How young do you treat biomechanical issues?

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Hi guys,
I have a pt who is bringing her 2.5yr old in to see me tomorrow and she has concerns that she has "flat feet" and that the child isnt walking correctly etc etc.. I'm just wondering is she too young to be treated - if indeed she needs to be?

Thoughts please. I've been asked by quite a few parents at my daughters school (aged 5+) to look at their feet and although happy to prescribe orthotics for my daughter, want to check on others opinions.

Thanks in advance,

Lucy

 

Do you treat? It depends.

Sensible, and pragmatic advice here:
http://www.japmaonline.org/content/98/5/386.abstract

and a good commentary here:
http://www.lowerextremityreview.com...-treat-the-pediatric-flexible-flatfoot-debate

You need to take into account any co-morbidities, pain, family history, and physical functioning. Take a birth history, and note any developmental concerns.

 

As soon as you suspect there is a problem that requires intervention. This was a six month old baby girl.

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=104

 

Lucy:

As soon as the child is weightbearing, the feet may be treated with in-shoe inserts in order to try to correct the kinetics and kinematics of gait. Treating children with obvious pathologies at a young age actually has more potential to cause a permanent change in the skeleton of the foot than waiting until they are 8 or 9 years old when their foot morphology has already matured into their basic adult shape.

Treatment doesn't always have to be a foot orthosis. In the 1 and 2 year olds especially, treatment may involve something as simple as adhesive felt pads placed into the child's shoes to alter the kinetic and kinematic effects of ground reaction force. I can't agree with all of the opinions of Angela Evans, even though I love her for what she has done for podiatric research in children. I will err on the side of treating children with asymptomatic flat feet with over-the-counter orthoses or in-shoe felt wedges simply because their feet and lower extremities function better with these wedges placed in their shoes.

I don't think that the ethical podiatrist should need to wait for symptoms to occur before treating the child with an abnormal foot structure that has gait disturbances with in-shoe supports or foot orthoses. This opinion of "only treat when the child is symptomatic" makes no sense from a biomechanical aspect, especially when their gait is abnormal and the parents also have foot pathology.

We are the experts in foot and lower extremity biomechanics. Because of this, I feel it is our duty to offer children the expert treatment that we can provide in order to improve their current and future lives. If we don't offer this treatment for these children in need, then who else will?

 

I know that I am as about as popular as something you have stepped on, when dealing with this subject.... However, I do ask that you think carefully about the ethics. Beneficence, and non-maleficence. Please, beyond all reasonable doubt, know that you are doing good without harm. I know it caused the excrement to hit the ventilator when published, but Macdonald and Kidd - ethics of treating childeren etc, was worthy of pause in its time. Rob

 

I think this is probably one of the most important features of when to treat and I think young children show many symptoms that if you are seeing enough, are more than just abnormal foot biomechanics.

In the abnormal paediatric flat foot there can be early deformity, delayed gross motor skill attainment, delayed adaptation of normal foot function during gait, poor balance, etc. These are things that can show at early weightbearing and these are all symptoms that you can measure and therefore have a rationale for treatment.

Reassurance, good shoe advice and regular monitoring are also valuable treatment options.

 

Here is my February 2003 Precision Intricast Newsletter from my third book which details how I deal with the child with a flatfoot deformity. Most of how I treat children and their mechanical foot problems are based on learning from two of the most ethical podiatrists I have ever known, Drs. Ron Valmassy and John Weed. These fine podiatrists were great examples of how to best treat the child with mechanical foot and lower extremity pathology.

Hope this helps.

 

Agree with Cylie on this one. Clinically, when seeing a lot of children, problems which otherwise may not be considered "symptoms" become quite important.

The thing that is critical in these situations is defining those symptoms to the parents and being very clear about what the outcomes are. "normalising" the foot position to have a nice high arch is not a goal in my opinion.

Consistency then becomes key because 6 months down the line, no matter how well you have explained the fact that we may not see kinematic changes in the foot position, the parents will still question the validity of the treatment because the arch hasn't "formed", despite a reduction in the symptoms defined at the beginning.

Just my 2p

 

I also agree that Cylie has made a very important point here. however, to be specific, the term "symptoms" refer to subjective complaints, not objective findings.

For the clinician that doesn't take a good history of the child with a flatfoot deformity, many of these children will be labeled as "asymptomatic". But the more astute clinician that takes a good history and has a wealth of knowledge of the various problems and complaints of flat footed children may discover symptoms in these children, that other clinicians, and especially pediatricians, may be ignorant of.

These symptoms may include, but are not limited to the following:

1. Child wants to be carried when going on long shopping trips or going to amusement parks for the day.

2. Child can not keep up with the other children in running sports.

3. Child has "growing pains".

4. Child complains of low back, thigh or knee pain which has not been attributed to their excessively pronated feet.

5. Child is relatively clumsy in weightbearing activities.

Therefore, one clinician determines that the child is asymptomatic, since he/she hasn't asked the right questions, while the other clinician determines that the child in symptomatic because he/she took the extra time to more thoroughly explore whether the excessively pronated feet could be contributing to these less obvious complaints.

Therefore, is the child that doesn't say they have pain in their feet truly asymptomatic or could they still be considered to be symptomatic? Many times it depends on who is evaluating these children.

Isn't it more ethical to err on active conservative treatment with careful observation of these children than to take the attitude of proclaiming that being "flatfooted" is normal in children, the child will eventually grow out of their excessively pronated foot and that there is no research that shows that treatment with arch supports or orthoses does any good for these children?

Hopefully, one day, we will start to take children and their foot problems more seriously and do good research studies that measures the kinematics and kinetics of gait in children with overly pronated feet and medially deviated subtalar joint axes and also do finite element analyses of the internal stresses within the structural components of the normal-arched vs flat-arched children's feet to more fully understand the biomechanical consequences that having this foot structure may have on a child's life and their development, both physically and psychologically.

Our children definitely deserve it.

 

:good:

 

Really sorry to have to say this: Where is the evidence? Rob

 

Thanks for the Kevin, far more articulate than my quick reply.

For which part Rob?

I agree there is an absence of direct correlation of asymptomatic flat feet with some of those symptoms that Kevin shared however a common association of decreased tone impacting on gross motor skills and increased energy expenditure often goes hand in hand with asymptomatic flat feet.

It is then essential after asking appropriate questions of the parents, that the child is assessed with assessments that are normalised for his/her age, reliable/repeatable etc. This then gives you the ability to give the parent some feedback on progression or non progression. In the case of both there is also the chance to withdraw treatment to determine if the treatment option is the changing force.

There are plenty of treatment options for many lower limb conditions out there, that there is no evidence for and yet we keep doing them. In this case my goal of treatment is about managing parent expectations and setting defined and measurable treatment goals. These are as imperative as is appropriate history taking, good clinical reasoning, assessments are appropriate.

That said, I primarily see kids under the age of 6 and I could count on one hand the amount of kids I have given a custom or off the shelf device. But, I'm a big shoe fan with or without a triplanar wedge. We all have our vices.

 

As an orthotist i generaly treat children from the age of 4 up, younger if there is obviouse biomechanical malalignment or if the child is symptomatic (poor postural balance, increased trips, pain ect.)
If its asymptomatic pes planus we would monitore and reccord the naviculare height, if its seen to lower we woudl try insoles if its static or self correcting just monitor.
but generaly any age when weight bearing if there is an issue or symptoms otherwise monitor.

 

Posts moved re Pros and Cons of the Subtalar Joint Arthroereisis Procedure in Pediatric Flatfoot Deformity to a thread titled the same

 

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Mandy and I were arguing for the asymptomatic (pediatric) flat floot. If there was a load of symptoms (in the child, not the parent), then our argument does not hold good. All we ever said was that If there are no symptoms from the childs point of view (re: list in posts above), then there is no ethical case to treat.
The excrement we received was beyond belief. I will not go into specifics now - the history books tell all. However, we believe that we have been demonstrated to be correct - if only (as always if only) we made the word stop and think......

If there is no evidence (ie proper randomised controlled trials) that demonstrate that your treatment strategy is is based in science, then you are skating on thin ice. DO not assume that it is wholesome because everyone else does it - that is what they said at Neurenberg. We never said you shouldn't; we simply asked the pertinent question: should you? Rob