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Achieving permanent correction with FFO therpy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mark Russell, Dec 14, 2009.

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    Has there been any published research in the efficacy of functional orthoses in the treatment of paediatric pes planus where the primary aeteology is ligamentous laxity - and is there any evidence to support the suggestion that permanent correction of this condition can be achieved if patients with the above criteria wear prescriptive devices over a period of time? If so, which patients respond more favourably - and does the same apply to all patients with soft tissue gait related pathologies?

    Cheers


    n.b. and can admin insert an "a" in the title please?!
     
  2. Hi Mark heres one for that says no change with the use of orthotics .Its a bit old and I just read the Abstract but something to get started with.
     

    Attached Files:

  3. Thanks Michael - on my bedtime reading list. What I am getting at is whether we can say (with any certainty) that prescriptive foot orthoses have the potential to achieve permanent correction in some foot conditions. For example, recent advances in splinting and soft tissue manipulation have resulted in tremendous clinical results in TEV treatment - utilising a similar approach could we see similar in some podiatric patients? I recently reviewed a 14 y/o girl who, at her initial consultation 3 years ago, presented with gross calcaneal eversion, flattening of the MLA and an abducted forefoot. She has been compliant in wearing her custion devices over the intervening period and I was happily surprised to see her rear and midfoot alignment had improved significantly. Her mother had asked the question - one that I'm sure most clinicians get asked on a frequent basis "will she have to wear the orthotics for the rest of her life?" - and I couldn't accurately answer her. Clearly Davis's Law has to have an effect in soft tissue modelling and joint alignment and I was wondering if there are any studies to quantify the effect of FFO in this regard.

    Also, are there other therapies - aside from mobilisation and manipulation - that can impact on soft tissue modelling? I read with interest the thread on Prolotherapy and the effect on ligament repair. Has anyone looked at this as an adjunct to orthotic management?
     
  4. Mark I read a study that was done in the 50´s in England ( I don´t have the referrence sorry), now I read this 15 years ago too so the memory maybe a bit off.

    They basically took thousands of kids split them in two groups gave 50% orthtoics of some kind and the others nothing.

    They measured arch height at the start then after 6 months. The group with the device had a bigger increase in arch height. Then then remeasured 6 months later and there was no difference between groups.

    I do agree that a device will reduce loads on some ligaments and muscles during growth which must have a +ve effect. It will of course increase loads on other muscles and ligaments which may have some -ve effects.

    There sould be some davis law changes as well, there will in a pes planus child be less elongation of the plantar fascia which may mean greater effectivness of the windlass effect.

    I do not have any other studies at hand. It is an intersting question and another question to consider would be if you removed your device from the above patient would the pes planus return due to the genetic make up of the patient.
     
  5. I guess that depends at which stage in development the device was withdrawn - and assuming that you have effected some structural changes in the first instance. I also think there may be an otogenetic primacy towards function over form, which may conflict somewhat with the present convention that genomic, rather than epigenetic factors control growth (just consider the bony changes that take place when foot binding was applied to Chinese women, for example). And if that is true, then the role of corrective foot orthoses may well be more important than just reducing abnormal stresses in soft tissue structures and aleviating associated symptamology. It would certainly make a case for orthotic managment in the developing foot in a greater number of cases than we see presently.

    What do you think?
     
  6. It would, so we come back to your orginal request for a small lit reveiw on the subject. I´ll do some more googling a see if anyone else has some research they can post up.

    Hopefully a few pead pods will read it over the next few days so we can see if you patient goes with or against the norm.
     
  7. Some more reading for you Mark. A more recent piece Which seems to have lots of references for you to look up.

    Hope that it helps.
     

    Attached Files:

  8. Interesting in the conclusion the author states
    Yet argues
    This reads to me that the author is someone in public health whose primary role is directed in justifying her cost/benefit analysis of paediatric flat foot management rather than what the most clinically effective short and long term management of the condition actually is - acording to the available evidence - which is, as she frequently states
    Further, she claims
    Whilst this may be consistent with some of the published research in the prefabricated -v- custom foot orthoses debates, it flies in the face of enlightened views - especially in the Arena community - and she provides no evidence to substantiate her claims in this article.

    Doesn't quite answer my question regarding soft tissue modelling and functional bone matrix hypothesis with FFOs....
     
  9. I thought that the references that she used might be a guide for you, for the finding more info on your subject. Not so much what she had written.

     
  10. Michael

    Have looked through the reference list and the only paper that indicates structural change is: PENNEAU K, LUTTER LD, WINTER RB: Pes planus: radiographic changes with foot orthoses and shoes. Foot Ankle 2: 299, 1982.

    I don't have access to the paper but if anyone has, I would be grateful if they could copy it here. Would've thought that such a topic may have been raised in the Arena before ...... Anyone care to point me in the right direction?

    Cheers
     
  11. Mark:

    Regarding the permanence of correction that foot orthoses can have on the developing pediatric flatfoot, I wrote a chapter on the conservative treatment of children's flatfoot (along with Donald Green, DPM) back in 1992 (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). Here is an excerpt from the chapter which (even though it has been 18 years since I wrote the words) still seems to give a good critical analysis of the subject you are seeking information on. (Please note that this is what I wrote and submitted for publication in the book from 19 years ago...the actual chapter was edited to be less complete.)

     
  12. I found an abstract which said.
     
  13. Kevin

    Thank you for taking the time the post this helpful piece on pes planus. A couple of questions, if I may...

    You wrote:

    I agree with the first two paragraphs which describe the changes in the developing foot, however it is the third paragraph that holds the greater interest. If we hypothesise that the child with early stage pes planus is subject to the abnormal internal forces you describe - but has not exceeded the elastic limit on the plantar fascia and plantar and ankle ligaments - then is there a possibility, that by maintining the foot in a "corrected" position, the associated soft tissues will adapt (reverse-creep, if you will) to the new position? Clearly, to what degree our present FFOs will achieve correction is debatable, but there is evidence to say that structural deformities can be corrected by serial casting, splinting and orthoses like with the Ponseti Method in talipes equinovarus. That intervention obviously occurs at a much earlier age but at what stage in development is it "too late" to effect chage in structure and function by a conservative approach?

    Finally, in regard to permanent changes in ligaments, where acute trauma occurs - such as in supination-inversion ankle injuries and there is damage to the anterior talo-fibular ligament - either a strain or a tear - early immobilisation and gradual rehab will return the integrity of the structure to pre-injury levels. Now I appreciate it's near impossible to measure in vivo ligament tensile performance for any comparative studies, but applying the principles of Davis's Law it's not unreasonable to assume that, even in the adult foot, soft tissue structures such as the plantar fascia and plantar ligaments can be remodelled by a variety of techniques over a period of time. Which brings me back to my original query - can we effect permanent correction in foot structure and function with the use of functional orthoses - and if so, to what extent is this a goal in your management of - not just pes planus - but any lower limb disorder where ligament and fascial elongation/deformation has occured? And are there any non-surgical techniques that can be employed to accelerate ligament contraction?

    Thanks again for your input.
     
  14. Many thanks for your help Michael - much appreciated. I'm not that surprised at the findings in the abstract - I think for radiographic changes to occur we would need to see a variety of techniques employed and over a longer period - and perhaps in a younger age group. Thanks again.
     
  15. Immobilisation.
     
  16. I had mentioned immobilisation in my reply to Kevin, Simon. I was thinking along the lines of infiltrated agents like those described in the prolotherapy thread. I haven't used the technique and do not know of anyone who has - but if the claims have substance then it might be a useful adjunct in orthotic Rx. For patients who present with acute PF or medial ankle ligament strain/disruption, I routinely use either low dye inversion strapping and/or an aircast walker prior to fitting FFOs as I find this helps reduce the recovery time. Just wondering if there are any additional techniques that we can employ....
     
  17. http://en.wikipedia.org/wiki/Prolotherapy
    I think I'd like to see the results of prolotherapy from a good quality RCT.
     
  18. Mark:

    It is a known physical characteristic of ligament and tendon that they will shorten when the stretching force is removed from them. Certainly, it seems reasonable to assume that if we can reduce the stretching force from the plantar ligaments over time in a pediatic flatfoot with a well-made custom foot orthosis, and this custom foot orthosis is consistently worn by the child, then these plantar ligaments will shorten to make the longitudinal arch higher into adulthood. However, without strong extrinsic and intrinsic muscles of the foot and possibly proper shoe gear and orthoses to continue to reduce that stretching force on the plantar ligaments later on into adulthood, the chances of the plantar ligaments by themselves resisting these stretching forces is not as good.

    With the knowledge available to us now, it seems very obvious to me that custom foot orthoses are the safest, least invasive and most therapeutic treatment option available to us for the treatment of pediatric flatfoot deformity and for the prevention of progression and worsening of flatfoot deformity into adulthood. I really don't understand why this is so hard to understand for a majority of the medical profession since orthodontists commonly use bracing techniques on the growing teeth of children to straighten their teeth and orthotists use bracing techniques on children to straighten deformities in other areas of their body using the same concepts that podiatrists and other foot-health professionals use with custom foot orthoses for pediatric flatfoot deformity. It seem to me that, when it comes to custom foot orthoses, many otherwise knowledgeable and wise health professionals suddenly seem to forget what is commonly done and medically accepted as treatment for other areas of the body. It remains a mystery to me!

    By the way, I am familiar with prolotherapy but have not used it myself and don't think it is currently used in children for the treatment of flatfoot deformity.

    Hope this helps.
     
  19. Kevin

    Helpful as always and I am grateful as ever for your thoughts. I agree that there are factors, other than ligament laxity, which influence paediatric flatfoot and clearly the clinician will always have to take these into account. But of course, not all clinicians advocate early intervention, especially where it is asymtomatic. This is a pity in my view. In consideration of current practice in orthotic managment, I sometimes wonder if we are too conservative in our approach and should be taking a more radical and progressive line towards foot remodelling in paediatrics. Obviously this has to be balanced insofar as we do not wish to overstress other lower extremity components - but this may go some way to explain why some patients find techniques and devices such as those promoted by Glaser et al. more beneficial than those orthoses modelled on a weightbearing or neutral cast, for example.

    Leaving paediatric flatfoot for the moment, if you have a patient with early stage hallux abducto valgus which is secondary to a medially deviated STJn axis and you prescribe a custom device with a medial -> lateral rearfoot post, how confident are you in predicting the forefoot condition will not deteriorate further - assuming good patient compliance?
     
  20. :D:D:D Fishing for a bite, Mark? LoL;)
     
  21. Mark:

    The development of hallux abducto valgus (HAV) deformity is multifactorial. Progression of HAV deformity may be caused by increased STJ pronation, by flatter longitudinal arch height, by tight and pointy-toed shoes, by metatarsus adductus deformity, by trauma, by surgery and by arthritic processes. Therefore, unless one can control all of the factors that may contribute to the production of HAV deformity, then one can't be too certain that even the best orthosis will actually do much good for HAV prevention or to limit HAV progression.

    For example, if the patient has a pronated foot but also has a high degree of metatarsus adductus deformity, it is unlikely that even the best custom foot orthosis will have the ability to change the abnormal angle of pull of the flexor hallucis longus tendon and plantar intrinsic muscles which may cause further hallux external rotation moment and, therefore, further gradual development of HAV deformity. However, as another example, if there is little to no abnormalility in the metatarsus adductus angle, and the patient doesn't wear tight or pointy-toed shoes, then, yes, the custom foot orthosis would probably help the patient with a mildly to moderately medially deviated STJ axis with preventing further progression of their early stage HAV deformity.

    Hope this helps.
     
  22. Kevin

    I realised I should have qualified the question to you by inserting "exclusively" before 'secondary to a medially deviated STJn axis' just before you posted your reply!

    OK, so some foot orthoses have the potential to effect permanent change - which is what I'm driving at - rather than just reducing pathological stresses on foot components which, in turn, produce symptoms. Firstly, returning to the paediatric patient - let's assume we have a ten y/o girl with flat feet and extreme ligamentous laxity. When considering your orthosis prescription, does your thinking include a degree of pedal remodelling - say by increasing arch height on the +ve cast - and by what incremental degree?

    Second, the current range of foot orthoses work by altering the GRF through the foot at various stages in the gait cycle. How can this be improved?
     
  23. Unless you can argue the design of a foot orthosis that does something more than alter GRF then that's all that they will they will ultimately ever do. Inert bits of plastic that alter the reaction forces at the foot orthosis interface. Bowker gives more, but hey ho. Or should I say Ho, Ho, Ho. What we need to know is how to better control these kinetic effects.

    Whatever happened to the foot orthoses consensus project??????

    Moreover,
    Whatever Happened to Pete The Chop?

    Feeling lyrical tonight: You know who-
    I like to smile
    But I like to mostly stay with you
    I like good times
    But I can't feel this without you
    By my song
    The heart is in the place
    I sing this song
    Probably so


    If I could sigh
    I'd tell the world I'd felt with you
    I like the time
    I like the feeling when
    I feel you in my arms
    I'll take you in my hand
    I'll let you go
    Somebody save me
    Somebody save me


    Sing it
    Sing my, sing my song
    We sing the same old song loud


    Smile...though your heart breaks in two
    Touch me...when will I be with you


    I like good times
    But I can feel it's going wrong
    You sing the same old song
    Now I think it's time to get it right


    Sing it out, sing out...
    Sing this same old song


    If I could swim, I'd swim in circles
    If I could drown, I'd, I'd drown with you
    If I had enough of my life
    I can't tell
    If I had enough of you
     
  24. For the majority of patients who seek our help then good quality custom devices will suffice. And if we are lucky, then sometimes we can effect permanent change/correction. However...... for some, where there has been say, medial ankle ligament damage and acquired midfoot collapse, current best approach may well be a combination of surgery and orthosis - and as surgery is not always an option in these patients, we often fall short.

    I'm fortunate to have a good laboratory and technician (Phil Wells, please note!) who provides quality products and advice, but there are times when even I am left wondering if what I am providing is enough to maintain reasonable mobility. For some patients, like those above, I have been combining prescription orthoses with neoprene ankle supports, which seem to work better than just the orthosis alone. Matthew Taylor at Dorset Orthopaedics has done some sterling work on SAFO devices for CMT etc. - where support is given above and below the ankle mortice.

    For patients where we need to support ligament function - i.e. in the paediatric flatfoot or elderly medial ankle atrophy - could this be a better approach?

    Tis a pity - have my guitar out tonight....could've penned a new xmas hit!
     
  25. Boots, "supports" AFO's etc all have a place in our arsenal, but can foot orthoses ever do anything other than alter the reaction forces between the foot and it's interfaces- no, unless they start using electrical stimulation of intrinisc muscles etc.- Too easy.
     
  26. Mark that make sense if by using the ankle brace you are reducing internal rotation of the tibia.

    As Craig stated in the pearls of biomechancial wisdom thread and Simon expanded a little in the auto support thread, the tibia internally roatating will casue STJ pronation. So if we have sometype of leg/tibia orthotoic that can control/reduce internal of the Tibia we will also have reduced the STJ pronation .

    Also the ankle brace maybe also helping support the detoid ligament which will also help control STJ pronation.
     
  27. Apparently Ive got to write 5 letters outside the quote
     
  28. Sammo

    Sammo Active Member

    Hi Mark,

    Firstly, thank you and everyone who have contributed to this topic. It is one that I am very interested in and have been following it closely.

    Mark, if I understand you correctly, you are an advocate of early intervention in paediatric flatfoot cases and I'd like to ask you a couple of questions regarding this (everyone, please feel free to chip in!!).

    Lets say we put a hypermobile 8 year old in a nice firm orthotic and boot to control their internal tibial rotation, STJ pronation and hold to the foot in the position we desire it, or perhaps we should say to stop it developing into the position we fear it to be in..

    - What propotion of the time would you have the child in this device?
    - What do you suppose will be happening to the intrinsic muscles of the foot while it is being held in such a position?
    - Does the foot need to have an insole with a rigid shell, or will a semi-rigid shell that provides some sensory feedback into the plantar area of the MLA area be sufficient to potentially stimulate intrinsic muscle activity??
    - At what age is the child then "safe" to come out of this insole? One could argue that if their hypermobility remains with them into adult life they may always "need" orthoses

    I understand that perhaps these question may not have answers, but I'm very interested in opinions and the rationales behind them!

    Once again.. thank you for a fascinating thread.

    S

    p.s. Mark, what guitar do you play?? I currently have a beatiful burgundy red Gibson Nighthawk, which I play through a Line6 Flextone III.
     
  29. Bass man myself, my current collection includes:

    Fender Musicmaster
    Fender Precision
    Squire Jazz
    Gibson EB-0
    Epiphone Thunderbird
    Burns Vistasonic
    + various law suit era Japanese copies

    Alison says I've got too many (don't tell her that I'm saving my pennies for a Fender Jaguar):drinks
     
  30. Hi Sam here is option, which I will admit is tidial .

    What propotion of the time would you have the child in this device? I would say that until the body has stopped growing and the developmential ligament laxity has stopped.

    What do you suppose will be happening to the intrinsic muscles of the foot while it is being held in such a position? These muscle will still be working when your using a device same as with adults, but these should be developing in a better biomechancial position ie not elongated, which indicates that this should have some positive effect for a more perminate change to foot mechanics, although a weak effect die to the lack of strength in affecting the axis position of the STJ and MTJ ( no research on this yet).

    The Plantar fascia should have a similar effect. ie being less elongated, but these effect on the foot will depend on the STJ axis position.

    see the auto support thread.

    Does the foot need to have an insole with a rigid shell, or will a semi-rigid shell that provides some sensory feedback into the plantar area of the MLA area be sufficient to potentially stimulate intrinsic muscle activity?? I´m not sure about sensort feedback effect but would say that the better controlling and more ridid the device the better chance of a positive result in the future.

    At what age is the child then "safe" to come out of this insole? One could argue that if their hypermobility remains with them into adult life they may always "need" orthoses Thats the big problem, The other thing to consider is that if the Axis position has not been changed the foot will retun to it´s old position very quickly. So most likly if there has not been a genetic/natural development change these type of patients will always require an orthotic.

    So if you take a child with pes planus pancakis put them in a controlling device which over the years allowing the ligaments which help to reduce stj pronation moments to develop in a shorter position. At 20 years old the patient come or a review you see and more stabile foot better position less medial deviation of the stj axis and the mother/father/patient asks you that question........... Is my/her/his foot corrected now and I/he/she can stop wearing orthotics.

    Im not sure we can say yes 100 % . It will depend on Genetics and if the Stj axis is slightly medially deviated overtime the ligaments/muscle/fascia/retinaculium that have developed in a better position will under go increased load which may mean they begin to stretch and then more medial deviation of the stj axis etc.

    but then to throw a question back Is a pes planus foot type always painful does it always lead to problems in Adulthood ?

    Lots of word hope it make sense I ill proof read but might miss some as usual
     
  31. Sammo

    Sammo Active Member

    Nice rig!

    I've also got a US fender tele, Stagg 335 and a Jackson (from the days of playing metallica and wearing black).

    Unfortunately I had to shift a load when I relocated... I had a 1984 gibson explored with a custom paint job for a while... I miss that baby :-(

    Officially, according to the gods of rock: you can never have too many axes... I got my eyes on a nice Les Paul at the moment..:butcher:
     
  32. Sammo

    Sammo Active Member

    Hi Michael,

    Thank you for your thoughts!!

    Response above in BLUE

    S
     
  33. Sam

    Good questions - I'm in surgery all day but will get back to you tonight. On the guitar issue - all acoustic - Yamaha, Gibson L4 (1938) and Froggy Bottom custom 'L' parlour. Can see an Arena gig sometime in the near future. Anyone know a decent drummer and keyboard player?
     
  34. It seems that this patient has not had any foot movement over many years, but in normal shoes with the appropriate poly device there will be some flex and normal stresses/movement of the intrinsic muscles, This goes back to the old orthtoics weaken my feet idea which is not true. But if there is no movement there of course will be muscle waisting.

    By using a soft device what are you hopeing to achieve. Increased muscle strength I guess. What was the position of the STJ axis of this patient ?
     
  35. Sammo

    Sammo Active Member

    Hi Guys:

    Mark,

    I look forward to your response. We could start a new genre - Pod Rock.

    Michael,

    She had a foot with a STJ axis straight through the 2nd met head. As I remember, all her RoMs were approaching hypermobile, although when she was walking had a bilat early heel lift (over active gastrocs - open chain DF approx 20-30 degress)

    This was a patient I used to see when I was in the UK. So was lost when I moved, and I haven't seen her for over a year.

    The idea behind the slightly more flexible device was to provide some level of dynamic support for the MLA, but did not take away too much of the intrinsic muscle work of the foot during stance phase, by allow the foot to pronate at a slower velocity, or to a less fully pronated position than it would have done without the insoles..

    Clearly this is all theory and I have no evidence to really to back it up with.

    Regards,

    Sam
     
  36. charlie70

    charlie70 Active Member

    Wow - interesting thread!
    I do "basic biomechanics" as part of my routine clinics in the NHS but am dipping a toe deeper into the water and trying to bring my knowledge and practice up to date. I started including the biomechanics after avoiding it for a decade (I found biomechanics subjective, little agreement about treatments and little evidence supporting treatments during my training - I did the diploma years ago - and it put me right off the whole discipline for a while) simply because nobody else in my little patch would do the clinics.
    Well, I'm glad I did because my understanding of the principles underlying biomechanics appears to be better with years of experience and evidence/research has also progressed.

    Erm, I'm waffling.

    My point is, most of the paediatric patients I see/treat have symptomatic flat feet - as does my 9 year old son.

    Its also depressing as here in this NHS we're being strongly advised against casted orthoses because of the cost. Pedipods with a bit of posting are, we're told by the specialists, just as good and a lot cheaper. The articles suggested above do not seem to agree with that!

    Purely anecdotally (and I admit, therefore not awfully useful) when my own son was waking most nights crying with pain in his legs/feet (at the age of 3-4 not really able to pin-point the pain) it was awful for both of us. He tried pre-formed orthoses (Formthotics) which did nothing. He was then casted and used casted orthoses for about 3 years, after which I've moved him to Pedipods for the moment until I can get him casted insoles again and he can cope pretty well in them. He still has pes pancakus and I fully expect him to benefit from lifelong orthoses.

    Back to my patients: I've always used the "if it doesn't hurt and the kid can keep up with his/her peers when playing, don't intervene. If there's pain, step in" approach so its nice to see that validated by at least one article.
    I have noticed that a lot of kids with ligamentous laxity also have tight hamstrings - is this a new thing? If they're compliant with stretching exercises, I've seen a reduction in pain in an awful lot of cases .... I'm assuming the hams tightened up either due to a growth spurt (in which case the stretching/reduction in pain makes total sense) but wonder sometimes if it's also the body's way of giving some stability : tighten/strengthen the muscles to make up for lax ligaments...

    Sorry, I'm using you lot as a sounding board. Not able to do at present with our "specialist" biomech pods as they ususally make me feel like an idiot or simply give me a reading list a mile long. I've got a kid, a stepkid with special needs and a life outside work!

    Anway, thank you all for a thread that's been informative and easy to read/understand, even for a fossil like me.
     
  37. charlie70

    charlie70 Active Member

    Wow - interesting thread!
    I do "basic biomechanics" as part of my routine clinics in the NHS but am dipping a toe deeper into the water and trying to bring my knowledge and practice up to date because my understanding of the principles underlying biomechanics appears to be better with years of experience and evidence/research has also progressed.

    Erm, I'm waffling.

    My point is, most of the paediatric patients I see/treat have symptomatic flat feet - as does my 9 year old son - so its great to read a thread about this that is easy to follow and even the linked articles are written mainly in English rather than biomechanics (which seems sometimes to be an entirely new language).

    Its also depressing as here in this NHS we're being strongly advised against casted orthoses because of the cost. Pedipods with a bit of posting are, we're told by the specialists, just as good and a lot cheaper. The articles suggested above do not seem to agree with that!

    Purely anecdotally (and I admit, therefore not awfully useful) when my own son was waking most nights crying with pain in his legs/feet (at the age of 3-4 not really able to pin-point the pain) it was awful for both of us. He tried pre-formed orthoses (Formthotics) which did nothing. He was then casted and used casted orthoses for about 3 years, after which I've moved him to Pedipods for the moment until I can get him casted insoles again and he can cope pretty well in them. With stretches of the hamstrings, some core strengthening activities (balancing on beams & trampoline in ithe garden) he became largely pain-free within a matter of a few months and has remained so ever since.

    He still has pes pancakus and I fully expect him to continue using orthoses for the rest of his childhood (and possibly beyond).: the orthoses have done nothing to remodel his feet - but that could be for a number of reasons, not least the fact that for the last year he's been in the Pedipods.

    Back to my patients: I've always used the "if it doesn't hurt and the kid can keep up with his/her peers when playing, don't intervene. If there's pain, step in" approach so its nice to see that validated by at least one article.
    I have noticed that a lot of kids with ligamentous laxity also have tight hamstrings - is this a new thing or has it always been the case? Is it linked with the less active lifestyle of a lot of today's children?
    If they're compliant with stretching exercises, I've seen a reduction in pain in an awful lot of cases .... I'm assuming the hams tightened up either due to a growth spurt (in which case the stretching/reduction in pain makes total sense) but wonder sometimes if it's also the body's way of giving some stability : tighten/strengthen the muscles to make up for lax ligaments...

    Sorry, I'm using you lot as a sounding board. Not able to do at present with our "specialist" biomech pods as they ususally make me feel like an idiot or simply give me a reading list a mile long. I've got a kid, a stepkid with special needs and a life outside work!

    Anway, thank you all for a thread that's been informative and easy to read/understand, even for a fossil like me.
     
  38. charlie70

    charlie70 Active Member

    Damn, I posted the same thing twice: apologies!
     
  39. I see what your saying Sam but my point is that if the STJ axis medially deviated (or laterally for that matter )during gait, due to the hypermobile Rom´s these muscle may change their effect on the foot.

    So non-weightbearing STJ axis thru 2nd toe normalish. But due to hypermobility in weightbearing medially deviated the muscle that were medial to the axis in none weightbearing may then become lateral to the axis and therefore cause a stj pronation moment and all that goes along with it.

    note : does sound like the patient was too aggressivly treated from the beginining.
     
  40. The old 3 post in 1 trick !!
     
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