap. The leather straps stretch over time, so tightening the straps as they stretch is necessary.

Placement of the Heel

The heel should be flat against the back of the boot.  It may take a few weeks for the heel to “drop” and sit flush in the boot. You should see *most* of the heel through the hole in the back of the boot. Make sure the heel is firmly planted in the bend of the boot, hold in position, and tighten the middle strap first. It's important not to force the heel unnecessarily as this can cause sores.

Degree of External Rotation (Abduction)

The boots should be at at an angle of either 60 or 70 degrees for a corrected clubfoot. If the child has an unaffected foot, the boot for that foot should be set to an angle of 30 or 40 degrees. (The last cast applied to a corrected clubfoot should have been rotated to 60 or 70 degrees.

*If the child has been diagnosed with atypical or complex clubfoot, the boot for the corrected clubfoot should be set to 20 or 30 degrees and worked up to 40 or 50 degrees.

Washing Mitchell Boots

  1. First, put the boots in a pillow case or mesh laundry sack for added protection.

  2. Gentle cycle.

  3. Warm water.

  4. Little or no soap.

  5. Add some towels to the load.

  6. Air dry (put in front of fan or in the sun for quicker dry time).

  7. Do not wash the bar.

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Protecting the Crib or Wall from the Brace

When children are in their brace at night, they may knock their brace on the side of their crib and wake themselves (or you) up. This can also damage the crib. There are a couple things you can do to avoid this and save your crib from boots and bar damage.

 

Crib Alternatives:

  • You can put the crib mattress on the floor until the child is in a toddler bed

  • Use a pack-n-play because it has soft sides.

 

Sleep Sacks and Pajamas:

  • Use a Sleep Sack

  • You can use footed pjs over the boots if you cut a slit at the bottom for the bar


Boot Covers:

Brace Bar Covers:

www.facebook.com/clubfootcover

Crib Bumpers:

NOTE: We suggest this option for older children to avoid the risk of SIDS

  • Regular crib bumpers

  • Mesh/breathable crib bumpers

  • "Bumpsters” Crib bumpers on Amazon

  • Wonder Bumpers: www.gomamagodesigns.com

  • A yoga mat to line the crib or protect the wall

  • Pool noodles

  • Chair seat pads to line the crib

  • 1 foot by 1 foot foam puzzle pieces mat to line the crib or protect the wall

  • Foam pipe insulation (tutorials below)

Preventing a Child from Removing Their Brace

  • Ensure the strap is woven through the silver buckle completely

  • Zip ties/cable ties

  • Twisty ties

  • Sleepsack (forward or backwards)

  • Wrap painters tape around the boots

  • Put a large sock over the boots, make a hole  in the heel for the bar

  • Put boots on opposite feet to make it more difficult for them (Mitchell boots are “straight last” boots meaning there is no curvature, thus, there is no left and right boot)

  • Footed pajamas over the boots, cut a hole for the bar

  • Coban (stretchy medical tape that sticks to itself)

  • Shoe lace covers (rubber band feel)

Swaddling while in braces is an option. An embe 2 way swaddle allows a legs in or a legs out option.

Difficulties Adjusting to Boots and Bar

  • It is critical that the feet are fully corrected prior to starting BNB.

  • There is an adjustment period with BNB.  Most experience an adjustment period of a few weeks where they are fussier than usual.

    • The skin is sensitive and the muscles are sore after casting

    • If your child is screaming nonstop and is unable to be soothed, call your doctor immediately.

  • Tylenol or Ibuprofen for the first week or so will help take the edge off while adjusting. (discuss with your pediatrician)

  • Wash Mitchell boots in the washing machine to soften the leather: put them in a pillow case first, gentle cycle, warm water, little or no soap, put some towels in the washer with them, air dry only, don’t wash the bar

  • Have baby sleep in bouncer, rock ‘n play, or swing while adjusting

  • Prop feet up with a boppy pillow or rolled up towel

  • Put BNB on about an hour prior to bed time so child can adjust

  • Boots should fit like shoes in both length and width.  Boots too small or too big may cause concern. 

  • Check the length of the bar, which should be the length of the child’s shoulders.

  • Play with your baby while they are in BNB to show them they can move their feet around with the bar on.

  • Lots of holding, cuddling, bottle feeding/nursing

Feet Slip Out of Boots:

  • It’s important to ensure the foot is fully corrected prior to starting BNB

  • Criss cross the top 2 straps

  • Tighten straps

  • Try socks with non-slip grip

  • If the foot continues to slip out of the boot after you've tried these suggestions, call you doctor/orthotist

Sores: 

  • A fully corrected foot, proper fitting boots and appropriate socks will help to prevent foot sores. 

  • Red marks are common.   

  • Aim to prevent any sore from becoming open and infected. 

  • Moleskin, Molefoam, blister band aids, and Duoderm may help too.  Bacitracin ointment on an open wound may help.

  • Pressure Saddles, aka “pringles” is a small piece of silicone that helps to distribute the pressure on the top of the foot that may be created by the middle buckle on the boot (www.mdorthopaedics.com) or sheepskin sewn to the tongue by your orhtotist or a local shoe cobbler helps also for preventing sores from the tightness of the middle strap.

  • Put baby powder/corn starch in socks to alleviate friction

  • Ingrown toenails may happen.  Typically, this is with the big toe.  In the event of an ingrown toenail, let them grow out and keep them a little and cut them straight across.  Do this long so the corner of the nail doesn't start digging into the skin.  (see image to the right)

 

 

 

 

 

 

 

 

*References:  www.mdorthopaedics, www.ponseti.info, clubfoot families, medical practitioners, and the book The Parents’ Guide to Clubfoot by Betsy Miller. *

Sheepskin

Sheepskin sewn or glued under the tongue can help to prevent redness

E6000 is a brand of glue recommended to glue the sheepskin down.  It can be purchased at Wal Mart, Amazon, or a craft store 

A local shoe cobbler/repairman, or seamstress can sew the sheepskin to the tongue 

 

Options to purchase:

*Disclaimer*

The information compiled is from clubfoot family experiences, and the medical community. Doctors and those in the medical field have opinions that may differ. This document is not a substitute for professional medical advice. Consult your doctor with questions. Every clubfoot situation and every clubfoot child's treatment plan may differ slightly.

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