Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Everything that you are ever going to want to know about running shoes: Running Shoes Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
  2. Have you considered the Critical Thinking and Skeptical Boot Camp, for taking it to the next level? See here for more.
    Dismiss Notice
  3. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Foot orthoses and asymptomatic pediatric flatfoot

Discussion in 'Pediatrics' started by Craig Payne, Dec 30, 2004.

  1. Craig Payne

    Craig Payne Moderator

    Articles:
    7

    Members do not see these Ads. Sign Up.
    This is another one of those perennial issues that keep coming up. Discussing it with some people is like arguing a religion (and because of the $$$ involved). Views are varied from one extreme of leaving them all alone to the other extreme of using expensive custom made orthoses every 6 months in them all. There are divergent views within the podiatric profession and divergent views within the orthopedic profession. There is even a difference between texbooks (usually depending if its published in the UK vs the USA :D - with the USA approach tending to be more interventionist). The evidence is limted - there is only the Kilmartin et al study. So we have to rely on expert opinion and consensus - bit hard to do when "experts" don't agree.

    As an educator, I have a responsibility to expose the students to all views and approaches, and most importantly try and give them the tools to make up their own minds. I spend a great deal of time going over all the issues, especially ethical decision making in the context of the lack of any real evidence for observaion vs intervention. Of course, the McDonald & Kidd paper is compulsory reading (I even promise them an exam question on it. HINT for students: READ THE QUESTION ;)

    The notes the students get before the lecture are explicit:
    What brought this up today for me, was the latest issue of the Journal of Foot and Ankle Surgery - yes I know there are no students around, but that does not mean the work stops :p. In it is the clinical practice guidelines from the American College of Foot and Ankle Surgeons on the Diagnosis and Treatment of Pediatric Flatfoot (its only available online to subscribers). Its a weighty 30 page documents, well thought out and the authors/committee are to be congratulated. The most interesting part for me was the flowchart for the asymptomatic flatfoot and a greater emphasis on observation of the asymptomatic physiological flatfoot than I have come to expect from publications out of the USA on this issue.

    What say you? :confused:
     
    Last edited by a moderator: Nov 9, 2006
  2. davidh

    davidh Podiatry Arena Veteran

    Craig,
    My personal feelings on this are that I treat asymptomatic paediatric flat foot, based on the following two premises:
    1. Subtalar joint neutral (or Ankle Joint Complex neutral, depending how "correct" you want to be) invariably, in my experience, leaves the forefoot in an inverted position relative to the rearfoot.
    2. Most biological tissue (humanoid tissue at any rate) is plastic, meaning it will deform over time in response to applied force, but not elastic , meaning that it will not resume it's original shape when applied force is removed.

    Orthoses may help to limit the deforming influences of bodyweight and suporting surfaces on the foot.
    Cheers,
    David
     
  3. Plastic vs elastic

    David and Others:

    Using the subtalar joint (STJ) neutral position as an indicator as to when to treat asymptomatic pediatric flatfoot patients seems rather puzzling to me. Do you treat all children with feet that are not in the STJ neutral position?? What is the mechanical basis behind this treatment protocol??

    Biological tissue is elastic but also may be plastic. Bone, ligament and tendon all are elastic strucures that may become plastic under certain loading circumstances. A good read for you may be one of the classic articles on plantar fascial elasticity by Gib Wright and Rennels (Wright, D.G., Rennels, D.C.: A study of the elastic properties of plantar fascia. J.B.J.S. 46 (A):482-492, 1964). If tissues weren't elastic then every deforming force on a tendon or ligament or bone would produce plastic deformation. If tissues were't elastic then a kangaroo wouldn't be able to jump at higher rates of speed and lower their oxygen consumption rate. They wouldn't call the characteristic of tendon and ligament "elastic strain energy" if these tissues weren't elastic .

    "Elastic strain energy is the energy that is stored in an elastic structure when it is either stretched or compressed."
    (Alexander, R. McNeill: Principles of Animal Locomotion. Princeton University Press, Princeton, New Jersey, 2003, p. 40.)

    I would be interested in any reference that states "Most biological tissue (humanoid tissue at any rate) is plastic, meaning it will deform over time in response to applied force, but not elastic , meaning that it will not resume it's original shape when applied force is removed."
     
  4. davidh

    davidh Podiatry Arena Veteran

    Hi Kevin,
    Thanks for answering my post on this very interesting topic, and for the questions which I will try to answer to your satisfaction.

    I don't dispute the fact that biological tissue is elastic - indeed I agree, but with one caveat - that over time deforming forces will produce changes in tissue. No need for research paper quotes. I can give you two great examples which I think are pretty self-evident.
    1. The foot-binding practice in old China, which I'm sure we are all aware of.
    2. The now defunct practice, amongst certain African peoples, of distorting necks, earlobes or lower lips with jewellery, or other artifacts.

    This was why I included the statement "deform over time" in my post, and was careful to do so.

    The question of using STJ neutral as an indicator to treat asymptomatic paed flat feet is tricky, indeed the whole question of teating asymptomatic paed flat foot is tricky, as CP intimated at the beginning of this thread.
    If you accept that most feet do not exhibit rearfoot and forefoot in the same plane when the STJ is placed in neutral (and this is my personal view,), and you also accept that human tissue is plastic, but not elastic when a deforming force is applied over time, then the decision to treat becomes perfectly reasonable I think.
    Regards,
    Davidh
     
  5. David:

    You stated in your first posting, "2. Most biological tissue (humanoid tissue at any rate) is plastic, meaning it will deform over time in response to applied force, but not elastic , meaning that it will not resume it's original shape when applied force is removed."

    Because you made the statement that humanoid tissue is not elastic and will not resume to it's original shape when applied force is removed is the reason I made my statement that, of course, human tissues (and animal tissues) are all elastic. I think your original statement seems to state that human tissue is not elastic. Am I reading this incorrectly???

    Bone, ligament and tendon are all elastic but may also be plastic. No biologic tissues are perfectly elastic and they will all lose energy as heat during deformation and will thus not return as much energy when resuming its original length/shape. As a result, they will develop a hysteresis loop during loading and unloading. All of these tissues also have characteristic stress-strain curves where they will develop plastic deformation if the stress to the tissue is high enough. In addition, ligament and tendon especially have the characteristics of creep response and stress-relaxation response which are time-dependent phenomena and are also strain rate dependent (Whiting, W.C. and R. F. Zernicke: Biomechanics of Musculoskeletal Injury. Human Kinetics, Champaign, IL, 1998, pp. 76-79).

    On the subject of pediatric flatfoot deformity, if you are using the lack of attaining subtalar joint (STJ) neutral position as your sole criteria as to whether a pediatric patient deserves foot orthosis treatment then you certainly must be making foot orthoses for at least 90% of the pediatric patients you see. Certainly you must be using some other criteria other than whether or not the patient is in STJ neutral position to decide whether they need foot orthoses.

    Do you also think that the goal of all foot orthosis treatment is to put the patient in STJ neutral position? Most of the adult patients that I see that stand in the STJ neutral position have pathological feet with symptoms caused by excessive STJ supination moments. Bill Orien, DPM, also feels that the most normal feet stand with the STJ pronated from neutral. I am very interested in your thoughts on this subject since the over-utilization of foot orthoses in mildly pronated asymptomatic children seems to be a main criticism that many members of the medical profession have of many podiatrists.
     
  6. davidh

    davidh Podiatry Arena Veteran

    Kevin,
    Apologies!
    Reading over my posting again I can see how you were mislead.
    The point I was trying to make is that over time most biological tissue will deform, given that constant force is applied.

    I'm sure Bill Orien is correct in thinking that most normal feet stand with the STJ pronated from neutral. This is entirely consistent with the hypotheses that 1) we have not really adapted for life on a hard horizontal surface, and 2) that when the STJ is placed in neutral most normal feet will exhibit a varus forefoot. The action of standing on a hard flat surface, such as an examination room, will produce a foot which exhibits STJ pronation.

    I think we need to establish whether or not we believe a joint, and specifically the STJ, should function around neutral. If we agree on that, and agree that human tissue is plastic (given adequate time and constant force), and we agree that most normal feet pronate on standing, then I believe you should be able to see part of my rationale for treatment. You are quite right in that I don't use STJ pronation alone as a rationale for treatment. I would also take into account factors like lig laxity, medial ankle bulge, any symptoms, no matter how mild, familial history of problems which may be linked to biomechanical etiology, and any lower limb biomechanical anomily which causes the child to be less active than their peers.
    Again, I apologise, my posting should have given more details.

    Incidentally, I'd be interested in any research to back up your statement that "over-utilization of foot orthoses in mildly pronated asymptomatic children
    seem to be a main criticism that many members of the medical profession have of many podiatrists".
    I'm pretty sure this is correct though, in the UK too.
    Regards,
    David
     
  7. David:

    Thanks for clarifying the above from your original statement. I'm glad to hear that you just don't use the STJ rotational position during relaxed bipedal stance as the sole criteria as to which pediatric patients are recommended treatment with prescription foot orthoses.

    In my twenty years of practice and lecturing here in the US and abroad, I have had the opportunity to discuss the subject of the treatment of children's flatfoot deformity with many podiatrists and other medical professionals from many countries. I have been practicing with orthopedic surgeons for the past twenty years also. If there is any subject that seems to generate contempt for podiatrists with physicians, it is the subject of over- prescription of foot orthoses for asymptomatic children. You must also know that this is not just a problem with non-podiatric physicians but also with other podiatrists, as Craig Payne has mentioned earlier. Personally, I am an advocate of foot orthoses for children, but only in select cases. I think it would be interesting to see what others feel are appropriate criteria for determining when a podiatrist should recommend foot orthoses for a child with asymptomatic pronation of the foot.
     
  8. Kim

    Kim Member

    Reading this thread I have learnt a great deal about different peoples rationale behind prescribing orthoses for children.
    Whilst I am still an undergraduate I felt compelled to add an opinion of the new breed of podiatrists (so to speak), I understand that not all undergrads will agree with me but not all pods agree as we can see by this thread.
    From what I can tell a lot of the disagreements and disillisions with members of our profession are by over zealous prescribing of orthoses by podiatrists. Instead of placing these children in rigid orthoses why not establish your checklist of factors/ observations that render orthoses a practical intervention (personally I find Craig's guidelines a practical and ethical way of establishing the needs for orthoses - especially history of symptomatic problems in parents) and if intervention is required use a direct moulded EVA device or a pre-fab orthotic in the attempt to maintain the foot in the position you think it should be held to prevent symptomatic problems in later life and re-evaluate regularly. This serves two purposes it will intervene to a necessary degree without the extensive deforming force on the foot and will demonstrate that we are not all about the almighty dollar. (So call me a cynic). For those who argue that you are only providing a band-aid solution I disagree. I find that direct moulded EVA devices particularly are very beneficial and achieve excellent control if made properly and those who need more aggressive devices wouldn't be asymptomatic and if they are then a rigid device is the way to go. Surely the patients who need an aggressive device are not at the centre of this discussion!
    I believe the key to prescribing orthoses in asymptomatic children is to ensure that your checklist or guidelines for intervention are sound and regular review of the patient and treatment to ensure treatment goals are being met.
    A bit of a ramble but I hope you get the gist.
     
  9. Treating Children's Pronation Related Pathology

    Very nicely said, Kim. You have an excellent handle on the main points that are important in treating children's flatfoot deformity.

    In my practice, I do recommend treatment of nearly all children with painful symptoms that are caused by excessive subtalar joint (STJ) pronation moments with custom or over-the-counter foot orthoses.

    In addition, I also recommend treatment of asymptomatic children with maximally pronated STJs and/or flatfoot deformity if the patient has one of the following criteria:
    1. Moderate-severe to severe flatfoot deformity and/or moderate to severe medial deviation of the STJ axis.
    2. Family history of painful flatfoot deformity.
    3. Significant gait pathology in walking or running that can be improved with foot orthosis treatment.

    Foot orthoses work in children's flatfoot deformity by increasing the STJ supination moment which will act to counterbalance the prevailing STJ pronation moments caused by medial deviation of the STJ axis (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). Foot orthoses also increase the rearfoot dorsiflexion moments and forefoot plantarflexion moments which will tend to decrease the tensile stress on the plantar arch ligaments, plantar fascia and plantar arch intrinsic and extrinsic muscles during weightbearing activities. There are multiple other mechanical effects of foot orthoses but the bottom line is that we, as podiatrists, can mechanically alter the magnitudes, anatomical locations and temporal patterns of stresses within the bones, ligaments, muscles and tendons of the lower extremity by judicious use of foot orthoses. Even though presciption foot orthoses are over-utilized by a few podiatrists, I would say that, in general, they are under-utilized by the medical profession as a whole for children's mechanically-related pathology.

    One of my biggest complaints with the medical profession (read pediatricians) as a whole is that they are ignorant to the dramatic effects that foot orthoses can make in the physical and mental well-being of children. I can't even begin to count the number of children that I have cured of pain with foot orthoses whose parents were told by their pediatricians, "Don't worry, it's just growing pains, they will eventually grow out of it" or "Don't worry, it's normal for children to have flatfoot deformity". How many of these untreated children decide that sporting activities aren't to their liking simply because they are left untreated by their pediatrician? How many of these children grow up to be adults with significant gait pathologies and/or foot deformities that could have been prevented if treated appropriately as a child?

    Money not need be an issue since these children can be treated temporarily very effectively with inexpensive adhesive felt wedging that can be fabricated in about two minutes in the office. The parent, when seeing their child walk or run better without pain with simple felt padding inside the shoe will invariably have no problems finding a way to pay for their child to be evaluated and casted for custom foot orthoses, if they understand that the felt padding simulates the mechanical effects of a custom foot orthosis. Money should not be a concern since there are many inexpensive ways to treat children mechanically on a temporary basis. However, since custom foot orthoses are much more expensive and time-consuming to produce, they need to be much more expensive to the patient to make it a worthwhile endeavor financially for your practice. I do give a discount for children's orthoses in my practice since I assume that the parent will be bringing their child back every 1-2 years for new orthoses once the old ones are outgrown.

    Of course, EVA can work to make an effective foot orthosis along with most other types of noncompressible shank-dependent orthosis materials. Anyone who teaches you differently doesn't know what they are talking about. I routinely use plastazote #3 for many foot orthoses in both adults and children. Plastazote is similar to EVA in mechanical characteristics. The main problems with the shank-dependent materials such as EVA and plastazote is that they will change shape during weightbearing activities depending on the shape of the shank of the shoe (Kirby, Kevin A.: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, pp. 75-76). Most shank-dependent orthosis materials also tend to undergo compression setting over time that changes their shape fairly rapidly. However, since children need new foot orthoses every 1-2 years anyway, this may not be a significant problem.

    Be an advocate for the children you see in your practice....sometimes you will be the only one that can recommend and perform a medical treatment that can cure them of their mechanically related pathology and pain.
     
    Last edited by a moderator: Jan 25, 2005
  10. Sean Millar

    Sean Millar Active Member

    what are we treating.

    Before I go on, I treat symptoms and modifiable gait pathology in children, not asymptomatic children with flexible flat feet.
    Consider the following. Are we providing children with what we believe to be the best solution to the childs symptoms, based on evidence (ancedotal or otherwise). Cost should not be the governing factor (if is cost nothing would your treatment plan be the same).
    Certainly in Australia many of the insurance health funds do not rebate on prefabricated devices. The difference between the cost of prefabed and customised (after rebate) is between $100-$130 AUD.
    Customised are more expensive beacasue it is a case fee, you undertake the task of improving the childs symptoms, regardless of the number of visit, modifications, represses, all at no extra cost. Prefabriacted costs cover devices only.
    Further, in my brief experinece poly lasts longer, and if well constructed and appropriately scripted needs less modifications.
    Is prefabricated false economy?
    Personally I find a semiflexible 2-3mm poly posted device with PPT under arch fill (orthic shell to ground) are comfortable and very well tolerated, have a good memory and provide excellent support. EVA devices as you mention compress, they become rigid. Thus semiflexible devives with memory must be a worthy option. :confused:
     
  11. Polypropylene is also my material of choice for foot orthoses for children. I use mostly 4-5 mm non-stress relieved polypropylene with welded polypropylene rearfoot posts for my children with pronation related symptoms (made by Precision Intricast, Payson, Arizona, USA). These devices are basically indestructable, have excellent memory (I've been wearing mine daily for the past 16 years with no evidence of deformation), and don't wear out. I use plastazote #3 mostly for the children who play high level soccer (i.e. football) due its increased flexibility in side to side movements. I generally add a Spenco topcover for those young athletes for their soccer boots. However, I don't normally add a topcover to children's foot orthoses since topcovers tend to add more maintenance problems to the orthosis for the parent.

    I use many prefabricated foot orthoses if the child's foot is large enough. I prefer the Superfeet insole since it has a good basic shape that can be modified without too much struggle.
     
  12. GarethNZ

    GarethNZ Active Member

    Hi Kevin and fellow collegues,

    Kevin specifically...

    I would be interested to know how you modify the Super Feet insoles. I work in New Zealand and have previously worked with Formthotics (Foot Science International) but have now changed to Footbionics (www.footbionics.com) and have found these to be much better.

    I have come across the green Superfeet insoles with certain patients who have been to outdoor stores in Chrischurch, purchasing them while being fitted for tramoing boots. I found them to be the most annoying insoles to modify. They already come with a very low medial arch profile and have a hard casing on the outside which makes for difficult adjustments.


    We use mostly temporary orthotics for children as mentioned above which we find last about a year with great results for patients. These get modified one week after issueing to suit biomechanical dysfuction. Only when there is a severe case of symptoms or foot posture do we opt for a more rigid based (poly shell/EVA heel post) which is usually between 25-35 degrees inverted.

    One question I feel is worth asking...

    Once a foot that is excesively pronated in posture seems to get sore in what ever activity (sport, accident) we seem to opt straight for treatment to reduce tissue stress on these areas.

    Is it valid to ask whether treating asymptomatic flat-foot with orthotics, what ever the type is more of a preventative protcol? Because you coudl argue that we are just waiting for something to get sore then we treat at that point.

    Your thoughts...
     
  13. When to Treat Flat-Footed Patients with Orthoses

    This is certainly a worthwhile question to ask, Gareth. Should the podiatrist treat all feet that are flat-footed with foot orthoses in the hopes that their treatment would reduce pronation-related pathology in the future? Or should the podiatrist only treat flat-footed patients with foot orthoses that currently have symptoms? I'm sure this question will be asked by podiatrists and podiatry students for many generations to come.

    My answer to this question is that I don't feel that I currently have enough knowledge to be able to predict with great certainty which patients with pronated feet will develop symptoms. Therefore, I choose only to treat those patients that are symptomatic and those patients that have the worst deformities and worst biomechanical function. I can make nearly any person function more ideally with foot orthoses, but I have no way to predict whether this mechanical intervention would prevent symptoms or possibly cause other symptoms to occur.

    The best advice in these types of situations is to ask yourself whether you would honestly recommend treatment for your asymptomatic child, brother, sister, mother and/or father if they had pronated feet. If you would treat your loved ones, with your best available knowledge and judgement, then I could not rightfully judge you to be wrong in treating one of your patients that had similar physical findings and biomechanical function.
     
  14. Bug

    Bug Well-Known Member

    Find this a great start to questioning treatment of children without symptomology....

    Do wonder though also about how many pod's go on to look that impact that the child's feet are making not only on thier walking and running but on their gross motor coordination and planning. Whilst we are not always trained in this area surely after years of working with other Allied Health Practitioners in the best interest of the patient that this knowledge can be developed and should be a valuable tool in the toolbox. Thoughts on this????


    I am also curious with the discussion on the use of semi-rigid/rigid/ off the shelf/custom made devices..... This is something I struggle with children and can't bring myself to use prior to the age of 6 and even struggle sometimes then even when the child is exhibiting all of the above!
    Surely the potential deforming force on the MLA has to be considered in developing bone and musculature and find myself leaning towards triplanar wedges/arch cookies with increasing regularity!!

    Thanks for the topic Craig :)

    Cylie
     
    Last edited by a moderator: Jan 25, 2005
  15. I don't think that triplane wedges have the mechanical ability to cause as much improvement in the gait pattern in children with excessively pronated feet when compared to a pad that has both varus heel and medial arch height components. Since the triplane wedge is only a varus heel wedge, it does not offer any resistance to medial longitudinal arch flattening that is generally very important for these children. I use a 1/8" adhesive felt to fabricate a medial heel and arch wedge (modified cobra pad) for these children to add to their shoes. I find the modified cobra pad works much better than triplane wedges (Kirby, Kevin A.: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, p. 273-274).

    The major deforming forces in children with flatfoot deformity is toward flattening the medial arch of their foot (a forefoot dorsiflexion moment) and toward causing STJ pronation (a STJ pronation moment). If you don't support the medial arch in these children, you are treating only half the deforming internal forces that are acting on their foot.
     
  16. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    Cylie - I was up working until after midnight --- you posted after that!!!! - me thinks some of us need a life :mad: .... and yes I know its the Australia day holiday today...but I usually work and take 6 Feb off instead (ask a NZer about that day ;) [​IMG]

    [​IMG] I had one of those "light bulbs going on" moments a few months back on this. There is all this disucssion in the literature on the formation of the arch in the <6year olds, the fat pad there etc etc .... there was an abstract presented at last years GCMAS mtg in which, among other things, they looked at the dynamic range of motion at the first MPJ in kids. There was no real increase in the first MPJ dorsiflexion ROM until about a mean of age 6 or so ..... which is sort of what you would expect as we usually say the "adult" walking pattern of heel contact, foot flat and propulsion does not start until then....

    After reading that, I wandered over to the Agora (LTU people know what that is) and then it hit me :eek: --- to paraphrase a Clinton saying "its the windlass...stoopid" --- if first MPJ dorsiflexion does not realy get going until age 6 or so, then the windlass is not working to raise the arch [​IMG]

    We need to give a lot of thought to this, especially:
    * facilitating and not inhibiting this mechanism in this age group
    * should we even be intervening before the windlass becomes active
    * is there something different we should be doing now given this

    Lots of good research projects in this sitting in the "research I will get to one day" file in my office.
     
    Last edited by a moderator: Jan 28, 2005
  17. Bug

    Bug Well-Known Member

    Thanks Kevin.....you put in words what I non-articulated in my post...being from QLD and sometimes using my terms back to front.... :D what you have decribed is my version of a wedge - a flexible dome with that back 1/3 the high point sitting under the sustentaculum tali and then bulk continued under the arch - ....just googled a modied cobra pad and can rest easy in the thought that I am like thinking with a great mind :)

    Now Craig :D ......great a life - I do!!! It's called 2 year old not wanting to sleep and just finding this and wanting to post every without appearing like a fool - you and that Windless effect - really should come and chat to you about it sometime as I'm sure my eye's glaze over when a student mentions it!!! :eek:

    But from what you mentioned - yes, yes and yes - agree we need to be looking at this...


    I guess to all boils down to the child coming in, about 4 years old - familial history, can't hop, struggles to jump in any form of coorindated fashion, struggles with basic balance activitied AND a excessivly pronated foot.... what do you do that's as non-invasive as possible, finacially viable for the parent and easy to use with great results you have seen again and again..... :)

    Continue now to feel more justified in my work practise - will have to find that article Kevin - would love to share it with some non-beliver's
    Thanks!
     
  18. Craig Payne

    Craig Payne Moderator

    Articles:
    7
    We will be running the Boot Camp later in the year:
    http://www.latrobe.edu.au/podiatry/boot-camp.htm
     
  19. Bug

    Bug Well-Known Member

    Now that just looks scary :eek:
     
  20. Modified Cobra Pad

    Here is what the modified cobra pad looks like adhered to the plantar aspect of a right shoe sockliner. I use this daily in my practice and it incorporates a medial heel skive and medial longitudinal arch pad. Hope this helps.
     

    Attached Files:

  21. Sean Millar

    Sean Millar Active Member

    cobra pad

    Kevin,
    Do you have a set review process, in which you would expect to have to change/replace a compressed cobra pad, or is it a case of the client returning when the symtpoms do?
     
  22. Sean:

    Good question. I typically will use the modified cobra pad for a month or two to see if it helps resolve the symptoms in the patient. The patient (or parent of the patient) understands that the modified cobra pad is not a long term treatment but rather is meant as a temporary measure that will only last for a month or two before it compresses or loses some of its mechanical effect.

    If the patient cannot afford presciption foot orthoses (I generally recommend prescription foot orthoses due to their durability and potential for more effective gait alteration), then I will have them go out and buy an over-the-counter foot orthosis and modify it in my office with korex (EVA would also be suitable) to make an orthosis that will probably last about 6-12 months, depending on the patient's weight and activity level.

    In children, an alternative treatment method that I have used before is to have the parent bring the child into my office with each new pair of shoes to have the modified cobra pad added to that pair of shoes. This generally means that they will be coming back every 3-4 months to have new pads added to their shoes. I generally don't charge anything extra for this service other than an office visit charge but I think you could easily justify charging for this service if you deemed this was appropriate for your style of practice.

    Hope this helps.
     
  23. Ian Linane

    Ian Linane Well-Known Member

    Kirby skives

    I have followed the children / orthotics debate with interest. In terms of prescribing devices I find myself very much in line with Kevin Kirby and David Holland in my own approaches and would agree that in many cases, those that actually need them, are under subscribed. I do wonder, however, if sometimes we are not radical enough in some cases.

    In general, however, and because I make my own devices, I have taken the approach of using Kirby skives on very young children rather than posting angles. This has proved very effective and to my mind is interventionist but not to radically for a young developing foot. With the skive bringing considerable medial control and by allowing the 1st ray to come down quickly I find good tolerance and frequent satisfaction.

    Perhaps part of my approach is that I feel the greatest point of vulnerability in gait is the MTJ from early heel lift onwards when I suspect the rearfoot posting to have minimal if any influence, and use the forefoot and support of the 1st ray to stabilise the limb at this point. Because of this I do not attempt to alter the rearfoot beyound pouring the cast vertical, often whatever the angle of the heel

    When the rational is clearly explained to parents cost does not become an issue.

    Cheers
    Ian
     
  24. I agree with you, Ian. I am more aggressive in using the medial heel skive in children since, in the 15 years that I have been using it, I have found that children tolerate higher depths of medial heel skive better than adults and do exceedingly well symptomatically with its use.

    In addition, I would say that, at this instant in time, if a practitioner does not use a medial heel skive (or some other form of varus heel wedged orthosis) in a pediatric patient with symptomatic flexible flatfoot deformity, then I would consider that this practioner is guilty of not giving the child's foot the best mechanical treatment available for their specific mechanical pathology. The medial heel skive should be a standard modification in all pediatric flatfoot deformity patients (unless these patients also have tarsal coalitions).
     
  25. pgcarter

    pgcarter Well-Known Member

    Hello Folks,
    A good read. A little off topic perhaps but related to the thread.
    Have a conversation with an orthodontist about the way they view elasticity and plasticity and why and when they treat children.
    After this you will feel far less concerned about much of what you have written here, and far more free to treat rather than learnedly doing nothing.

    As a profession they have no qualms about taking thousands of dollars off parents for treatment which is largely cosmetic....why are we so worried about a hundred bucks here or there....and if you do nothing during the growth phase of a child you will have plastic results in bone shape about which you can't do much later. If you believe that human bone is plastic and if you are seeing any results or influence of this or suspect it may develope over time then the prophylactic use of orthoses during the growth phase is actually a good idea.....as long as you think it won't hurt....and it may help in a way that you can't duplicate later.
    Regards Phill Carter
     
  26. Ian Linane

    Ian Linane Well-Known Member

    Hi

    Having come to an opinion that some mild degree of what we call "supinatus", when the foot is in none weight bearing STJ, could be more appropriately called "normal", rather than the view of the mets being in the same plane at the rear foot at this point, I find a rational for treating children a little easier in the decision making process. (indeed, adults also)

    Taking this approach I consider a mild degree of supinatus being natural and the terrain being unnatural. Contolling foot action then is seen as preventing unnatrual terrain having a likely pathological affect upon a "normal" (mild supinatus) foot.

    The decision becomes much more one of justifying why I should not intervene with some kind of orthosis rather than the so often confused cnd conflicting rationals behind deciding why I should treat.
    Cheers
    Ian
     
  27. Here is what I wrote about that same subject about 14 years ago:

    "In the pes valgus deformity, pathologic internal forces resulting from the excessive pronation moments acting on the subtalar joint, in turn cause excessive calcaneal eversion and excessive medial longitudinal arch collapse. The increase in the medial longitudinal arch flattening force causes an increase in the compressive forces within the talar head, navicular, cuneiforms, and the three medial metatarsals and also causes increased tension within the plantar ligaments of the medial longitudinal arch and on the more medial bands of the plantar fascia. Since the dorsal parts of the bones of the medial arch are under greater compressive loads than the plantar parts of the bones, early remodelling of the shapes of the bones is very likely to occur, especially while the young bones are more plastic and not yet completely ossified. Any remodeling of the bones of the medial longitiduinal arch during the first decade of life that causes the dorsal half of the bones to decrease in size and/or the plantar half of the bones to increase in size will effectively decrease the height of the medial longitudinal arch.

    In addition, chronically increased tensile loads on the medial bands of the plantar fascia and within the plantar ligaments of the medial longitudinal arch may actually cause permanent elongation of these ligaments. The actual amount of elongation is dependent both on the magnitude and duration of that pathologic stretch and on the elasticity of the ligaments. Strong medial arch flattening forces, such as those seen in pes valgus deformity, may then result in greater permanent flattening of the medial longitudinal arch as compared with the lateral longitudinal arch, depending on the intrinsic plasticity of the bones and ligaments of the medial arch. Because of this differential flattening of the medial as compared with the lateral longitudinal arch, either a forefoot varus deformity or a forefoot supinatus deformity may be created during childhoodd in feet with large pronation moments acting across the STJA."

    (From: 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.)

    I still don't see, especially with what I wrote above nearly fifteen years ago, why the treatment of pes valgus deformity in children with custom foot orthoses is such a big deal for so many podiatrists. As a profession, we certainly are not doing something that other professions, such as orthodontists, haven't been doing for decades already.
     
  28. robthepod

    robthepod Member

    What about HOM's?

    Firstly, please accept my apology for the very late addition to this thread. I am new to Podiatry Arena and read with interest the many and varied podiatric debates/discussions, this thread being one of the more contentious topics.

    As it has been mentioned, on several occasions in this thread, there is little evidence, anecdotal or research based to support the use of othortic intervention in the asymptomatic flat footed paediatric patient. Indeed our profession, although striving to provide evidence based medicine (or as I prefer to say, research enhanced healthcare), struggles to support many of treatments with good quality, systematic, rigorous research.

    With this in mind, it immediately puts us in a slightly precarious position with regards to cases of litigation. If we treat a paediatric patient without symptomaology what are we using as our health outcome measure(s)? Should a patient, after being prescribed orthoses by a podiatrist, go on to develop pain there may be an argument to say that the orthoses were the cause of the pain, regardless of whether the patient would have gone on to develop pain or not.

    Regards, Rob.
     
  29. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Corrective shoes and inserts as treatment for flexible flatfoot in infants and children.Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL.
    Texas Scottish Rite Hospital, Dallas 75219.

    We performed a prospective study to determine whether flexible flatfoot in children can be influenced by treatment. One hundred and twenty-nine children who had been referred by pediatricians, and for whom the radiographic findings met the criteria for flatfoot, were randomly assigned to one of four groups: Group I, controls; Group II, treatment with corrective orthopaedic shoes; Group III, treatment with a Helfet heel-cup; or Group IV, treatment with a custom-molded plastic insert. All of the patients in Groups II, III, and IV had a minimum of three years of treatment, and ninety-eight patients whose compliance with the protocol was documented completed the study. Analysis of radiographs before treatment and at the most recent follow-up demonstrated a significant improvement in all groups (p less than 0.01), including the controls, and no significant difference between the controls and the treated patients (p greater than 0.4). We concluded that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children.

    PMID: 2663868 [PubMed - indexed for MEDLINE]
    Steven J. Levitz
     
  30. Rob:

    First of all, I have yet to see, out of the approximately 1,000 children that I have treated with foot orthoses over the last 21 years of practice, any child develop any long lasting pain from orthoses that I have made for them. On the contrary, most children actually like to wear their orthoses.

    Second, if I was to limit my treatments only to those with research- based evidence then that would effectively eliminate about 90% of the very positive, life-changing treatments I can offer to patients as a biomechanically-oriented podiatrist. These 90% of treatments are supported by anecdotal evidence only but can be explained quite easily using biomechanical modelling techniques.

    Lastly, I agree that treating mild asymptomatic pediatric pes planus deformity with foot orthoses makes no sense and I would consider this a form of "over-treatment". However, I do not agree that orthosis treatment of asymptomatic moderate to severe pediatric pes planus deformity, especially with a family history of symptomatic pes planus, is risky, unethical or not advisable. On the contrary, I could make a very good biomechanical argument that for a podiatrist to allow an asymptomatic child with a signficant pes planus deformity and a family history pathological pes planus deformity to go untreated without foot orthoses, is not only preventing the child from receiving the best conservative treatment that could be provided to their growing foot to positively influence their adult foot structure, but is also unethical given our current knowledge of foot and lower extremity biomechanics.

    I would be happy to send you a pdf copy of the chapter I wrote on the subject of orthosis treatment of pediatric pes valgus deformity over 14 years ago with Don Green, DPM, if you would like to become more educated on the subject of pediatric flatfoot deformity (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).
     
    Last edited: Nov 16, 2006
  31. robthepod

    robthepod Member

    HOM's??

    Kevin,

    Please do not perceive my post as an attempt to incite. I would be most grateful if you would send me your chapter via e-mail (robert_stringer@hotmail.com), I will read it with great interest.

    The original point that I was attempting to make was how do you measure the success (or failure) of your management plan (i.e. orthotic intervention) in a patient who experiences no discomfort and/or pain?

    In addition to this, if a patient did go on to develop pain, post-orthotic intervention, how would you differentiate between pain caused by the intervention and pain that would have occurred regardless (due to the deformity)? Not to mention the possible differences in severity of any discomfort.

    Regards, Rob.
     
  32. Rob:

    Chapter is on its way.

    If a child develops persistent pain while wearing orthoses, then the simple clinical solution is to either adjust the orthosis or temporarily remove the orthosis from their shoes to see how they respond. If the pain does not improve with orthosis adjustment, then either the adjustment was not of sufficient magnitude, was the wrong adjustment, or the orthosis did not have anything to do with the patient's pain in the first place. The next step is orthosis removal. If the pain does not improve with orthosis removal, then the pain is likely not caused by the orthosis. It is really that simple.

    Orthosis improvement can be measured by observable changes in gait function and changes in static posture. Is the orthosis causing the patient's foot to undergo less contact phase and midstance pronation?, resupinate earlier in stance phase?, have increased duration of propulsive phase?, alter their angle of gait?, and/or hold the medial arch in a higher position? These are all objective criteria I use to determine if the orthosis is functioning properly in a pediatric pes planus patient.

    These are all fair and very good questions, Rob. No worries.
     
  33. Dikoson

    Dikoson Active Member

    Colleagues,

    I faced a massive dilemma in the UK in the late 90's. There used to be a trend in some clinics to put kids with assyptomatic flat feet into orthopaedic footwear. Certain UK footwear distributors claimed the were "making your childs feet normal"!!

    I conducted a systematic literature review while doing my MSc, this was published in a jounal called BAPOmag (association of prosthetists/orthotists journal). Summary, no evidence foot orthoses or any footwear/exercise changed the development of the childs foot. As previously stated Wagner et al did the best study i could find at the time.

    The interesting study i found was by Staheli (1978 from memory). He found foot "deformities" in adults were statistically lower in people who did not wear shoes until adulthood. Those who wore shoes from a young age had more "deformity". Ths study was done in India, so its epidemiological significance to the western world could be questioned.

    The issue is still relevant in the UK and causes some debate as to when to treat and when not too. The general rule is treat pain, muscle imbalance/tightness and gross deformity. No definitions of these though!!!
     
  34. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Corrective shoes and inserts as treatment for flexible flatfoot in infants and children.Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL.
    Texas Scottish Rite Hospital, Dallas 75219.

    We performed a prospective study to determine whether flexible flatfoot in children can be influenced by treatment. One hundred and twenty-nine children who had been referred by pediatricians, and for whom the radiographic findings met the criteria for flatfoot, were randomly assigned to one of four groups: Group I, controls; Group II, treatment with corrective orthopaedic shoes; Group III, treatment with a Helfet heel-cup; or Group IV, treatment with a custom-molded plastic insert. All of the patients in Groups II, III, and IV had a minimum of three years of treatment, and ninety-eight patients whose compliance with the protocol was documented completed the study. Analysis of radiographs before treatment and at the most recent follow-up demonstrated a significant improvement in all groups (p less than 0.01), including the controls, and no significant difference between the controls and the treated patients (p greater than 0.4). We concluded that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children.

    PMID: 2663868 [PubMed - indexed for MEDLINE]
    Steven J. Levitz

    NUFF SAID
    AGAIN
     
  35. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Flexible Flatfoot In Chidren Without Neurological Pathology

    Corrective shoes and inserts as treatment for flexible flatfoot in infants and children.Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL.
    Texas Scottish Rite Hospital, Dallas 75219.

    We performed a prospective study to determine whether flexible flatfoot in children can be influenced by treatment. One hundred and twenty-nine children who had been referred by pediatricians, and for whom the radiographic findings met the criteria for flatfoot, were randomly assigned to one of four groups: Group I, controls; Group II, treatment with corrective orthopaedic shoes; Group III, treatment with a Helfet heel-cup; or Group IV, treatment with a custom-molded plastic insert. All of the patients in Groups II, III, and IV had a minimum of three years of treatment, and ninety-eight patients whose compliance with the protocol was documented completed the study. Analysis of radiographs before treatment and at the most recent follow-up demonstrated a significant improvement in all groups (p less than 0.01), including the controls, and no significant difference between the controls and the treated patients (p greater than 0.4). We concluded that wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children.

    PMID: 2663868 [PubMed - indexed for MEDLINE]
    Steven J. Levitz

    NUFF SAID
    AGAIN
     
  36. Dikoson

    Dikoson Active Member

    Steve,

    great study, quote it daily, good work

    Simon
     
  37. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Good Work Simon

    Most Podiatrist's have never read this paper and if they did would keep it very quiet.
    Respectfully
    Steve Levitz
     
  38. Dikoson

    Dikoson Active Member

    Steve,

    I am not a podiatrist, i qualified as an orthotist. Now clinical specialist in lower limb biomechs for NHS.

    If you send me your email i will forward the review

    Simon
     
  39. Colleagues:

    What did this well-known study by Wenger et al actually measure? It measured the static posture of the foot after being treated by various conservative treatments for pediatric flatfoot deformity, nothing more, nothing less. As most podiatrists know, Helfet heel seats and orthopedic shoes are useless for treating children's flatfeet. In addition, foot orthoses with little specific correction for the abnormal STJ pronation moments routinely seen in children with significant flatfoot deformity, probably also are of minimal help for these children.

    Secondly, in regards to the design of this study, I don't remember the last time I assessed the dynamic function of a child's (or adult's) foot and lower extremity solely by viewing static radiographs of the foot. Now, maybe some clinicians use radiographs to assess the dynamic function of the foot??? However, most intelligent clinicians would say that a static weightbearing radiograph is a useless test for determining gait function and specifically for determining the overall health effects of a conservative mechanical foot therapy.

    If, however, I was a clinician that had an interest in showing that foot orthoses are useless for all types of pediatric flatfoot deformity, then I would design the study as Wenger et al did. However, my view is that this study by Wenger et al is about the equivalent of measuring the refractive error in the eyes of a group of myopic children before and after treatment with eyeglasses for three years, finding that prescription eyeglasses did not change the refractive error of the children's eyes that wore prescrition eyeglasses vs controls, and then concluding that that there were no health benefits for these children wearing prescription eyeglasses since they "do not influence the course" of myopia in children's eyes.

    Now, if a quality biomechanics researcher wanted to perform a study of the health effects of children's foot orthoses on flatfooted children, would they use only static radiographs of the children's foot to assess the functional benefits of foot orthoses??? Absolutely not!!

    Here is what a quality biomechanics researcher would likely study:

    1. They would assess overall gait function with and without foot orthoses in place.

    2. They would assess endurance and any symptomatic complaints of children either during or after performing different weightbearing tasks and sports activities.

    3. They would perform 3D kinematic gait analysis with force plates and then use inverse dynamics to determine internal moments on the foot and lower extremity with and without foot orthoses.

    4. They would do finite element analysis of a childrens flatfoot deformity both with and without a anti-pronation foot orthosis to determine the internal stresses on the structural components of the child's foot to determine which therapy would be most likely to put pathological stresses on the maturing structural components of the foot of the child.

    Wenger et al's static weightbearing radiographs are useless, by themselves, for assessing the functional effects of foot orthoses on flatfoot children. I would be sure that children's parents are informed that the study by Wenger et al was not designed properly to assess the overall mechanical benefits of foot orthoses on the flatfooted child and, as such, should not be considered in their decision-making process as to whether foot orthoses are necessary or not for their child.

    Now there is "nuff said".
     
    Last edited: Nov 21, 2006
  40. STEVE LEVITZ

    STEVE LEVITZ Active Member

    Too Much Said
    Steve Levitz
     
Loading...

Share This Page