Achieving permanent correction with FFO therpy

Hi Charlie.

A few question do the orthotics they recommend you to use have a medial skive ?
do you consider the STJ axis postion during your assessments?

off the shelf device can be great if modified properly.

As for the pain approach to treatment I agree but would add a few others to the list when treating.

Weight of the child if overweight treat.
level of activity of patient if active treat
familiar history of pes planus foot type and other problems such as knee pain treat
how stressed are parents of these patients if stressed treat.

If no treatment I will see the patient every 6 mths to 12 for a revaluation.

Hope that helps

 

I agree with you on this point Michael.

However my patient, as I remember, had a good arch profile. The pain in the forefoot could well have been due to muscle weakness and an early heel lift overloading the forefoot and plantar intrinsics. She may never have had a flat foot... but the treatment she received immobilised the foot sufficiently to cause atrophy, or retarded development of the intrinsics. (that'd be an interesting study - MRI/US measurement of intrinsic foot muscles in kids with and without long Hx of orthotic use??)

Charlie brings up an interesting point about muscle tightness in his very interesting post..

One thing I have been noticing quite a lot with kids I have seen here and some of the boys on national service, is that they tend to have hypermobility and tight gastrocs (often less than plantigrade with foot in STN). I feel there is some connection (although haven't spent enough time putting it into words to do it justice here) between hypermobility which means the ligaments are providing a lower level of pronatory resistance.

Work with me on this one but: the foot is in a pronated position when the child starts a growth spurt. This foot position means calcaneal inclination angle is lower, so when the tibia grows it increases the tension on the calcaneum, perpetuating the lower calcaneal angle. The lax ligaments in the foot do not have the integrity to counter the escape pronation forces applied by the gastrocs. If the foot ligaments have a higher level of rigidity, perhaps they will resist the forces of the gastrocs enough to encourage it to stretch during and after the growth spurt.

I understand the risk I have taken putting this down. Hopefully I won't be shot down in flames..

I said baby what's the goin' price
She told me to go to hell
Shot down in flames
Shot down in flames
Ain't it a shame
To be shot down in flames

 

Michael Weber wrote:
Hi Charlie.

A few question do the orthotics they recommend you to use have a medial skive ?
do you consider the STJ axis postion during your assessments?

off the shelf device can be great if modified properly.

As for the pain approach to treatment I agree but would add a few others to the list when treating.

Weight of the child if overweight treat.
level of activity of patient if active treat
familiar history of pes planus foot type and other problems such as knee pain treat
how stressed are parents of these patients if stressed treat.

If no treatment I will see the patient every 6 mths to 12 for a revaluation.

Hope that helps
__________________
Michael Weber


The depths of my ignorance revealed again: no, I haven't been considering the STJ axis...until now. Am currently reading (since you prompted me to look it up) up on it.
Also a "kirby skive" has been mentioned in passing by a few people but I haven't really understood it from what's been said in in-house training: I'm now reading up on that too, if I can find any decent articles on Google.

I suspect my practice will be altering slightly in the very near future.

 

OH!
Have just realised the "kirby skive" may be related to this Kevin Kirby bloke I've seen posting here. Crikey. I've passes celebrity and not realised it.
:-D

Right. Oh good grief, maybe the specialist was right in giving me that bloody long reading list. Well, better plough into it!

p.s. "that Charlie bloke" is a woman. Soz about the confusing nickname...still I've had it for decades and rather like it.

 

Sam I would suggest that the tightness in the Gastroc does indeed occur from the pronated postion but I disagree on the reason Why.

If a pesplanus foot the Gastroc may become a pronatory muscle due to the medial deviated of the STJ axis so it no fighting the pronation that cause overuse and tightness.

Think about the main action of the gastroc and sol, it casues a plantarflexion moment on the talocural joint. If the foot is pronated and unstable it will not be a rigid lever arm so the Gastroc, sol muscle must work harder to get the plantarfexion moment to gain propulsion.

Overtime they will become overused stronger and as it often the case shorter.

Hope that makes sense.

On another muscle ever notion how the hamstrings are alway shorter, usually the medial hamstrings.

 

If you PM me your email address I send you a highlights package to get you started.

 

Just thought of some other reasons.

Change in position of the talus position with in the talocural joint with pronation which effects exentric stretching during gait. ( even noticed that people with pes planus develop pain in the ankle when stretching programs are provided)

Also the gastroc, sol must work harder to gain propulsion due to the lack of kenetic energy return as the PF and intrisic muscle do not shorten they do not add to propusion when the return to normal length. So the gastroc, sol must work harder again.

 

Hi Michael.. I like the points.. they make alot of sense..

I still think there something in what I proposed, but adding it to your ideas would make more sense.

My thoughts on this thought is that when you get person with this foot position. I often feel that they don't have a true toe off; base of gait is widened, stride length is decreased, the patient often displays a FnHL (functional hallux limitus, so I wonder how hard the gastrocs are working? It appears to me that the whole talocrural structure is locked in position, with very little dorsi flexion available at the TC joint and with the gastroc-sol working isometrically. Often you get the rocker bottom foot appearance, with toe-off obliquely through the 1st.

You do get decreased rigidity in the foot which means that it is not as efficient a level to propulse from, but I don't think one can solely attribute gastroc shortening to this increased workload.

I feel it is possibly a combination of the two? As with any biomechanics case, there are often several things in play causing any given pathology/foot position...

Chicken and egg?

 

Gastrocnemius can generate external pronation moment even if the internal moment it generates is supinatory. We discussed this in another thread (somewhere). Basically as the gastroc/ soleus generate plantarflexion moment about the ankle, the CoP is shifted distally and may result in a net GRF vector that passes laterally to the STJ axis. This is the basis of the equinus paradox.

 

I´m sure there a combination effect.

Now Spooner, Kirby, Fuller etc will come along and tear down the house and say we have talking out of hats for the day or not.

 

Tune, BTW

 

As I see it, it will be very difficult to get an permanent improvement in arch height with orthotics. Yes, they can decrease the amount and length of time deforming forces are acting, but those deforming forces are still there. In gait, after heel off, the contraction of the Achilles, body weight acting through the tibia, and ground reaction force on the forefoot will cause arch flattening moments.

To achieve a permanently higher arch you would either have to either change the shape of the bones or permanently shorten the ligaments. Permanently shortened ligaments are possible if held in a certain position. e.g. Chinese foot binding or hammertoes. (I keep wondering if we teach youngsters who show a tendancy to have curled toes to actively straighten their toes, would this prevent loss of motion of the joints of the toes?) In the case of height of the arch: the mere act of walking will tend to dorsiflex the forefoot on the rearfoot to the point where the ligaments will become tight. The orthosis, in conjuction with the muscles, could conceivabley prevent further lengthening/flattening, but its hard to imagine a permant shortening of the ligaments in the presence of normal walking.

Regards,

Eric

 

Mark:

The rule of thumb I use in treating children's flatfoot with foot orthoses is to attempt to achieve the following goals:

1. Eliminate any symptoms.
2. Optimize their gait function.
3. Not cause any new pathology or symptoms.

So, in a ten year old, that basically already has their adult foot shape since their foot skeleton is nearly completely ossified, all you can do is to try and prevent further collapse of the medial longitudinal arch (MLA) and prevent further medial deviaton of the subtalar joint (STJ) axis as they age, with little hope of making permanent structural correction to the foot. Even though I know I will probably make their symptoms get better or completely resolve, and I will be able to make them function more normally during gait, they may still be more pronated at the STJ than normal even with the best orthosis I can make for them.

If, however, I was able to start treating this child at age 2 or 3, and I had good compliance on wearing the orthoses, then I would likely have a much better chance of influencing the eventual shape of the bones in their adult foot since the bones of a 2 or 3 year old child are more cartilagenous and less osseous than when they are 10 years old. I have attached an illustration that I drew from 18 years ago for our chapter on children's flatfoot treatment that presents a mechanical model as to how this may occur (Kirby KA, Green DR: Evaluation and Nonoperative Management of Pes Valgus, pp. 295-327, in DeValentine, S.(ed), Foot and Ankle Disorders in Children. Churchill-Livingstone, New York, 1992).

If the foot orthosis is made with the correct modifications and is worn every time the foot is subjected to ground reaction force (GRF), or during all weightbearing activities, then the foot orthosis needs to do nothing more than alter the location, magnitude, location and temporal patterns of GRF acting on the plantar foot. Rather, if we want to improve the results with foot orthoses for the treatment of flatfoot deformity, we do not necessarily need to worry only about fine-tuning the design of the foot orthosis, but rather need to worry also about the following factors that need to be present in order to ensure optimal foot orthosis treatment of pediatric flatfoot deformity:

1) The orthoses are properly constructed.

2) The orthoses are worn 100% of the time that the foot is on the ground.

3) The orthoses (or at least corrective pads) are started as early as possible in the child's life, preferably by the age of 2-3 years old.

4) The orthoses are replaced every 1.5 - 2.0 shoe sizes.

5) Other biomechanical abnormalities such as muscle weakness or tight muscle-tendon units are properly addressed and treated also.

Of course, factor 2 never occurs, but we, as foot-health specialists, should still strive toward making sure that the patients and their parents totally understand these these goals need to be strived toward if we want these children with flatfoot deformity to have the best chance of improving their foot posture into adulthood.

 

Kevin, Eric, Sam et al.,

Thank you again for your replies, which are most helpful. I would agree with Kevin's principles of intervention - reduce symptoms; optimise gait; do no harm - however I see an increasing number of young children at various stages in development who have parent(s) with flatfoot problems - and those parents are, understandably, concerned their child doesn't follow in their own footsteps - so to speak. Many of these children are asymptomatic. Some have shin splints, some knee pain, some muscle pain - especially during sporting activities. It is near impossible to predict if a asymptomatic flatfoot will, at some stage, become symptomatic - and more often than not, my advice would be along the lines of avoiding activities which exposes the lower extremity to extreme ROMs - running, jumping and other high-impact activities.

With symptomatic pes planus it's relatively easy. Whether it's compression syndrome, post tib tendonitis, shin splints, medial ligament strains, etc etc, appropriate custom devices will help. However, in asymptomatic children, is there a role for orthotic intervention as a prophylaxis? I have three such children currently whose parents have opted for orthotic management - all of whom are on their second set of devices. All find them comfortable. None have any symptoms after 3 years. Two of those children (ages 5 and 7 years) appear to be developing a reasonably formed medial arch. Their relaxed calcaneal eversion angle has reduced considerably during the same period - although whether this can be termed "progress" or "success" through my intervention - is impossible to define. The other child (age 11 years) has no discernable improvement in arch height or calcaneal position - but remains asymptomatic. That said her ligamentous laxity is incredible - she can rotate her forearms through 360 degrees!

The problem with early intervention - say at 2 years - is that it is difficult to predict whether the child will develop a normal arch height or whether the genetic factors will influence their development along the lines of their parent(s). To treat or not to treat is such a difficult judgement to make in these patients and I am grateful for the advice once more - although I'm not sure I am any clearer in my own mind whether to intervene or not!

 

Actually, Dr Evans is an academic and private practitioner, not the public sector you suspect. This paper is part of a sytematic review of all evidence published, and weighted according to strict guidleines from the Cochrane database. As such, it carries the greatest weight of any paper for the summation of all evidence available.

As a full-time podpaed I am relieved to find this article as it confirms what I find in clinic day in and day out, and provides me the evidence base to back up my clinical decisions.

Like you I wonder of the ST changes that orthoses make. With regards to arch height and all the rest of the gubbins of foot posture, we DO know that foot posture will 'improve' over time anyway, that is normal development. Mature foot posture is not acheived until over 10 years (as per evidence) anecdotally, I'd say some as late as 14 years.

What we hope - is that we can accelerate or alter this in a way that is apart from natural course of development. It would make for a wonderful PhD! Any takers?

As far as clinical pratice is concerned, how I work with and around this is to:
firstly
- Do full BMX / MSK assessment
- Prescribe exercise program to correct soft tissue length/strength to deal with ST gait compensations
- THEN re-assess gait to see what BMX compensations remain: this is what I prescribe orthoses on.

However, it must be said that most children are better (ie. pain-free and fully functional) just after the exercise Rx and don't need orthoses. If they do need orthoses, I suggest once they grown out of them (2-3 shoe sizes) they go without them for a short period. If symtpoms do not return, no further orthotic therapy is indicated. This is where I suspect we make a change that remains.

That said, there are some kids through experience I take 1 look at their foot posture and prescribe immediatley. Also if theire symptoms have beena round longer than 3 years, as it suggests something more than symtpoms post-growth.

I hope with all that I have that orthoses DO make a permament difference for some children. But it is belief more than evidence, and I tell my patients (and importantly their parents) this and make no promises as to permanent changes. I do however promise that they will most likely make a big difference to their problem now.