Is It Unethical to Prescribe Orthoses for Children with Asymptomatic Flatfoot Deformity?

One last question, Simon, if I may. The father of this boy in you photographs comes to you and asks whether orthotics might help his son's feet. The boy is asymptomatic with a keen interest in sport and has not sustained any injury to date. What do you say?

 

Mark:

These procedures are not routine here in Northern California but are done by a few surgeons. Most podiatrists would treat the child that Simon saw with orthoses first, just as Simon did, and only consider surgery if the patient was unable to walk, run and play without pain.

I don't recommend subtalar joint arthroereisis procedures to asymptomatic children but some podiatrists do. It is very much dependent on the community standards which can vary widely from one state to another or one medical community to another.

However, I think you would have a hard time defending a malpractice case where a asymptomatic flatfooted child developed a subtalar joint infection, scarring and chronic pain in their foot after you placed a subtalar joint arthroereisis implant into their sinus tarsi. This is why I don't do foot surgery on asymptomatic individuals.

 

I haven't noted any adverse reactions in the admittedly small (>25) cohort of patients I've seen and I guess one of the reasons you want to consider concurrent treatment is to reduce the risk of pain and scarring occurring. I can't see why you wouldn't consider surgery providing you did everything to minimise the risk if it offered the real prospect of corrective remodelling on a permanent basis. If you subscribe to the principles of intervention in asymptomatic flat foot, then the same principles should apply to different interventions with the same conditions: do no harm, minimise risk etc. If the outcome can be a structurally remodelled foot which is functionally more stable and performs better and addresses some of the medial displacement that is obvious in Simon's patient, then surely that has to be a primary consideration?

I would have just as many ethical and malpractice concerns with someone who routinely offered first MTPJ athrodeisis surgery for HAV/HR unless it was the procedure of last resort. But then, I'm no surgeon either.

 

Mark:

As a surgeon of 30 years experience, and seeing how even "simple" surgeries can cause pain and scarring where none existed pre-surgery, I can tell you that there is a big difference between surgical treatment and foot orthosis treatment.

With a foot orthosis, if the treatment doesn't work or causes pain, the patient can take the foot orthosis out of the shoe and not have any permanent pain, deformity or scarring. However, with foot/ankle surgery, as soon as your scalpel penetrates the skin, soft tissue and bone infection, painful and/or prominent scarring, complex regional pain syndrome, etc. may occur.

How many podiatrists do you know of that have a patient sign a consent form before they make foot orthoses for them? Not a single podiatrist I know does that. Alternatively, I don't know of a single podiatrist who does not have a patient sign a consent form before subtalar joint arthroereisis surgery on a patient's foot. Why do you think that is?

Juries here in the United States rarely (if ever) have found podiatrists guilty of malpractice for making foot orthoses for patients. However, foot surgery is the most common treatment used by podiatrists who are eventually found guilty of malpractice here in the US. Maybe it is different in Britain, but here in the US, these are the facts of podiatric practice.

 

Indeed. As you wrote in your previous post

and, of course, the legal environment is part of these considerations. Of course surgery carries greater risk, but I don't think it should be discounted. If you look how the dental profession has embraced implant technology and the benefits it has offered their patients - and you can see the parallels with orthodontic provision -v- implant surgery with our own dilemma - if I can call it that. I don't see any reason why we should push surgical boundaries as well as others. If your own preference is for conservative management that's great - but I'm sure there are surgeons who use this type of surgery with acceptable levels of complications who achieve consistent results that far exceed what you might be able to achieve with orthotic management on its own. For the record I have consent for every patient I see - it's part of their initial consult and paper records and it covers all aspects of what I do - surgery and orthotics too.

And I disagree with your point about minimal risk with orthotics. I've seen some quite shocking prescriptions over the years in one case leading to a compression fracture of the navicular where the patient was told to "wear them through the pain". The problem is the level of knowledge present in the body professional - and I guess that is something present in every country where podiatry is practised. My local NHS biomechanics department takes a "meat pie" approach to everything. A simple insole with a 5 degrees medially posted rearfoot wedge and a 2cm square 3mm wedge under the 4th & 5th met. That's it. For every condition from PTTD, achillies tendonitis, shin splints, peroneal tendonitis, hallux limits, hallux valgus, calcaneal bursitis, plantar fasciitis, plantar plate tears and the occasional chilblain. I kid you not. Most of the time there is no harm done. The patient either gets better or not. If it's the latter, they usually seek help elsewhere and sometimes they get lucky. But occasionally you see some patients who have sustained permanent injury from wrongly prescribed devices and there is risk to consider here too.

Just out of interest, have you ever wondered what percentage of the podiatry profession could actually be considered competent in the understanding of foot mechanics and their importance in orthotic and surgical provision? I know readers of these pages will certainly apply some of the knowledge they have gained here - but that is just a fraction of the podiatry profession worldwide. Every day colleagues are dispensing devices on the premise that pronation is bad and hyperpronantion is very bad with the most inappropriate of devices and content in the knowledge that they know absolutely nothing at all about what they are talking about. Here's a suggestion, Kevin. Next time you're on tour somewhere - go incognito to a podiatry office and ask for some advice a for a foot condition. I'm sure you can apply some imagination and choose something interesting. It will be an enlightening experience I can assure you.

Podiatry needs to build its knowledge base from the bottom up - urgently. The majority of podiatry dispensed orthotics are no different to what a patient might expect to obtain from a local pharmacy and probably underpinned with the same degree of specialised knowledge. But in the context of this discussion I think it's particularly refreshing to examine the possibilities at the other end of the scale - including the combination of podiatric surgery and orthotic provision, which seems a sensible and worthwhile collaboration to me.

 

Mark:

I have no problems with doing surgery and combining surgery with foot orthoses since I have been practicing this way for the past three decades.

The point I was trying to make that is that the risk of injury to the patient and the risk of malpractice exposure to the podiatrist increase considerably when comparing conservative care to surgical care. That does not mean that surgery shouldn't be offered or recommended, it just means that surgery carries greater risks. All these factors should all be taken into consideration by the podiatrist and patient, especially when the patient is asymptomatic.

 

Of course, but you are hardly representative of the podiatry profession as a whole!

Absolutely, but I simply make the point that they should be considered all the same.

 

Thank God for that!

 

As I previously stated: what I actually do is relate what the evidence base- from anecdote through to controlled trial tells us about their childs feet and allow them to make an informed decision about how they wish to proceed with their childs care.

Of interest here, there is no positive family history, I have examined both parents feet, neither parent recounts a positive history in their own parents either.

Re: surgery, the key here is that the parents do not wish to go down a surgical route.

 

Well, it's been an illuminating discussion once again and does leave me with more questions than answers - not so much about the clinical aspect of paediatric flat foot - but the profession's approach in dealing with it, especially those who take a single-strand approach to management. A few months ago I was discussing the management of intermetatarsal neuroma with a colleague. Her approach is to supply a dome insole and/or silicone digital splints in a effort to adjust the pressure on the nerve tissue from the adjacent bone. I asked whether she did an US or MRI to determine whether it was neuroma or bursa and to gauge the size? No. Did she refer to her local pod surgeon for an opinion then? No. What happens when the pain becomes intractable? She sends them to see their GP. Can she offer a steroid infusion? No. Would she consider sending them to a colleague who can? No - she might lose the patient if she did that.

I'm all for taking a careful, considered approach to patient care and absolutely subscribe to the principle of "doing no harm" - but I fail to see why there is such a gulf between the surgical and non-surgical divisions in podiatry, almost to the point where their is real hostility - especially in the UK. Thirty years ago it was a local orthopaedic surgeon who specialised in foot and ankle surgery where I worked - Mr Ian Brown FRCS - who approached the podiatry department to see if we would be interested in a collaborative project for his HAV patients where we would assess the patient and fit them with prescriptive devices if we thought there was a contributory factor. Unfortunately the local NHS podiatry service did not have the capacity - both in terms of numbers and knowledge - to run a joint programme and it didn't get off the ground, but it highlighted an area that could work to the advantage of the patient and the profession(s).

There are probably many surgeons who don't understand the various mechanical forces that area play in the foot and who would benefit greatly from the expertise of clinical specialists in that area - just as there are many biomechanists who haven't a clue what surgery can offer as an adjunct treatment to their own specialisms. That is a great weakness in our profession. I don't get this "I'm not a surgeon" or "the parents don't fancy surgery" business. As general practitioners we should have the knowledge of all the various foot procedures and the benefits/risks it offers our patients - and how it can supplement and enhance the care that we provide. In the case above it is mentioned that the orthopaedic surgeon made a diagnosis of accessory navicular but no radiographs or other investigations were made. How was he/she able to reach that diagnosis? What type? How big? Is it fused, semi-fused? Degenerate?

Here's a quote from another surgical colleague who has been following this thread.

and in respect of informed consent...

I'm not suggesting there is any negligence in the case illustrated - but the dismissive tone re surgery and its benefits is sadly one that has characterised the professional recent times - to everyone's disadvantage.

 

If this surgeon is so confident of themselves, then why doesn't he/she come on to Podiatry Arena to enlighten us as to how we should all be practicing? Why are you acting as the go-between?

 

I'm sure they will be happy to discuss how their practice and ours can be complimentary rather than conflicting - as opposed to than "how we should all be practising", which in the context of your quote seems terribly condescending. I'll ask if they might be minded to offer a reply..

 

To the impetus of the thread and asking the question of "is it ethical to provide podiatric devices to the asymptomatic child" I will also offer this:

12 year old girl playing vollyball comes to my door with a lateral ankle sprain. She is provided a lacer with cross strapping to limit inversion. During exam it is noted that bilaterally there is a laterally deviated sub talar axis (which probably lead to the sprain in the first place) so I indicate that and the implications for possible ligament damage contralaterally. Mom buys one for BOTH left and right. Am I un ethical?

Young man comes in to discuss his football program at high school and wants to protect himself as he is a linebacker. He wants to prevent knee injury as he has not yet had one and does not want one. He is provided basic knee control devices off the shelf and they are fitted to him. He wears them for practice and some games. Am I unethical?

Scenarios like this happen often. We know we are being preventative and prophylactic knee orthosis use in football is not unusual at all. Preventative ankle support is used in basketball and vollyball routinely. Is that an unethical thing to do?

Just food for thought.

 

Mark,

A few in point of facts:

I don't think anyone here has suggested "a single-strand" approach to management.

The case in point of my patient: the family in question had seen a very experienced orthopaedic surgeon who specialises in foot surgery prior to presenting to any podiatrist. Knowing the parents as I do, I am fairly certain they would have asked a battery of questions regarding the son's feet and the best form of treatment for him. Thus, in this instance, the surgical managment option was not initially presented to the patient, nor this child's parents by the Podiatrist. Rather it was initially presented by the surgeon. If the parents felt that surgery was not the route they wished to go down at this time then it was down to the way the surgeon presented this option, not the podiatrist. I have no doubt however that it was presented in a "professional , knowledgeable , and positive way".

As I said , I have also discussed other surgical options with the parents since meeting them, however, they were adamant that they did not wish for their son to undergo surgery until conservative options had been exhausted. Now, while I read and keep abreast of surgical research as much as time allows, as I stated I am not a foot surgeon. Thus, ultimately I defer and refer to those with expertise in the field to ultimately make the decision as to the type of procedure they should perform- BTW, is a subtalar arthroesis the procedure of choice in this case? In a similar vein, I should not expect the practitioners who refer patients to me for foot orthoses to tell me how to manufacture and design the foot orthoses, since this is my area of expertise which they recognise and the reason they have sent the patient to me.

Now, as far as I am aware you cannot force people to undergo elective surgery in this country. So whether you "get it" or not, is really neither here nor there. The parents as legal guardians in this case have been presented with information in a "professional , knowledgeable , and positive way" and they have made an informed decision with regard to their child's care. At the moment at least, they seem delighted with the way that this is progressing.

Question: do you have any children of your own, Mark?

 

Thanks for this, Simon. It is a more comprehensive history than you first posted and explains your position much better, thank you.

Yes.

 

Then I'm sure you will appreciate the feelings and emotions that these parents and similar are going through here.

 

I'm sure that like most parents, they will be very concerned with their son's foot and ankle problems and determined to get the best possible outcome for him. I'm also sure you will do your very best to achieve that outcome too. Good luck.

 

Sorry....I am like that at times....no harm meant.:drinks

 

British Journal of Podiatry November 2004 ; 7 (4): 101-105
Conservative treatment of juvenile hallux
valgus - A seven-year prospective study
Andrew J H Macfarlane, T E Kilmartin

Conclusion:
"There is clear justification for deferral of surgical reconstruction until
skeletal maturity when the outcomes of surgery are likely to be more
predictable. "

Why did Kilmartin, a highly experienced pediatric surgeon believe that hallux valgus surgery should be deferred until skeletal maturity was reached? Does the same apply to flat foot surgery?

 

Why not ask him and see if his views have changed in the ten years since the paper was published? The surgery certainly has - and it is worth noting that Tim's paper was for juvenile HAV not paediatric flat foot. Different condition; different surgery; different priorities.

 

Yes, that's why I asked:

Mark, I don't know what your problem is with me lately, but I think it'll probably be in the best interest of the other members of this community if you and I don't bother trying to communicate with one another any more. Good luck with your future.

 

Simon

I don't have any problem with you; why should I have? I've nothing but the utmost respect and admiration - and always have and I'm sorry if you feel I've been pointed or critical - it's certainly not intended that way. But I would like to explore what other colleagues think about the subject you raise i.e. bone or structural remodelling, whether that is unaided or by conservative and/or surgical intervention. I also don't have a problem with the approach others take or what views they have - it's a condition that has certainly challenged me over the years and one that holds special interest given the outcomes I've seen recently with both surgery and orthotic management. I thought that given your expertise and knowledge on unaided and orthotic remodelling, you might have had some thoughts on the potential of surgery to enhance or accelerate a staged remodelling (dare I say "correction"?)which is rarely achieved otherwise - which is why I've tried to push you on that precise point. Absolutely no malice intended - and besides, as you remarked in a previous post on this thread:

Good! I hope we all do.

As an aside, I've also lost two close friends in as many weeks and I have to say I'm not my usual happy-go-lucky self at the moment so if I have come across as irascible then please accept my apologies. And I look forward to that pint you owe me next time....:drinks

Kindest
Mark

 

Let me answer this differently. I can understand the principle you are trying to assert, but I do think there are different considerations for both conditions. I agree with Tim and his position regarding juvenile HAV, before the osseous centres have matured - even with the more dynamic procedures like the scarf-Atkin osteotomy. It makes sense to wait until bone maturity - the structural position should not deteriorate to the point where surgical intervention is more complex or should not be indicated at all.

However, my feeling is that in juvenile flat foot, early intervention may be preferable - but conditions apply. There are any number of flat foot procedures - a simple talor implant is but one. Sometimes they are done with soft tissue release, like TA lengthening or in tandem with a calcaneal osteotomy - but in children with excessively medially deviated STJa and flat foot, usually it's just the implant, which is a relatively safe and simple procedure - in my experience, of course.

At the end of the day it's about what you're trying to achieve and if it is some degree of structural correction, especially in such a load bearing structure as the medial longitudinal arch, then it may well be that the earlier intervention - the better prospect of success. That is certainly the case for clubfoot or TEV - should that principle not equally apply?

Mark

 

One last thing I will add is that depending on where you reside the simple act of writing the script yourself and then filling it are in itself a conflict of interest ....... let alone the well placed altruism related to the accuracy of your assessment or the timing of application.

 

Mark, just trying to get my head around "force/impact absorbency as opposed to shock absorbency". Are they not the same?
Thanks

 

Seamus

They probably are the same and I'm struggling to find a term that describes the difference between the action of the high density EVA referred to and any of the PU rubbers such as Poron and Sorbothane. The following is taken from a sorbothane blog http://www.sorbothane.com/blog/what-types-of-materials-are-best-for-shock-absorption/

Ok, we're all familiar with the properties of Poron and Sorbothane and they are certainly amongst the most popular choice for podiatrists who wish to provide some 'shock-absorption' for their patients, for example; plantar lesions; symptoms associated with atrophy/dysfunction of the plantar plate and calcaneal bursitis. I can't provide comparative analysis for the EVA as I don't know how to measure the force impact/damping effect (perhaps one of our lab gurus might..?) - but in my experience, therapeutically it far out performs any PU rubber materials in almost every aspect - the only 'negative' is that they need replacing every 4-6 weeks.

Think about it this way. If you were to jump out of an airplane without a parachute - what would be your preferred material in the LZ? Cardboard boxes or sorbothane? Both will 'absorb' the impact - but one will kill you in the process, the other you can walk away from.

Mark

PS - the jumper is Gary Connery who did the Bond jump with the 'Queen' in 2012. Spoke to Gary this morning - the reason he chose cardboard boxes is that it is the displacement of air within the structure at impact that provides the best shock absorption - the critical properties are the retention and displacement rate within the structure/material. The boxes are 3' deep - stacked seven high and are unsealed. As he points out, it doesn't work quite so well jumping onto 21' stacked flat-packed cardboard - or sorbothane for that matter. Apologies I can't provide a more scholarly explanation, but I'm sure there are a few who can...

 

Just discuss in terms of stiffness Mark

 

Hi Mike - in terms of stiffness, generally the less stiff the material the higher the energy absorption - but I would guess there are other factors that are just as critical. I'm sure you have a good deal more knowledge than I have in the relative properties of materials and their effect on plantar pressures - why do you think a closed cell EVA performs differently than PU rubber in energy absorption?

 

Here is what wikipedia says about shock:

The best way to simplify this discussion for those interested in better understanding "shock absorption" and "cushioning" is by focusing on this last sentence: Cushioning reduces the peak acceleration by extending the duration of the shock.

In other words, all that a shock absorbing material such as sorbothane, poron, Spenco (which I prefer for orthosis topcovers) or empty cardboard boxes do when they "absorb shock" is to increase the duration of time over which the object is being decelerated when the "shock" is occurring. In other words, a shock absorbing material "dampens" the shock.

For example, let's drop an egg from a 1.0 meter height onto a concrete floor. What happens? The egg breaks. Why? The egg undergoes a rapid deceleration at the instant of impact with the concrete floor, traveling at about 4.4 m/sec, and decelerating to 0.0 m/sec in probably less than 0.05 seconds (less than one twentieth of a second).

However, let's now drop an egg into a box containing a 20 cm (0.2 m) thick layer of Styrofoam beads resting on top of a concrete floor so that the egg hits the cushioned surface of the Styrofoam beads after falling 1.0 m. What happens? The egg doesn't break. Why? The egg still hits the top of the Styrofoam beads with a velocity of 4.4 m/sec. However, the egg doesn't as decelerate rapidly as before, but rather decelerates now over a longer period of time, lets say 1.0 seconds. Since the egg is now being gradually decelerated by the 20 cm thick cushion of the Styrofoam beads over a 1.0 second duration, instead of being decelerated over a 0.05 second duration before it comes to rest at a velocity of 0.0 m/sec, the Styrofoam beads dampen or "cushion" the magnitude of deceleration of the egg so that the egg doesn't break on impact.

In other words, the egg decelerates about 20 times less when hitting the box full of Styrofoam beads than when hitting the concrete floor so that the "shock" (i.e. the magnitude of deceleration) acting on the egg is also 20 times less when hitting the Styrofoam beads.

That is why the box of Styrofoam beads (and the multiple layers of cardboard boxes filled with air in Mark's video) prevents injury to the egg (and prevents injury to the skydiver in Mark's video): both the Styrofoam beads and empty cardboard boxes increase the duration over which the deceleration of the object occurs so that the maximum magnitude of deceleration of the object is kept below the critical magnitude of deceleration (i.e. critical magnitude of "shock") where injury occurs.

If you watch the first one minute of this video (and turn down the volume of the annoying soundtrack), you will get a better idea of what I am talking about.

Hope this helps.:drinks

 

Thanks Kevin, that's great. I'll see if I can get some information on the stiffness and other properties of this material is anyone is interested and post it up when I have it. I had a feeling we had been around this particular stump before vis-a-vis subtalor artheroesis in paediatric flat foot management http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=71449 Good discussion.

 

Mark:

It's not all about stiffness. How well a shock absorbing system absorbs shock is dependent on many factors including the velocity of impact and the mass of the object. Stiffness of the shock absorbing system is important but it is only one of the variables which may may a shock absorbing system work well or not work so well.

For example, let's look at a running shoe midsole. Two running shoes are compared, both with a midsole that has a foam with the same durometer (i.e. same stiffness). However, one shoe midsole is 20 mm thick, and the other midsole is 5 mm thick. Which one will better decelerate impact during running (i.e absorb shock)? Of course, the 20 mm thick midsole will better absorb shock since there is more shock absorbing material under the foot at the instant of impact. This is one of the reasons the Hoka One One running shoe is so popular, because they simply have a thicker midsole than nearly any other running shoe so, they have a thicker layer of shock absorbing material under the foot of the runner.

In another example, if we have a two running shoes with the same midsole thickness, but one has a higher durometer midsole (i.e. more stiff) and the other one has a lower durometer midsole (i.e. less stiff), which running shoe will better absorb shock? It depends! How each running shoe will absorb shock will depend on the stiffness of the midsole material, the thickness of the midsole material, the mass of the runner and the velocity of impact of the runner with the ground.

If the midsole is too soft (i.e. low durometer) and too thin, then the heavier, faster runners will tend to bottom out the material so that they actually experience more shock than if they ran in a midsole material that was harder (i.e. higher durometer) that didn't bottom out. For the lighter runner, the lower durometer midsole running shoe may be the best choice for them since they simply are hitting the ground at footstrike with less mass so that the their momentum and kinetic energy of impact is less than that of the heavier runner.

This is why running shoes (and running shoe midsoles) should to be tuned for the weight and the speed of the runner so that maximum shock absorption can occur with a minimum of shoe mass.

Maybe this discussion should be moved to another thread since it doesn't seem to apply at all to asymptomatic flatfeet in children.

 

Thanks again, Kevin - that makes sense. Let me know when you receive the material I sent - would be interested to hear your views. Reverting back to the thread, I am no wiser whether the consensus is for or against intervention in asymptomatic flat foot - or whether it may be unethical. Perhaps a poll might be enlightening?

 

Which is effectively the same as having a 5mm spring and a 20mm spring made of the same material; what does Hookes law tell us about how this influences the amount of deformation per unit load, i.e., the stiffness? All other factors being equal the thicker sole is less stiff, or more compliant. Thus, at impact the rate of change of momentum is lower and equilibrium is reached over a greater distance in the thicker soled shoes.

However, what none of this takes into account the CNS mediated influence of surface stiffness on lower limb stiffness, which will also influence rate of change of momentum in the system, i.e force = Newton's 2nd.

Which brings us back to the "spring wedge problem".

 

Now there's another thought. The difference between a falling object (the egg) and a foot which has intelligent influence from the CNS (learning, memory etc). Anyways that is/was a great thread. Drawn to it in pursuit of an an answer to what seems an eternal question, for me, 'To treat or not to treat, the happy childrens feet'. Then a great aside on another favourite subject - shock and its absorption. Thats one I'll have to go through again with my mechanical engineering son looking over my shoulder. And, yes, maybe it needs splitting from the main theme.
Thanks to all.

 

For those interested, here is pdf copy of my article in Podiatry Today Magazine (Kirby KA: Is it unethical to prescribe orthoses for children with asymptomatic flatfoot deformity. Podiatry Today, 27 (12):74, 2014).

 

Rolls eyes in exasperation. Let us look for a common word: symptoms................ All the stuff you are talking about here is symptomatic flat foot - that is not what we were talking about. And you know that. Happy to talk more when you wish to come to the party..................................

 

Definitions:

Symptom: subjective evidence of disease or physical disturbance

Sign: an objective evidence of disease especially as observed and interpreted by the physician rather than by the patient or lay observer

I've been at the party all along......for some reason you just never noticed....

 

There is a reason why when we describe the findings from history and physical examination of a patient that we say the "signs and symptoms" of a patient.

At least here in the USA, but maybe not in Australiia, we are taught by our professors (who were medical doctors) that symptoms are subjective complaints that are reported by the patient and signs are the objective findings from our examination of the patient. That was made very clear from our first year of podiatry school and was hammered into us during our four years of podiatry school and during our surgical residencies.

Therefore, here in the USA, but may not in Australia, when a podiatrist or medical doctor says a patient is asymptomatic, this means that the patient has no subjective complaints but doesn't necessarily mean that are lacking objective findings of disease and/or pathology (i.e. signs).

Therefore, all the stuff I was talking about in my article was valid, and I do know that!! When a child has flat feet but has no subjective complaints, by definition, that child is asymptomatic. However, when a child with flat feet has no subjective complaints but has objective findings of abnormal gait function then the child, by definition, is asymptomatic but with signs of gait dysfunction.

Regardless of all this exasperating nonsense, I will still go on treating the many children I see with flatfoot deformity the same way that I have over the past 30 years, just like I would treat my own children or my own grandchildren if they had the same problems, regardless of what someone else wants others to believe and regardless of what someone else proclaims as ethical and unethical behavior in podiatrists.

 

I think that you know perfectly well that in this context, signs and symptoms were synonymous. Odd how you bring this up after all this time.

 

Sorry, that I couldn't read your mind better but, no, I did not know, until now, that you consider signs and symptoms the same thing. In fact, I don't know of any physician in the USA that considers signs and symptoms the same thing. It must be an Australian thing. Odd why you didn't clarify that in your original paper.

Since I now know that you think that signs and symptoms are synonymous, then we are in agreement. I would not treat a pediatric patient with flatfoot deformity without signs or symptoms of pathology.