From the Guidelines
Treatment for valgus ankle and pain associated with pes planus in patients with Ehlers-Danlos syndrome should prioritize conservative management, focusing on custom orthotic devices, physical therapy, and pain management, due to the higher risks associated with surgical options in this population.
Conservative Management
Conservative management is the preferred initial approach for treating valgus ankle and pes planus pain in Ehlers-Danlos syndrome patients. This includes:
- Custom orthotic devices with rigid medial arch supports and lateral posting to control excessive pronation, as orthotics and braces are valuable adjuncts to therapy and can help correct biomechanical problems such as pes planus deformity 1.
- Physical therapy to strengthen the supporting muscles around the ankle and foot, particularly the posterior tibial tendon.
- Ankle bracing or Arizona braces for additional stability.
- Pain management with NSAIDs like ibuprofen or naproxen, used cautiously due to the increased bruising risk in Ehlers-Danlos syndrome.
- Activity modification, avoiding high-impact activities while maintaining gentle movement.
Surgical Options
If conservative measures fail after 6-12 months, surgical options may be considered, including:
- Subtalar arthroereisis for flexible deformities.
- Lateral column lengthening.
- Triple arthrodesis for rigid deformities. However, surgery carries higher risks in Ehlers-Danlos syndrome patients due to poor tissue healing and joint hypermobility, requiring longer immobilization periods and careful rehabilitation 1.
Multidisciplinary Approach
Treatment should be multidisciplinary, addressing the biomechanical issues while considering the systemic nature of Ehlers-Danlos syndrome. This approach ensures that the patient receives comprehensive care, minimizing the risks associated with the condition and its treatment.
From the Research
Treatment Options for Valgus Ankle and Pain Associated with Pes Planus in Ehlers-Danlos Syndrome
- The treatment of valgus ankle and pain associated with pes planus in patients with Ehlers-Danlos syndrome (EDS) is complex and multifaceted, requiring a comprehensive approach 2, 3.
- Physical therapy and occupational therapy have been shown to be effective in improving symptoms and reducing pain in patients with EDS, with 70% of patients reporting improvement 2.
- Bracing and other orthotic devices may also be beneficial in managing valgus ankle and pes planus in patients with EDS 2, 3.
- Medications such as nonsteroidal anti-inflammatory drugs and neuropathic modulators may be used to manage pain, but their effectiveness and tolerability can vary widely among patients with EDS 2, 3.
- Surgical intervention may be considered in some cases, but it is associated with a high risk of complications, including persistent pain and instability, and should be undertaken with caution and careful pre-operative planning 4, 5.
- A multidisciplinary approach to treating chronic pain in patients with EDS, including physiotherapy, occupational therapy, cognitive behavioral therapy, and pharmacologic interventions, may be effective in reducing pain and improving quality of life, although the evidence for this approach is currently limited 6.
Orthopedic Considerations
- Patients with EDS are at risk of developing valgus ankle deformity and other orthopedic complications, particularly after surgical procedures such as free vascularized fibular graft harvest 5.
- Syndesmotic stabilization or primary syndesmotic fusion may be considered at the time of graft harvest to prevent valgus ankle deformity in patients with EDS and generalized joint hypermobility 5.
Pain Management
- Pain management in patients with EDS is challenging and requires a comprehensive approach that takes into account the underlying mechanisms of pain and the individual patient's needs and preferences 3, 6.
- A multidisciplinary approach to pain management, including physical therapy, occupational therapy, cognitive behavioral therapy, and pharmacologic interventions, may be effective in reducing pain and improving quality of life in patients with EDS 6.