11 year old boy with rigid flat foot

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Hi there I am interested in any feedback or input on this Childs foot. He presented with pain with walking, running and sore lower limbs. He is not sport orientated and has very low motor tone and delayed milestones. The is 0 rom in both feet at the mid foot, reduced rom in both stj's. His navicular is on the ground with excessive pronation in all stages of gait cycle. His mother is unwilling to have an xray although I believe this would show some sort of tarsal coalition.He has had previous orthotics which have not worked and was sent to me by his Gp for a second opinion. I am wondering about an consult with a Orthopaedic surgeon. Any suggestions or ideas?

 

At the very least this needs to be x-rayed. If the mum won't accept your word on that then refer her to an Orthopaedic surgeon who will undoubtedly give her the same advice.
good luck
Michael

 

Get an x-ray or tell them to go away. If the mothers is not willing to have an x-ray, then tell them there is nothing more you are willing to do.

 

Zero range of motion in the midfoot strongly suggests tarsal coalition. Your note did not say which joint's ROM was reduced, so I am just guessing as you are until you get proper imaging. Common things occur commonly. Dwight L. Bates, DPM, DABPS

 

Will an X ray change your management? If they are unwilling to pop for an x ray I doubt they'll be interested in surgery!

The interesting question for me here is was this preventable. If they had been placed in piedros and orthoses from an early stage, would the midfoot have set in this position?

Orthoses wise, If there is a soft tissue element, I have managed to drag a few degrees of forefoot eversion back in cases like this. Obviously depends on the foot but I have got a foot from a non correctable supinatus with WB navicular to something approximating to an arch using trainers / boots and a shank dependant, Low density EVA *device with an aggressive Medial heel skive and graduated degrees of arch / forefoot intrinsic correction. The aim being at all stages for the orthotic to be shaped to a little more forefoot eversion than the foot can acheive.

Whatever the x'rays show, assuming they are not interested in surgery, I'd be at least trying this.

Regards
Robert

*
I go for Shank dependant because it gives you most control, it CAN'T move within the shoe, and Low density EVA because at Shank dependant is still gives a tremendous resistance to compression.

 

:good:

In saying that, I would be trying the orthopod route in addition to this. They have a habit of giving it to them a bit straight. And their opinions usually carry a little more weight, rightly or wrongly.

Robin

 

Thanks everyone for your advice, i believe i will get no where with the mum as she cant bear the thought of radiation or paying for more orthotics. So i will refer on to an ortho and hope this child gets the treatment he needs.
Thanks all.

 

Riiiiight.

So she wanted you to fix it without finding out exactly what the problem was and without orthoses. What exactly did she expect you to do?! Psychic surgery!?

Definite hand grenade referral. If you DO try to go down the insole route its a long job, with frequent cheques (sorry, checks) and frequent updating of insoles as the foot changes. Not a road to travel down with anyone who is not 100% committed to getting better.

To steal Craigs expression, refer to your enemies.

 

Love it. We call them hot potato's as in "HOT POTATO..(chuck the referral)..YOUR TURN!!

Ask if they have ever been on a plane, exposure to radiation from one foot/ankle series plain films is similar to the amount of radiation exposure on a plane trip from Melb to Sydney. Hot potato them to an ortho, if they are considering surgery they will MRI them anyway.

As an aside, I'm not sure about other states, we can refer to MRI in Vic, patient out of pocket about $200 and no radiation. Just something else to consider.

Good luck.

 

Explains Craigs "superpowers".

 

If YOUR patient needs an xray then get one. Do not allow the patient's mother to direct treatment or diagnostic testing, unless she's a medical specialist.

You are most likely correct; tarsal coalition possibly, or cong. vertical talus. Either way, difficult to treat even WITH a proper Dx.

Steve

 

Your in Australia, there is public funding available for this type of client for custom footwear and orthosis.

In this childs case (?) the funding will cover 100% of the cost of the custom footwear, not the same for the orthosis am afraid, based on what l charge anyway.

l would like an x-ray before starting also, but l dont know that it would change what l do, it would for a surgeon l am sure.

The reason it would not change what l would do, l would be treating the symptoms, l would want to give him some relief in the hope of increasing his physical activity between now a possible surgery, if you dont his general health and mind may suffer.

Surgery if it is needed or by the time they get around to it, could be a very long time in a childs life

Why should this child be left to suffer in pain? :hammer:
.

 

I once asked the question about radiation dosage for feet, in conjunction with serial X-rays to examine for interval deterioration. Our local radiology dept told us that the dosage for feet was minimal, and they would have no qualms about X-raying feet serially.

Sounds like the mums a problem, Did she just think that you would thrown an orthosis into the shoe and correct her childs problem?

 

Nope,

Like I say, obviously expecting psychic surgery. Distance healing perhaps. For free.

 

It is not a case of letting someone direct treatment, I can only give this woman the direction not force her to have an xray done on her son. It would not matter which way treatment goes with this type of patient you wont get anywhere. She wants minimal intervention and came armed with two sheets of questions in regards to side effects of orthotics. I have refered on.

 

I think she wanted a miracle not just orthotics, faith healing may be the answer or maybe crystals

 

Good work. Whenever anyone comes in with pages of questions my view is you have a law suit coming your way if you get involved.

LL

 

Or that phrase in one of those quiet moments during the consultation.." do you think the accident caused this?"

 

I feel for the child. What is mum thinking?

X-rays are your starting point. The mother needs a good, firm talking to.

At the end of the day you can only advise people on what to do... you can try telling them, but they won't always listen.

Good luck.

 

Thought for one horrible moment there, that you were going to say something else