Treatment for Type 1 Rocker Bottom Foot
The primary treatment for type 1 rocker bottom foot is immobilization with a non-removable knee-high offloading device, preferably a total contact cast (TCC), which should be initiated as soon as the diagnosis is considered. 1
Understanding Rocker Bottom Foot
Rocker bottom foot is a deformity characterized by a plantar convexity of the foot, typically seen in:
- Congenital cases
- As a complication of clubfoot treatment 2
- Most commonly as a manifestation of Charcot neuro-osteoarthropathy in diabetic patients
Treatment Algorithm
First-Line Treatment
- Total Contact Cast (TCC)
- A well-moulded, minimally padded, knee-high non-removable fibreglass or plaster cast
- Maintains total contact with entire plantar surface and lower leg
- Should be applied immediately once diagnosis is suspected 1
- Provides best immobilization of the ankle and foot joints
Second-Line Treatment
- Non-removable Knee-High Walker
- Pre-fabricated walker rendered irremovable with cast material or tie wrap
- Provides similar offloading but possibly less optimal immobilization than TCC 1
Third-Line Treatment
- Removable Knee-High Device
- Only if non-removable devices are contraindicated or not tolerated
- Patient must wear it at all times
- Risk of non-adherence may lead to progression of deformity 1
Adjunctive Measures
- Assistive Devices: Crutches, walkers, or rolling crutch walkers to reduce weight-bearing on affected limb 1
- Contralateral Shoe Raise: To minimize limb-length discrepancy when wearing the device
Duration of Treatment
- Continue offloading for 4-6 weeks after clinical signs have resolved 1
- Total treatment time may take many months until the condition goes into remission
What NOT to Use
- Below-ankle offloading devices (surgical shoes, postoperative sandals, custom molded shoes) are not recommended due to inadequate immobilization of diseased bones and joints 1
Monitoring and Follow-up
- Regular monitoring for:
- Skin lesions or ulceration
- Pain
- Muscle weakness and atrophy
- Falls
- Musculoskeletal complaints in contralateral limb
Special Considerations
- Treatment should begin immediately once diagnosis is suspected, even before fractures are visible on plain radiographs 1
- MRI may show active disease even when X-rays appear normal
- Patients who comply with partial weight-bearing instructions experience shorter healing times (approximately 34 days faster) than those who don't comply 1
Potential Complications of Treatment
- Development of foot ulcers
- Skin lesions from cast removal
- Pain
- Muscle weakness and atrophy
- Falls
- Musculoskeletal complaints in knee or hip due to limb-length discrepancy
- Psychological impact from reduced mobility
The evidence strongly supports early immobilization with a non-removable knee-high device as the cornerstone of treatment for rocker bottom foot deformity, with the goal of preventing progressive deformity and potential skin ulceration 1.