When in doubt

Where we started: 

 Pearl was born with severe atypical bilateral clubfoot. Many children with feet like hers have underlying neuromuscular or connective tissue issues that are hard to pinpoint or the clubfoot is connected to another syndrome like tethered spinal cord. Pearl's gluteal cleft is asymetrical and we are waiting until she is about a year old to evaluate for possible tethered cord. Next week, we see a geneticist to evaluate whether or not we have a connective tissue disorder that could be connected to her feet. She has good range of motion and flexibility now, and I have no doubt the brace has played a vital role in that. The brace also continued to correct her feet after the casts came off following the tenotomy (heel cord release). We've monitored her progress with x-rays and photos. She sees a physical therapist each week who assesses her flexibility. Recently, I became concerned because the creases on the bottoms of her feet are persisting. I took her to the local orthopedist and he doesn't think she needs casts but he was concerned that she didn't have enough external rotation of her feet to properly stretch the Achilles tendon (relapses occur because the tendon gets too tight during growth spurts). He also commented that braces can't or aren't intended to correct feet only hold correction. He is correct to an extent. The traditional boots and bar brace does not correct feet. It was designed to hold correction made from casting the feet. The DTKAFO brace is different.

Venting Side bar: I gave him the technical paper on the brace, x-rays, pictures and contact information for Cunningham Prosthetic back in April. It is clear to me that he didn't look at any of that information and doesn't care. He suggested we switch to the traditional brace more than once in the 20 minutes we were in his office. I've heard of doctors reporting mothers to CPS for choosing not to use the traditional brace and babies being blacklisted from every orthopedist in a state for the same reason. Certain vendors of orthopedic braces are now refusing to sell components for alternative braces due to pressure from a handful of influential physicians. Progress is stifled by such resistance. A recent study indicates that baby feet adapt quickly to changes made by casts and that a week long casting period isn't necessary (they placed pressure sensors in the casts). The results indicate that casts could be applied over a shorter period of time, reducing treatment time from 2-3 months to about one month. The study also discussed how a brace could be designed to do the correction based on that information. When the researchers approached orthopedists in their country about it, they were dismissed. 

Progress and where we are now: Pearl started wearing braces in December 2017. After only 3 weeks we began to see improvement in her feet and it was clear that the braces were correcting her feet. We took x-rays at the beginning of bracing and after two months and will take them again soon. Those are discussed in a previous post. While the braces have helped, and other moms have told me feet like these are a process, I began to wonder if we'd reached a plateau with correction and talked to Jerald about making adjustments to the braces to help continue her progress. When I work on her feet I can stretch the plantar surfaces so that the bottoms of her feet become flat and the creases almost completely disappear. When she stands on them, they flatten out properly as well. Her heels are slowly dropping into place which is also a common issue with clubfoot babies. They often have "empty" heels because the bone that belongs in the hind foot is elevated inside the foot and out of position.

I asked Jerald if we could modify the foot bed to
 provide that plantar stretch while also adding more force to abduct her feet outward (think duck walking). We sent the braces via fedex on Wednesday and received them today. The foot bed has been modified to extend her feet outward and a wedge has been placed at the front of the foot bed to raise her metatarsals to stretch the bottom of her foot. The straps were modified to facilitate this stretch as well. We are taking the braces off every two hours to check for pressure points and red skin and to give her time to adjust to increased stretching and changes in sensations in her feet.

Why the status quo isn't good enough: There is no cure for clubfoot. It is caused by a change in the cellular structures of connective tissue, muscle fibers and how those tissues are enervated and receive blood and nutrients. Adults with clubfoot are more likely to develop arthritis and this is exacerbated by scar tissue from surgeries and lack of flexibility in the feet. Some adults experience such debilitating pain that they end up in wheel chairs or opt to amputate. The research on success rates in the traditional brace is skewed because they don't follow patients long enough, counting successes as no relapse up to age 5. In reality, children should be followed through puberty. I am certain Pearl would not have tolerated the traditional brace and she would not have the range of motion she has now if we used the static boots and bar. Stay tuned to see how the latest modifications to her braces make a difference.

It takes a village: early interventions and clubfoot

Clubfoot is the most common birth defect, yet it is commonly misunderstood by practitioners and families caring for children with the condition. There is no cure for clubfeet. The deformity is caused by mutations in DNA that result in changes in how connective tissue, muscle fibers, fatty tissue, capillaries and nerve endings are laid down in the feet. Even after stretching casts and tenotomy, the anatomy of the foot predisposes it to changes in form and function. Studies indicate that the forces applied to feet during walking are distributed differently in clubfeet compared to normal feet. These changes in pressure distribution affect gait and how children stand (Pauk, J., Daunoraviciene, K., Ihnatouski, M., Griskevicius, J., & Raso, J., 2010).

The function of the foot impacts the biomechanics of the leg, knee and hip. Dysfunction in the foot can lead to lower limb, knee and upper limb/hip/lower back injury or pain (McClay, I., & Manal, K., 1997, Dananberg, H., & Guiliano, M., 1999). When clubfoot is treated, attention should be given to the entire leg and lower back. One of the reasons we decided to use the DTKAFO brace is because we believed the brace would be more ergonomic and would be an effective tool for treating the leg and foot system affected by the clubfoot deformity.

Any type of device that is used to support parts of our bodies can have a negative side effect of weakened muscles or compensation for lack of use by other parts of the body. Bracing wear time schedules for traditional braces and for the DTKAFO factor this in. It’s a fine balance between optimal brace time for maintaining correction and brace free time for muscle development and gross motor skill development. Pearl is struggling a little with reaching certain gross motor benchmarks. 

We are working with a physical therapist who taught us how to position Pearl when she is sitting to help her learn to transition into a crawling position. We practice this with the braces off and on. We also position her in standing positions, holding onto to sides of chest high boxes or toys both in her braces and out. We stretch and massage her feet and lower legs every day. An occupational therapist visits her every other week to monitor how Pearl uses her hands and wrists. We also used stretching and massage along with a splint to correct the deformity in her hands. Yesterday, we met with another occupational therapist who specializes in how babies and children eat. She taught us some strategies to help Pearl learn to eat properly. Pearl is struggling with how to use her tongue and mouth to push food back and swallow it.

All of these specialists come to our home or the daycare. In the US, the federal government allocates money for each state and territory to provide services to children with disabilities between the ages of 0-3. These early intervention services provide families with access to therapy, adaptive devices, and other services in the home or the daycare. This program is a powerful tool for helping children reach significant growth and development benchmarks. If the providers didn’t visit Pearl at home or at the day care, we would need to travel an hour each way to visit a therapist. This program removes barriers to access to care for many families.

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In addition to the specialists we see through early intervention services, we Skype monthly with Jerald Cunningham, reviewing her progress in the DTKAFO brace. Last month, our physical therapist joined in on the call as well. Jerald is able to troubleshoot issues with the brace during these video calls. We’ve modified the brace twice via Skype call making adjustments specific to Pearl’s feet. Pearl’s teachers at the daycare are also a critical part of this team. They follow the therapy routines when Pearl is with them.

There are many uncertainties ahead of us. Pearl’s feet were under-corrected when we started bracing. The brace is correcting her feet, which a traditional brace cannot do. But the brace may only be able to correct her feet to a certain point and we will need further stretching casts or other interventions. Pearl may need speech therapy, she might also have a tethered spinal cord. Those two things we will revisit closer to her first birthday. In June, I will be evaluated by a geneticist to determine if Ehlers Danlos is also part of Pearl and my medical stories.

All of it can be overwhelming, worrying about her feet and a relapse, wondering if there are other underlying medical issues, stressing out about her being behind with some of her growth and developmental benchmarks, sticking to the stretching and massage routine even when exhausted. Our caseworker reminded us that Pearl has been through a lot already in her life and playing catch-up with reaching certain benchmarks is to be expected. I am grateful for the support we have from the specialists we work with, family, friends and other families who also have children with clubfoot. 

References: 

Dananberg, H. J., & Guiliano, M. (1999). Chronic low-back pain and its response to custom-made foot orthoses. Journal of the American Podiatric Medical Association, 89(3), 109-117.

McClay, I., & Manal, K. (1997). Coupling parameters in runners with normal and excessive pronation. Journal of Applied Biomechanics, 13(1), 109-124.

Pauk, J., Daunoraviciene, K., Ihnatouski, M., Griskevicius, J., & Raso, J. (2010). Analysis of the plantar pressure distribution in children with foot deformities. Acta Bioeng Biomech, 12(1), 29-34.

New brace

Once the decision to continue bracing had been made, we had to gather a few utensils before planning another Skype appointment with Jerald to take Jonas's measurements. Since we were looking to avoid the trip to the US, we needed a seamstress tape measure and calipers to get precise measurement of Jonas's leg, tibia and foot (length, width and thickness).

Easter came and went, soon followed by Jonas's second birthday. Needless to say that the boy was spoilt rotten with a day trip to a local petting farm and more presents he can actually play with!

His new brace arrived on 24th April. It looked soooo CLEAN!! I'd actually forgotten it was meant to be bright white, not greyish 😅. I was eager to know whether it would fit or not. It looked just as small as his current one and pretty tight.

I knew the plastic would obviously stretch but I wondered why the brace wasn't any wider than the other one. Due to the time difference and Jerald's busy schedule, I couldn't get a hold of Jerald straight away so decided to slip it on and see.

I struggled a bit and had to take away most of the padding Jerald had stuck to the lower spiral, but eventually found a way and the fit looked absolutely perfect. The brace is a lot stronger and easily got Jonas's foot to those 45° external rotation we were aiming for, whilst not bothering him in the slightest.

I took a few pictures and sent them to Jerald. 

A few hours later, I got a reply, saying that indeed the brace looked perfect, and I should get Jonas used to the new stretch by using the brace a few hours here and there over the next few days, before going for his normal nap and night-time wear schedule.

Ooooops... Jonas had been asleep for a good couple of hours then...
Oh well... From day 1, back at the end of November 2016, the brace became a simple extension of his leg, I guess the added stretch must not have felt uncomfortable to him, he slept through his usual 12 hours and woke up with a smile.

Finding Our Feet: Bracing progress and daily routines

 The other day, our orthopedist said the goal of clubfoot treatment is to get a functional foot that can  fit properly into a shoe without pain. He said, at this point we'd reached that goal and Pearl could comfortably wear shoes.

Shoes.....I donated all of her shoes after we learned she had clubfeet. I knew she'd be in casts until she was three months old and braces 23 hours a day until she is about 1 year old. And then she can wear shoes because bracing will only happen while she's sleeping. But even then, I wonder if we will use reverse last shoes, which are specifically made for children with orthopedic issues. I wore them for in-toeing when I was a toddler. These shoes will help keep her feet turned outward, one more intervention to hopefully prevent relapse.

We traveled half way across the US for her
casting, tenotomy and braces. Her feet came out of casts in December and I was heart broken when I saw them. I knew right then that her feet weren't fully corrected. Her feet are atypical and she is at greater risk for relapse and failed treatment. Traditionally, a child in her situation would have additional stretching casts and another tendon release. I asked if we could see if the brace could be modified to continue to correct her feet. While it isn't advisable to brace when feet are not fully corrected, we did it anyway. Ultimately it was our decision. The x-rays show that the brace is working! Her bones are aligning properly and there is less flexion in the mid foot. She still has creases on the bottom of her feet. I suspect those will be there for several years. But her feet are pliable and have great flexibility. When the braces were made, she had 5 degrees of dorsiflexion in her right foot and 0 in the left. She is now at a 12 in the right and 7-10 degrees in the left. The braces were modified to facilitate the realignment of her forefoot and mid foot so that the entire foot will position properly under the tibia.

She is learning to stand and starting to take her first steps in the braces and out of the braces. We see a physical therapist once a week and we do massage and stretching/exercises 3 times a day.

We've got a plan!

AT LONG LAST! 

This past month has been a rollercoaster! My mind has been doing laps:

- YAY we're done bracing!

- C'mon! You can't stop now! He's not even 2!

- But It's probably best for Jonas to stop if he doesn't need it!

- What on Earth are you thinking?! Brace for longer or he'll relapse?!

- But what if he doesn't?

- And what if he DOES!

- But his foot is PERFECT!

- Says every CF mum ever 6 months before their child relapses!

- Arrrrgh!

- Told you so!

- But...

- DON'T go there!

And obviously, Jonas was totally oblivious and far more interested in bouncing about like a bunny! (As you do...)

On 17th March, we had a Skype appointment with Jerald, another full check-up to check on dorsiflexion, external rotation, general flexibility and gait. As always, everything looked perfect, so we "only" needed to discuss getting the next brace or not.

The difficulty for us was that Jonas had been in boots and bar for almost 5 months before getting the DTKAFO. There's no way to know whether or not those 5 months matter or not for Jonas's future.

Typically, the DTKAFO/Cunningham brace is worn straight after casting until the child outgrows the 2nd brace around the age of 2. In our case, stopping now would mean that Jonas only wore it for 15 months.

There is absolutely no data on children starting the brace later as... hum... Jonas is one of the first few to have done it. And the little data gathered over the past 13-14 years by Jerald Cunningham really isn't enough to try and predict what will or will not happen to Jonas. Either way, as we know, clubfoot is an unpredictable condition so decisions have to be taken in the present, for the child's best interest.

Claire, the physio, and the local orthotist we met through her, didn't really want to share their opinion with me. They agreed that the Ponseti bracing schedule wasn't based on any research proving that 4-5 years of bracing was better than 2, but they didn't feel qualified to advise me as to what was best for Jonas, using the DTKAFO. Alex, the osteopath, felt that bracing longer in our situation and with our brace couldn't be detrimental for Jonas. Other CF mums I talked to privately were confident that whatever the decision I took, I would always find a way for him 💖

Talking to Jerald, I felt a lot lighter knowing that we were in good hands. Our current brace was definitely getting to the end of its life. Jonas was starting to get a slight red mark on the outside of his foot from the foot piece becoming too narrow and the plastic spiral hadn't held the reset very well over the last month and was back to being very stretched, after its patch up in February. Jonas had got so strong that it only held his foot at about 20° external rotation.

The low quantity of data on the Cunningham brace didn't bother me when we first got it, because, to me, boots and bar meant night time wake-ups with a distressed baby and spiraling into depression at the thought of tethering his feet every night for 5 years, whereas jumping into the unknown and trying this innovative brace was a way of getting my happy baby back and letting this bracing business take second place in our night-time routine. The threat of the ATTT surgery is always on my mind. However, the self-reported relapse rate with the C-brace is around 10% and according to Jerald Cunningham, casting is usually enough to stop it and reset the correction. Comparatively, to me, the Ponseti method felt a lot riskier.

This time, I don't have any date to lean on to. My husband and I just want the best for Jonas and there's no way to know whether bracing for longer or not will be beneficial to him. Jerald agrees with Alex that indeed, it can't be detrimental, and that's kind of as good an opinion as we can get, really!

So that's it, then, let's get the next size up!

1st Osteopath appointment

Soooo... On 14th March, I met Alex Green at Bolton Osteopathic Clinic. Jonas had first met him when he was about 3 months old and in full-time boots and bar. At the time, I was worried about his hips and knees and wanted to make sure everything was in order. This time, I wanted a new full check-up for Jonas and to discuss a post-bracing treatment plan.

Clubfoot doesn't stop at 5 years old. Clubfoot doesn't really care what age you are. And Clubfoot cannot be cured. Yes, some people are born with it and are lucky enough to simply forget about it as they grow up, because casting and bracing have been enough for them. However, it is thought that 30 to 50% children will end up needing a tendon transfer after 2 years of age (https://www.orthobullets.com/pediatrics/4062/clubfoot-congenital-talipes-equinovarus) and relapses after 5 years old do happen but don't seem to be typically recorded.

Dr. Ponseti agreed that clubfoot was probably genetic, but had this thought that maybe the gene causing it would "switch off" around the age of 4-5, once his treatment plan stops. After 2 years of reading other children's stories and talking to other parents, I simply cannot believe it. I absolutely wish with all my heart that Jonas's foot remains as perfect as it is now for the whole duration of his life. But since the resurgence of the deformity is thought to be linked with growth spurts and the boy grows like a weed, I intend on being proactive and on teaching him how to take care of his foot.

From the research shared on the Clubfoot Resource Facebook group, it seems that holistic treatments might be the way to go. We're talking of osteopathy, chiropractic, physiotherapy and taping, as well as e-stimulation. Because they look at the body as a whole, osteopathy and chiropractic understand the need for the full lower limb, from hip to toe, to be in perfect alignment with each other in order to maintain a clubfoot's correction.

I'm pleased to report that besides a slight tightness in Jonas's left hip, Alex found him in perfect shape, from top to toe! He was really amazed by the perfect shape and mobility of Jonas's left foot and asked to have a look at our brace. He looked properly mind-blown by it:

"It just all makes sense! 

You'd only need to sit and think about it long enough to come up with it!

It's genius!"

I told him about our dilemma, I was still very undecided, one of my fears was that we would continue to brace and cause Jonas damage in the process. I've read so many stories of children bracing till 4-5 with the boots and bar and relapsing within 6 to 12 months, that I came up with a little theory. A pretty unpopular one I expect, but here it is: what if bracing for longer was NOT the solution? What if it was, on the contrary, part of the PROBLEM? 60-70 years ago, when the Ponseti method was invented, it was thought that if you had a sore back (or ankle, or wrist, etc.), your best bet was to immobilise it, until it wasn't sore anymore. Nowadays, it is common knowledge that you should, instead, mobilise it as much as possible in order to strengthen it and prevent any further pain. In that regard, how does it make sense to immobilise children's feet for a full 2.5 years out of 5 years of life?

What if the brace acted like a back support? You're doing great so long as you wear it, but the one day you take it off and go lift up a couch you break your back? I just can't shake off the idea and it scares me.

That being said, our brace is totally different, being dynamic and with the way it attaches to the thigh, the spiral being shorter than the tibia, it offers a resistance to the child, engages the calf and ankle and, as it stretches the foot into the corrected position, it strengthens the calf and teaches the child how to best position their foot when active. I know all that. I do. I just needed a professional opinion on it and until now, nobody I'd spoken to had actually looked at the brace and the way it's made and given me an answer.

Well, Alex did. After studying the brace and looking at it on Jonas, he concluded that the way Jonas's foot is today and the way he can move it practically like his right foot stems from our brace, and that its dynamic design, he can't see it being detrimental to Jonas, if we brace for longer. According to him, since there's no way to predict the future nor whether Jonas is likely to relapse or not, be it in 1 year or 10, using the DTKAFO an extra year won't do him any harm. And he's happy to see us regularly to check up on his mobility and prevent him from tightening up.

What a relief!! At last, someone took the time to listen to me and answer my questions in all honesty!

Next step was our appointment with Jerald on 17th March. Just a few more days and we'd finally have a plan.

Still debating!

It's so tough!

I'm sorry for not updating you earlier! My mind keeps going from one option to the other:

- It's safer to brace for an extra year, then I wouldn't have to worry about a thing! But that's selfish isn't it? I NEED to make our decision in JONAS'S BEST INTEREST, not mine.

- Bracing can be so tough with the boots and bar for ex. and I really wouldn't want any child bracing longer than necessary for them. Jonas has easily accepted the Cunningham brace, within 2 minutes of having it on, he seemed to already have forgotten it was there. However, does it make it right to keep bracing after being told that he doesn't need to anymore?

I decided to ask around what other people's opinions were:

- friends and family are not necessarily well-versed in the subject, but seeing me worry about it, most seemed to "agree" that an extra brace would be/feel safer.

- the physio we see privately, Claire, is mostly interested in finding ways to strengthen Jonas's leg and she feels that maybe we would see even better results if Jonas didn't have his brace anymore as the strap running just above his knee has left a thinner imprint on his thigh. She won't comment on whether or not we should keep bracing, but does agree that his foot flexibility and mobility are both excellent.

Running laps in the kitchen!

- following one of Claire's suggestion, I met with a local orthotist. He'd never seen our brace and initially thought it was just a removable cast. I explained to him how it works and showed it to him on Jonas. He then watched Jonas walk and run with his shoes on, then barefoot and was really impressed at the way he seems to use both his CF and his non-CF equally, actually preferring to use his clubfoot when climbing stairs up. He then had a good feel of his bone alignment and checked his flexibility intently. I got a shock when he concluded:

"There's absolutely no sign of talipes left in his foot, his flexibility is close to his non-CF's and that's really amazing for a CF. The shape of his foot is also very similar to his non-CF. I can't help with the decision of bracing or not. However, I wouldn't have any worry whatsoever about him relapsing. If you did want an extra brace, I don't see the point of getting an over-the-knee one again, you could get a short one focussed on stretching the Achilles tendon, but as I say, I wouldn't think it's necessary."

- I booked an appointment with an osteopath next week for yet another opinion and will have a Skype appointment with Jerald soon to (hopefully) come to a final decision.

The face that makes it all worthwhile

Decision time...

The past week has ended in a blur of questions and uncertainties and we're kind of still savouring the feeling of knowing that everything is going so perfectly with Jonas's foot.

We got his brace back on Friday, all pimped up 😂 It looked so tiny! I hadn't realised how stretched it was. Jerald "reset" the plastic spring and added an elastic band at the side to prevent Jonas from stretching it back too quickly. He also added a layer of spring steel under the foot piece.

I was a bit scared to put it back on, thinking that maybe the extra stretch would bother Jonas after 4 nights of total freedom. He surprised me once again: absolutely unphased, he had a wee play with the elastic band before I put his PJs on, then went out like a light! Waking up with a smile 12 hours later. I feel he'll simply never stop amazing me!

My husband and I discussed our options over the weekend, between keeping the kids entertained, working and studying. It's such a tough one!

- I trust Jerald when he says he thinks Jonas could be fine if we stopped bracing now. I trust him when he maintains that 2 years of bracing with his brace should be enough to make our little one's feet perfect. However, Jonas has only been in the brace since the end of November 2016, that's only 14.5 months and I can't help wondering whether missing out on those extra months could mean that we're not as safe as if we'd started bracing with it straight after casting.

- Jonas is growing extremely fast, he'll be 2 in April but already towers over children older than him and despite the 3 years difference there is between him and his sister, I feel he'll probably catch up in height within the next year (he's only 12 cm shorter!). The big growth spurt between 2-3 yo scares me.

- The Ponseti recommendation is to brace till 4-5 yo, but all research done till now only ever involved a  2 year bracing period only, leaning that the decision to brace any longer isn't actually research-based.

We've decided to take more time and discuss our next step with more professionals before making our final decision.

Double check-up

What a week!!

Jerald Cunningham announced a few weeks ago that he'd be passing by London on his way back from Kenya where he was collaborating with CURE International: he travelled with his daughter with he aim of training/retraining a medical team to the use of his brace, checking-up on little patients he'd met a couple of years ago and fitting new patients.

The decision was easily made, we packed the kids up for a weekend to the capital. My almost 5-year-old daughter was desperate to meet Paddington bear so this was the perfect occasion!

Monday came and with it our appointment with Jerald and Sam at the London Orthotics Consultancy office in Kingston. The scariest part was "tubing it" with 2 young children, but I'm pleased to report that both Abigail and Jonas were absolutely perfect (thankfully - or not (I'm not too sure the secretary agreed) - they waited to get to the reception area at LOC to turn into crazy little balls of energy 😅).

Whilst we were waiting for our turn, we met a few people interested in the brace and chatted for a while about how well Jonas had taken to it and how well I felt things were going. To me, Jonas's foot looks pretty similar to his non-cf. It doesn't feel as dense and his arch isn't as high, but it looks, feels and moves like a normal foot.

Jerald watched Jonas walk (or should I say... run and bounce and stretch up on his toes?) and examined his foot. He was extremely pleased with it and particularly happy to see how well his arch has formed since October. He commented on the fact that he still shows quite a bit of external rotation/overcorrection, meaning that as he grows and things tighten up he should have enough of a margin for his foot to get to neutral but not relapse. He noticed that Jonas is getting to the limit of his brace capacity and decided to keep it so as to adjust and strengthen it the day after our appointment.

He had an important meeting right after our appointment and had to rush, but promised to be in touch shortly.

We got home on Monday night, tired but relieved. We still had to go to Jonas's 6-monthly check-up with our consultant on Wednesday and I really needed this boost of confidence. I just can't help it, I'm always scared to go to our hospital and meet our consultant for check-ups!

Well, we got there, Jonas had a wee play in the waiting area and we got called in. There was a bit of a surrealistic conversation about socks. Jonas had an orange sock and a blue one, which he was proud to wave at us "Socks socks socks!" he said. Luckily enough, our consultant wasn't bothered with the odd socks. Just as well as I simply can not store them in pairs! However, she commented on the fact that apparently, some people are so obsessed with socks that they IRON them???

I really need to ask: where do people even find the time to plug in their iron?? Mine only got out of storage recently and is only used for... Hama beads!

Anyway... let's get back to our check-up! Our consultant seemed really pleased with Jonas's progress and said that his foot looks better than expected based on what it looked like 6-7 months ago (very flat, with a risk of planovalgus). She performed a full lower limb check-up and also appeared satisfied with it. She was also curious to know about our check-up with Jerald on Monday and his visit to London.  I felt our appointment was very positive and we're booked to see her again in August.

I felt we'd had a very good week already and absolutely DID NOT expect to wake up to an email from Jerald this morning. After a short confirmation that the brace was on its way back to me, he stated that Jonas is close to outgrowing it and we are now coming to decision time:

- do we want to size up and brace longer?

or

- do we want to take a break (potentially indefinite) from bracing and monitor closely?

...

2nd Physio appointment

After a lovely Christmas and lots of squatting and stretching on our tiptoes, Jonas was in top shape to meet Claire again :)

We had our 2nd appointment with her last week and she was really impressed with the way his quads and calf muscles have developed in such a short amount of time. He no longer feels the need to step back when coming back up from a squat and the muscle definition in his calf has increased again. 

Our next step is to get him to learn to balance all of his weight on his left foot. He already does it briefly, when kicking a ball or holding onto something, but our goal is for him to be able to hold the position a bit longer and keep strengthening his leg.

This was once again a very positive appointment that confirmed that he's got great flexibility and motricity.

Claire suggested we start using a balance board with him. We don't have one yet and most models are too big for him so we've just purchased a yoga balance pad and expect to have hours of fun with it!