FAB/DBB tips and tricks - for Parents new to the brace

August 2, 2004

Time for the bi-weekly post of tips and tricks - I know there is at least

one new mom (Sharon from NoSurgery) who needs this. Perhaps more. So once

again... hope this helps :~}

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Lots of people have good advice for starting out in the DBB fresh out of

casts. I wrote this up a few months ago and it needs modification and some

things added because while it's got lots of info in it - it's not complete

and not the *only* way to do it. It is however what worked for us after

weeks and weeks of unhappy baby and a rather severe sore on her heel that

just wouldn't heal. Darbi's foot was well corrected, she did not have the

tenotomy and we STILL had issues. I even asked about AFO's even though I

knew they weren't the answer I was so frustrated. Our problems stemmed

from not getting her heel down 100% - I didn't have the tools to know how

to make sure it was seated properly and the Ortho at the brace shop, while

very good and trying very hard with many different things to figure out why

she got and couldn't get rid of the sore didn't know these tricks to make

sure the heel is down either.

We lived - and when it was all said and done I had a totally different baby

whose foot did not hurt and who finally acted like the baby I knew she

was. She was totally happy in her brace from then on. So it's really,

really very true... they don't mind the brace at all if it's fitted

properly and isn't hurting them. I think I say this in the text below but

I'll say it again... Listen to you baby and trust your instincts. A

little frustration is normal - when your baby is crying and telling you

he/she hurts she probably does and you need to find out why before it makes

a sore and it REALLY hurts and won't heal. It is VERY important to keep

the shoes on - but if you can't without making sores or causing pain you do

have options other than AFO's (which do not work) to keep the

correction. Your doc may not agree and tell you to put the shoes back on

or even to take them off for a few days or a week - don't listen. Demand

another cast and move on and try again.

OK - so here it is - my tips (see below). I hope this helps those who have

unhappy babies and/or those who have the DBB/FAB to look forward to in the

near future. I know I could have used this information when we first

started. Other parents please chime in and tell us what worked for you and

your child. Maybe someday we can have a fully comprehensive file to share

with new parents with all our tips included in one text. Anyone have time

to compile something like that?

Kori

Mama of

Kenton 6/98

Merek 3/00

Darbi 3/03 - Rt. CF - DBB 12hr/day

(¨`·.·´¨)

`·.¸(¨`·.·´¨)

`·.¸.·´

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How to put Markell Open Toe Boots attached to Brace FAB/DBB (Foot Abduction

Brace/Dennis Browne Bar)

Before you put the shoes on the first time:

Take the laces out and tie a knot in the middle. Then re-lace the

shoes. Tie a knot at the very ends of each lace end so they don't come out

of the holes. This has been a lifesaver for us - we never have to re-lace

them and can pull them very loose to get the shoes on. The knot in the

middle shows us that they're even each time so I never worry about one side

being longer than the other. I love this tip!

Consider slitting the tongue keeper slit up to the top of the tongue. This

allows the tongue to sit low on the top of the foot - and allows the top of

the boot to be tightened up on the ankle enough so the fatty baby calf

doesn't pull the heel up and out. The tighter the ankle, the better seated

the foot will be. Also, you do not have to use the top hole for

lacing. With little feet it can help keep them in if you don't lace the

top hole.

We find it easier to have the straps and buckles on the inside rather than

the outside. Since the feet are pointed out in the first place cinching

them up on the inside is just easier in general. Straight Last shoes can

be installed on either side of the DBB - as they are not a right or left

shoe. The Ponseti Method uses straight last shoes although sometimes a

baby will get reverse last. If you got reverse last shoes ask about the

straight last shoes. Some people like the straps on the outside - you will

have to decide which is easier for you.

Install the strap in the lower hole on each side of the boot. Apparently

this is the best position to keep the foot in the shoes.

If you have the older style Markell boots (no extended heel pocket, minimum

padding at the ankle and no factory padding on the tongue) you will need

the plastizode heel insert and some brace shops pad the tongue with

plastizode as well. Some brace shops are still padding the heel in the new

style shoes. We have found that it is not necessary, but for some feet it

might still be necessary. You will have to decide with your orthotist

whether or not you want to try it with or without he padding at first. The

padding on the tongue from the factory (new style)has shown with some

babies to cause red marks and even sores in some cases. They are working

on changing the tongue padding so it doesn't do this, look for a

differently designed tongue soon. If your baby gets red marks that don't

turn into sores it should be fine (Darbi has had red marks on the top of

her feet for a year now - but no sores). If sores form you can try

loosening the strap and tightening the laces but it may be harder to keep

the foot in the shoe if you don't tighten them enough. Some parents have

taken the tongue out entirely and that has helped but most parents don't

see sores, just redness which doesn't seem to irritate much but it looks weird.

Medium thickness cotton socks are recommended. We like the Old Navy or

Gymboree socks with the rubber grips on the bottom. They are regularly 7

for $10 at Old Navy. I suggest you get at least 7 if not more. They seem

to get lost in the laundry... and it's not fun trying to find that perfect

sock when you need it. Plus you can make sure you've got the right colors

on hand for accessorizing :~} In the winter after the initial first few

months of getting used to the DBB and worrying about slipping I use

tights. Not only for girls - I put my non-clubfoot boys in tights (white,

black or blue of course!) in the winter too - it helps keep their legs warm

when their pants hike up while being carried outside. But tights work very

well with the DBB in our experience. The thicker the better, make sure

they're stretchy so they fit the feet nice and tight. Do not use loosely

knitted socks. You know, the kind that make marks on the tops of your feet

where your shoes press? A tightly knitted sock is much more comfortable on

baby's skin

(learned that the hard way a while ago when she woke every 15 min

all night long)

Remember - when you first get the DBB take it off every 2-3 hours to check

the feet for sores or red marks that don't go away. Leaving the brace on

for longer periods of time if baby seems happy is fine. If baby is showing

signs of distress take the shoes off and inspect the feet. Then use the

following instructions and re-install the brace. You should check the feet

often over the first couple of days or more if baby is showing signs of

distress. If you do not see signs that sores or blisters are forming

things are ok - keep the brace on.

Installation tips (how to put the DBB on a wiggly little baby without

causing pain or sores)

1- If you can - take the shoes off the bar. If you have a gold bar this is

simple. You may have to use a wrench or pliers to get it off the first

time as some brace shops really tighten them up. Don't loose the nut and

make sure it's tight when you put it back on the bar (or it could strip the

grooves and you will need a new bar and/or sole plate). It

is best to put the nut back on the shoe after you take it off the bar - as

it helps keep them around and getting kicked in the thighs without that nut

there really hurts! Mark on the plate where your shoes are to be set at

with a Sharpie marker. This makes it very easy to put them back in the

right spot - even in low light. If you have the red adjustable bar it is

harder to take the shoes off but not impossible. The way the Fillauer red

adjustable bar is designed it is much more difficult to see the degree

markings and keep the sole plate in the grooves with a foot in the shoe (0

degrees is the shoe pointing straight forward on the bar - mark this point

on the bar with a permanent marker so it's easier to set them back if you

do take them off the bar). But if you can, try

it. I really feel it's a better way than trying to put the shoes on with

the bar. This way you know if it's the shoes alone or shoes *and* bar

that's causing baby to be upset. If you find you need to take the shoes

off the bar but your red bar makes you crazy you can get a gold

non-adjustable bar from Markell, have your brace shop order it for

you. Use the gold bar for the first few months (newborns will need a 6 " or

8 " bar) and when you're comfortable with putting the brace on without

taking the shoes off you can go back to your adjustable bar. We used the

gold bars for about a year till another list member gave us an adjustable

bar (Thank You Angel!). We had stopped taking the shoes off the bar long

ago so it was easy to transition to a bar that wet can't take the shoes off

of easily.

2- Loosen the laces up all the way to the knots and pull the tongue up as

well. If you have short straps, buckle the strap into the last hole

loosely so as not to pull it out when the foot goes in. The longer straps

don't need to be buckled.

3- With the shoe off the bar insert the foot into the shoe and bend the

knee 90 degrees. Push on the top of the knee and hold the sole of the

shoe. Press the heel deeply into the back of the shoe and flex the toes

upward (dorsiflexion) as far as possible. Keep pushing on the knee and

flexing the foot and make SURE the heel is seated well into the bottom and

back of the shoe.

4- With the knee still bent and pressure applied press with your thumb or

other convenient finger on the strap where it goes through the tongue

keeper slit and hold the heel into the back of the shoe and tighten the

strap. Buckle it tightly. Dorsiflex the foot again and press again on the

knee and sole of the shoe to make sure the heel is in properly. Re-tighten

the strap very tight. If the heel is down you can't tighten it too

much. If there is any wiggle or looseness press the foot into the shoe

again push with your thumb on the strap and re-tighten the strap again. It

must be very tight - tighter than you would imagine it needs to be. So

keep going till it's really tight.

5- Pull the sock at the toes to make sure the seams aren't going to press

into baby's toes - it also helps make sure the heel is seated. It's ok if

they look all bloused out in front. This is good - gives baby room to

wiggle toes and who cares how it looks anyway!

6- Pull the tongue way down over the toes. As far as you can. I prefer it

to sit *under* the top of the boot at the ankle just a little bit. If it

sits high you may need to cut the tongue keeper slit a little more. (don't

cut it above the stitching)

7 - Tighten the laces nice and snug all the way up and tie them. The shoe

should get tighter with the laces being tightened. Some people find it

easier to tie the laces at the bottom rather than the top. If you've done

everything you can and the foot is still slipping you can try this.

8- Check to see if the foot can slip out of the boot at all. If it moves

it'll loosen up with time and slip. If it's not tight repeat the above

instructions with emphasis on the pressure on the knee and pushing the heel

into the bottom of the shoe with the foot flexed up (toes pointing toward

the baby's head) all at the same time. This isn't easy at first, but you

will get used to it and very good at it in short time.

9- Repeat the procedure with the other boot.

10- When both boots are on - take the nuts off and put the bar back on. If

your baby is bi-lateral it doesn't matter which side you do first. If baby

is unilateral it's easier to put the clubfoot side on first as the other

side set at 45 degrees is easier to put on the bar second.

Signs of trouble:

Baby cries a very unnatural (for your baby) unhappy in pain cry all the

time, kicks legs violently like she's trying to kick the shoes off, wakes

at nigh every half hour or less (other than being hungry), purple/black

marks on the heels or other parts of the foot, blisters form or sores form.

All these are typically caused by the shoes not being on properly. If

pressure sores or blisters appear - you MUST fix whatever is causing the

problem before you put the shoes back on. Sores will not heal in the shoes

once they appear (skin falls off and actual sore is resident - as opposed

to just a purple or black mark). It might mean a trip back to the Dr. for

a healing cast. Which is ok - it keeps the correction while the sore

heals. You MUST find out why the sore came - if it's slipping or pressure

or whatever - find it and fix it. When you go back to the DBB follow the

above directions and make SURE the heels are down 100% in the bottom of the

shoes. Blisters are caused by friction or rather slippage. Slippage is

often caused by the strap not being tight enough. It may seem tight

enough, but if slippage happens it very likely is not tight enough. If the

heel is rising up it seems tight but once you get the heel down you'll find

you can tighten it up another couple of holes. Dorsiflexing the foot while

you put the shoes on really helps prevent this.

After having persistent sores some parents have resorted to actually

cutting a large hole in the heels of the shoes. This helps to relieve

pressure so that baby can continue to wear the DBB while a sore heals. It

is not a long term fix. The foot must be in the shoe properly for long

term wear. However, after cutting the hole many parents have found that

they were not getting the heel down all the way and were then able to see

to make sure the heel is down. I don't recommend this - it is a short term

bandaid to the larger problem of proper fitting of the shoes. However it

is a good option to going back to casts for healing and starting again with

the 23/7 schedule for wearing the FAB. The shoes will not fall apart and

are essentially disposable as they can only be worn for a few months till

baby needs a larger size. For more information about this you can contact

me personally - frogabog@... and I can help you find a solution to

healing your child's sores. We have endured this and hope to not see any

other babies have to go through this pain and unhappiness. Remember -

there is a light at the end of the tunnel and you can find a way to keep

the FAB on so your baby can take advantage of the most effective brace to

complete the non-surgical treatment.

Other reasons why baby may be uncomfortable are:

Skin sensitivity right after casts are taken off. This is unfortunate, but

will get better with time. Don't rub the legs - this hurts more. A little

lotion is ok but keep it off the feet or give the lotion time to soak in

before putting the boots on as it can cause slipping. Use a good lotion -

non greasy. Eucerin works well and is alcohol free (and often came home

with you from the hospital in a sample size).

Bar is too long or too short. The heels of the shoes (fixed on the bar in

the correct positions - 70 degrees for a clubfoot and 45 for non clubfoot)

should be shoulder width apart. Any less or much more is uncomfortable for

baby. It is not the length of the bar - it is the distance between the

heels. Take the brace and place it up to baby's shoulders to check

this. To small or too long of a bar also contributes to the feet pulling

out of the boots so make sure to check this as soon as you get your DBB/FAB

and don't let the brace shop or orthotist tell you it's right when it

isn't. The last thing you want is to have baby get sores/blisters because

they insisted baby needs a 10 " bar at 6 weeks old.

Foot is at the wrong position. The clubfoot should be at 70 degrees or *AT

LEAST* as far turned out as the last cast. Parents - save your last

cast. Take that cast and put it up to a protractor with the knee pointed

to 0 degrees and see where the midline of the foot portion points to. Then

set your DBB. If it is much less than 60 degrees consider talking to your

doctor about another cast. The last cast in the Ponseti Method should be

at 70 degrees. If your cast is not there, and your doc doesn't see fit to

re-cast you can try to get there slowly over time. Set your brace to where

the cast is set at and slowly once a week increase it by 5 degrees. Do not

put the foot further out than the last cast as this causes considerable

discomfort for the baby.

Baby is irritated by not being able to move legs independently. You can

show baby how to move his legs together. They might not like this at first

but will soon learn to lift their legs up with the brace on. This is minor

irritation for the baby. They get used to this fairly quickly.

It is very important to not take baby out of the brace. Do everything you

can to make sure your baby stays in the brace. But listen to your child

and follow your heart. If you see signs of sores there is a problem you

need to tackle and rectify. Do NOT keep a brace on a child who has a

weeping sore. This is painful and you wouldn't put a tight shoe on your

own foot with a sore like that. If your child is telling you she's in pain

she likely is and you need to find out why. Do what you can to keep the

brace on - but don't make a bad situation worse by putting it on

incorrectly and causing sores. See your Dr. about healing casts or cut a

hole... but don't make sores worse.

If your baby is irritable at first consider co-sleeping so everyone gets

some sleep the first few nights. You can side lie and nurse a baby wearing

the dbb, it's a little different than a baby who doesn't wear one but is

absolutely doable (we're still doing it over a year later - I wouldn't have

it any other way - so easy!). Even if you only do this for a few days

while baby is

getting used to the brace - it will help everyone in your family get sleep

the first few nights and will NOT spoil baby. Enjoy the extra rest and be

there right away at night to comfort your child while he gets used to the

brace. Put a pillow under baby's feet. It is easy enough

for baby to side lie in the DBB with a pillow under his feet or propping

the brace up. Older children who can roll over don't need it, in fact have

a hard time with pillows because they can't roll as easy but they seem to

do just fine without them.

Good luck and don't forget to post to the list if you need help. We're

here for you and have lots of different takes on how to make the shoes and

bar work so there's lots of different ways to work through problems.

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August 2, 2004

I was reading your tips... and I am confused about something. You said that

clubfeet should be set at 70 degrees. has bilateral clubfeet and both of

his feet are set at 45 degrees per our dr. recommendation. Now I am not sure if

this is right. Should I question my dr????

2/9/04 BLCF DBB 23/7

frogabog frogabog@...> wrote: