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Pediatric flatfeet correction with foot orthoses

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Gab Moisan, Aug 11, 2014.

  1. Gab Moisan

    Gab Moisan Member

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    Hi everyone,
    I'm a podiatrist and I'm currently finishing my master degree on foot orthotics. I'll start a PhD in december and I'm here today for your help. I'm planning to do a long-term research on the correction of pediatric flat feet with foot orthoses. I have started looking for some literature on the subject and of course, nothing interesting.
    So, I have two questions:
    1. According to your knowledge/clinical experiences/others... Is there any correction of a pediatric flatfeet possible with a foot orthotic and what is the mecanism of action. How does the foot get corrected? I had a teacher arguing that the correction was achieved according to Delpech and Wolff's laws? Do you agree?
    2. Do you have any idea on how to build a solid experimental protocol to prove if a foot orthotic can or cannot correct a pediatric flat foot? I wonder why there is still no good study on the subject after all these years!

    Thanks for your answers

    Gabriel Moisan, DPM
  2. Deka08

    Deka08 Active Member

    I am hoping that better people than me reply with more, but I have some free time.
    I will try and address your 2nd question, specifically the 2nd part.
    Do you have any idea on how to build a solid experimental protocol to prove if a foot orthotic can or cannot correct a pediatric flat foot? I wonder why there is still no good study on the subject after all these years!
    My 1st question for you would be, are you aiming intervention at symptomatic or asymptomatic flat feet? I wonder about the ethics of recruiting paeds with asymptomatic flat feet to provide an intervention that they may not need. Also every foot develops differently, at different stages and rates, how do you know if a change is due to orthotic intervention or natural developmental changes? So how are you going to prescribe a device? Off the shelf or custom? Will a tall, overweight 8 year old flat foot and a short skinny 8 year old flat foot respond in the same way to an off shelf orthotic? Or do you need to prescribe individual customs, that need changing after each growth spurt? From what age do you propose to start intervention? These (and likely more) are all valid things to think about.
    The other issue is correction... If you have symptomatic kids and provide an intervention that resolves their pain, but provides no correction - is that a "failure"?
    What do you think constitutes a corrected flat foot? Do flat feet need to be corrected?
    There are various threads under the pediatric flat foot table of contents that you may wish to read through if you haven't done so already. And probably enough from me really, as there are people on here that have more to do with both research and paeds than what I do. Just my 2 bobs worth.
  3. In theory there might be some change, then the question as pointed out above comes into play.

    I correcting of pediatric flat feet a desired out come in the 1st place?

    There has been at least some studies looking into arch height changes and devices in kids, I know. There was one major study done in the 50's in england, they looked at speed of development and change of arch height from memory. That might be some help, no idea where you might find it and how goodmit really was, I read it 20 something years ago.

    It might be hard to determine changes though, how are you going to define flat foot and what degree and then review that and compare in growing then adult feet.

    Some of the measurements will be very hard to compare just due to growth and weight changes.

    not sure it is much help but it might be just too hard and too long a subject to look at for a PHD ?
  4. Rob Kidd

    Rob Kidd Well-Known Member

    I am unsure as how to start an answer to this. First the words. Correction? Do you really think that you will be able to frame a Doctoral thesis around the correction of paediatric flat foot with mechanical therapy? To me the term correction would suggest that they originally have the condition (generic as it may be), and after your intervention the problem has gone away. I would talk at length to your supervisor about ethics, protocols, sample sizes (ie power functions), and revisit validity of classifications of mechanical therapies, etc etc. Which university are to enrolled in?
  5. Gabriel:

    Welcome to Podiatry Arena.:welcome:

    I have been interested in the evaluation and treatment of pediatric flatfoot deformity now for the past three decades. In fact, I coauthored a book chapter on conservative treatment of pediatric flatfoot deformities over twenty years ago, which you would probably benefit from reading (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.).

    One thing I don't understand is your use of the term "correction" of pediatric flatfoot. What exactly do you mean by "correction" of a flatfoot? Do you mean that foot orthoses are going to make the flatfoot deformity develop a normal arch shape over time or do you mean a resolution of symptoms with foot orthosis treatment?

    Foot orthoses do not have the potential to make severe to moderately severe flatfoot deformities into normal arched feet, in my opinion. However, foot orthoses do have the potential and likelihood to relieve the pain in pediatric flatfoot and make these children run and play more with fewer symptoms.

    Good luck with your PhD.:drinks
  6. Gab Moisan

    Gab Moisan Member

    I'm aiming at asymptomatic flatfeet. I have treated many symptomatic flatfeet with custom made orthotics and I have always had good results. Therefore, I don't see the point of doing a research on this! You mentionned good points. I'll have no choice but to standardize the intervention of prescribing a foot orthotic by giving the same model to every subject. I thought prescribing a custom-made foot orthotic probably with a medial wedge to the experimental group and no orthotic to the control group. I think that's the main problem with the articles published, no RCT has been done. By correction of flatfeet, I mean to start with a pes plano valgus and end up with a rectus foot.
  7. Gab Moisan

    Gab Moisan Member

    I read an article a while back (don't remember the authors name) studying the effect of a UCBL compared to no treatment on the correction of the x-rays angles. Even thought there was a lot of bias in the article, the general idea was good. I thought maybe I would take this idea and try to be more rigourous and add a few things.

    I don't know how long it will take to do a project like this, but I can always do/finish it after my PhD!
    thanks for the answer!
  8. Gab Moisan

    Gab Moisan Member

    I read pretty much everything you wrote. I appreciated every word of it. You influenced my practice of podiatric biomechanics in a very positive way. Thanks for that.
    By correction, I mean bring a flatfoot to a rectus foot so the patient won't need orthotics after a few months/years. Like I said in a previous post. I believe foot orthotics work great on a symptomatic patient (plantar fasciitis, PTTD, Sever's....).I'm talking about asymptomatic patient in a goal of prevention as many foot diseases can be related to hyperpronation.
    Thanks for the answer!
  9. Gab:

    You are welcome.

    Many children that have flatfoot deformity probably have this deformity because of genetic abnormalities of their foot structure. This may include differences in the shapes and sizes of their bones, muscles, and ligaments. Many children also have flatfoot deformity probably because of genetic differences in the tension stiffness of their plantar ligaments/plantar fascia: those children with abnormally increased plantar ligament/plantar fascia compliance (i.e. abnormally decreased stiffness) will tend to have flatfoot deformity while those children with normal plantar ligament/plantar fascia stiffness will tend to have more normal arch shape. How do you propose, Gab, that foot orthosis therapy will change the structure of bones or the stiffness of the plantar ligaments and plantar fascia of these children with flatfoot deformity?

    As Rob Kidd stated, you may be "biting off more than you can chew" to do a PhD on "correcting pediatric flatfoot deformity with foot orthoses". Rather, I believe it would be smarter and more practical to narrow your focus so that you can answer one specific question in regards to the treatment of pediatric flatfoot deformity.

    I believe you could do a lot of good for the worldwide podiatric/orthopedic/medical community by focusing your PhD on studying the kinematics and kinetics of children with flatfoot deformity vs children with normal feet and how the gait of flatfooted children change when given custom foot orthoses with 3D gait analysis techniques. To my knowledge, this has never been done. Measuring the dynamic changes in gait of flatfooted children to foot orthoses would be infinitely better than using static measures of the foot, such as plain film radiographs or medial arch height or relaxed calcaneal stance position, in your hope that they would change genetically pre- determined foot structure over time.

    In the thousands of flatfooted children I have treated with foot orthoses over the past three decades, I can only account for one case of where the child's foot went from looking flatfooted to normal arched shape, while all the other children may have improved their foot structure slightly over time with foot orthoses and nearly all of them had symptomatic improvement of their presenting chief complaints with the orthoses. Therefore, I would suggest on focusing your PhD on how foot orthoses produce their outstanding therapeutic effects on flatfooted children's bodies and move away from trying to do your PhD based on your assumption that foot orthoses will change foot structure over time.
  10. efuller

    efuller MVP

    Hi Gabe,
    In desinging any study you need to carefully define the variables that you want to examine. (What is correction and how do you measure it?) Is the intended measure valid for its intended use? If you are going to look at flat foot then you need a measure of flat foot. You will also want to know everything that has been done with that measurement. Is low arch height correlated with any problem. Are there better predictors than arch height for that problem. Is low arch a problem? You might want to study these questions before you look at arch height before and after the use of orthotics. You need to question all the assumptions you have made up until this point. The one big assumption you have made is that low arch height is bad. Why is it bad? Is it bad 100% of the time? If not, why not? That's an interesting research question by itself. If you have read many of Kevin's articles then you should understand the importance of STJ axis position. Do flat feet tend to have a more medial STJ axis? Do the flat feet that have more problems have a more medial STJ axis? As Kevin pointed out, it might not be arch height, but foot joint stiffness that is a problem. I can make a case that a higher arched foot will tend to be stiffer, but is it the arch height or the overall stiffness that matters?

    It is also interesting to think about adaptation of the foot to external suroundings. Two examples come to mind. One is chinese foot binding. From my reading about that it seems that the foot is broken and allowed to heel with the forefoot plantar flexed on the rearfoot. The other is the treatment of clubfoot in infants with serial casting. There the ligaments are stretched, and held in a stretched position, where growth allows the ligaments to become normal again. I'm just hypothesizing, no data.

    So, what would be the mechanism by which an orthotic would raise the arch permanently. Would you get some plantar flexion at some midfoot joints and then the ligaments would contract? How would the joints stay contracted when the person takes their shoes off? There's no binding involved.

    Another thing to think about is how do orthotics work. I've told this story before here. A couple of weeks after I got my orthotics, when I was a podiatry student, I was walking barefoot into the bathroom one morning and noticed that I was holding my feet in a more supinated position. I could easily relax my feet. When I was doing the biomechanics fellowship at CCPM, I had a patient back for their two week follow up after they got their orthotics. I watched them walk in their shoes with the orthotics and there was resupination. I didn't remember how they walked before their orthotics so I had them take their shoes off and walk barefoot. The first two trips up and down the hall, barefoot, they walked with resupination. Then, they reverted back to walking style that stayed pronated. The only explanation for these observations is that there is a change in muscle activity at least in some people when they wear orthotics. And this muscle activity can persist when not wearing orthotics. So, it is concievable that you could train the muscles, with an orthotic, to prevent loss of arch height so that the ligaments could contract and stay contracted just like they do in hammertoes. However, it seems unlikely that increased arch height would be maintained against the force of gravity acting on the body.

  11. Gab Moisan

    Gab Moisan Member

    In fact, I was interested about this subject because right now, among podiatrists in Quebec, Canada, whether or not it’s possible to permanently correct a flatfooted child with foot orthotics is debated. I thought this debate was actually worldwide spread. I must be mistaken. The point is, in Quebec, even thought I don’t have any statistic, I’d say half podiatrists believe that a foot orthotic can permanently correct a flatfooted child . Personnally, I don’t agree with this philosophy.
    Even among teachers of our university, it’s a big debate. I once ask one of my teacher this same question. His answer was : when you place the foot in the correct position, you can correct it according to Davis’ law. By stretching the tissue on the lateral and plantar sides of the foot (STJ capsule, MTJ capsule, ankle joint capsule, plantar ligaments, plantar aponeurosis and muscles) and by elongating the tissue on the medial and dorsal sides, the tissue will remodel accordingly. Same principle with bones and Wolff’s law. It’s the best that I’ve got and I know it’s not sufficient. That’s why I came here to seek for a better answer.

    In my opinion, to base a profession on such premises without any evidence-based data to rely on is an aberration. That’s why I wanted to do a PhD on the subject, to clarify the subject once and for all.
  12. Ros Kidd

    Ros Kidd Active Member

    This is not my area of interest but I have been through ethics committees to use human subjects a few times. The fact that you want to apply an intervention to an asymptomatic human is going to be a problem unless you can clearly show benefits and no harm.
    But good luck as Rob says talk to your supervisor/s
  13. Ros:

    Many studies have been done on foot orthoses and in-shoe wedging in asymptomatic subjects. The problem may be in how long they will allow asymptomatic children to wear foot orthoses. That may vary depending on the ethics committee.

    On the other hand, parents place their children into shoes that don't fit their feet or are unsafe for the activity they are performing quite often. I don't think a custom made foot orthosis is going to do any more harm to a child than what parents do by allowing their children to wear "pretty shoes" that don't actually fit their feet well.
  14. Gab Moisan

    Gab Moisan Member

    Thanks for your time. In my opinion, it's really hard right now to correlate the results of static tests (FPI, Arch Height, RCSP, NCSP, navicular drop...) to foot function. I believe this part of the study will be the biggest challenge. I don't think these static tests are very representative of a dynamic foot while walking or running. Moreover, there are very few dynamic tests that can assess foot function and even less that can quantify and compare flat feet.
    What do you think?
  15. Gab:

    Here in the USA, most podiatrists seem to believe that custom foot orthoses have the capability to prevent the pediatric flatfoot from becoming flatter over time but most don't believe that a normal-arched foot will be created with the use of foot orthoses in the vast majority of flat-footed patients. I wouldn't worry too much about what your instructors think when you are deciding on your PhD since their opinions don't necessarily reflect the beliefs and knowledge in other countries, or even other provinces or states.

    As you probably know, I have been lecturing on the treatment of children's flatfoot deformities for many years, so I believe that I am better informed than most podiatrists on what the current level of knowledge on the treatment of pediatric flatfoot deformity with foot orthoses worldwide. In fact, in a few days, I will be lecturing at a podiatry conference in Townsville, Queensland, Australia and one of my lectures is specifically on the orthosis treatment of pediatric flatfoot deformity.

    I am excited that someone like you has decided to devote your PhD to exploring and researching this topic since I believe that any extra insight you can give us all on this subject will be greatly appreciated by those of us who have an interest in the treatment of pediatric flatfoot deformity. Have you considered doing a functional study of treating children's flatfoot deformity, involving measuring dynamic gait function parameters of flatfooted children with and without foot orthoses, rather than doing the static measures that have been used by other studies? I would think a study of dynamic function of children would yield more clinically useful data than would a study using only static measures of foot shape pre and post orthosis use.

    With that in mind, the following is summary on orthosis research on children's flatfoot deformity that I wrote over 22 years ago from our chapter on evaluating and treating pediatric flatfoot deformity with foot orthoses (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.)

    When will someone actually measure dynamic function of flatfooted children with and without foot orthoses as I first recommended over two decades ago??
  16. 1998 ;). http://informahealthcare.com/doi/pdf/10.3109/03093649809164454

    There are lots of problems with the PhD as proposed, I'll come back to give more comment later if time allows.
  17. Thanks for that one Simon. It would have been nice if a UCBL hadn't been used and a more typical custom foot orthosis had been used instead in this study.
  18. efuller

    efuller MVP

    Getting back to basics. What is dynamic foot function? What aspect of gait do you want to measure, or predict, with static measures and why? Is what you really want a measure that will predict injury?

    Does anybody have a good definition for the term foot function?

  19. Foot function = a function of: genotype + environment + (genotype x environment)
  20. efuller

    efuller MVP

    So the function of the foot is to make sure your DNA survives?
  21. Sally Smillie

    Sally Smillie Active Member

    Gotta agree. Its a bitof a Pandoras box. Unethical to treat asymptomatic,
    do you have 10 years or more to follow up? (and a good 5 to recruit), what outcome measures do you use? Is it the right question to be asking ie. does 'flat foot' really matter at all (or just as much as people often think).

    I'd love to know all those answers, I just wish someone (or many someones) had the time and correct tools for finding any answers.

    Personally, I would be hunting for the right question first. And that might be harder than you think.

    Please keep us all posted
  22. Why is it unethical to treat an asymptomatic child with severely pronated feet and whose parents have symptoms related to their own severely pronated feet? Please explain.
  23. efuller

    efuller MVP

    One reason is the derth of evidence that the measurements that we do are predictive of pathology and that the interventions based on those measurements would be effective in preventing pathology. For comparison look at whooping caugh and the pertusis vaccine. A vaccine that prevented a whooping cough infection would prevent some pretty serious morbidity. We don't have the evidence for orthotic therapy being effective in the prevention of problems.

    That said, If my sons had a STJ axis as medially deviated as mine is, I would have no problem giving them orthotics with a medial heel skive. I feel that the logic of the medial heel skive is impecable for the treatment of a foot with a medially positioned STJ axis. I have a very firm belief, but no proof. Someone else could come along with a firmly held belief that say functional foot typing would lead to a treatment that could prevent pathology. Or a firmly held belief that magnets will suck the toxins out of your feet. At what point do we accept firmly heald belief over evidence? I do beleive that there will eventually evidence that deviation of the STJ axis will be shown to be correlated with some pathologies. I can see how the case can be made that it would be unethical to treat asymptomatic feet with a treatment that has no proof. We do have to start somewhere. I don't know if STJ axis rotational equilibrium theory is even taught in all podiatry schools. Can we ethically do a treatment on an asymptomatic foot that is not even taught in all the podiatry schools. We have a long way to go. We have to start the research somewhere.

  24. Orthodontists don't seem to have any problem treating children with crooked teeth with braces. Do we tell the orthodontists of the world that they shouldn't be treating asymptomatic children who have crooked teeth also? No.

    Do orthodontists have prospective research that treating children with crooked teeth with braces will prevent future functional tooth/jaw problems in the future? I don't know.

    I only hear about this idea that treating asymptomatic children with foot orthoses is somehow "unethical" outside the USA. Why? I don't know. In the UK, Spain and Belgium this does not seem to be the belief, to my knowledge. In addition, here in the USA, podiatrists routinely treat children who have significant flatfoot deformity that have either poor gait function or have a strong family history of painful adult flatfoot deformity who are also currently asymptomatic with custom foot orthoses.

    In fact, in the 31 years I have been a podiatrist here in the USA, I've never heard a single US podiatrist call this type of treatment "unethical". Dr. Mert Root, John Weed, Jack Morris, Paul Scherer and Richard Blake, all who I trained under, would have no problem making custom foot orthoses for asymptomatic flatfooted children in order to treat their gait dysfunction and give them the benefit of the doubt in regards to preventing future problems with their feet in the future, especially if their parents had pronation-related pathologies as adults.

    I believe it is unethical to not offer the parents of asymptomatic flatfooted children who have either gait dysfunction or a family history of painful flatfoot deformity treatment of their children's gait dysfunction of flatfoot deformity with either modified pre-made foot orthoses or custom foot orthoses given our current knowledge of foot orthosis research, foot and lower extremity biomechanics and the effects of abnormal internal stresses on the development of the human body from childhood to adult.

    Therefore, I ask the question again:

    Why is it unethical to treat an asymptomatic child with severely pronated feet and whose parents have symptoms related to their own severely pronated feet? Please explain.
  25. krome

    krome Active Member

    Hi Everyone
    It is really interesting reading the dialogue between colleagues relating to a very controversial topic area. Gab stated started “looking for some literature on the subject and of course, nothing interesting.” We have conducted two reviews that illustrate the issues with the use of foot orthoses for the management of children with flatfeet.

    When we first started the Cochrane review we found that only three studies could be included because of the strict criteria set up (Rome K, Ashford R, Evans A. Non-surgical interventions for paediatric pes planus). Cochrane Systematic Review 2010; 7.
    We reported the following: “Three trials involving 305 children were included in this review. Due to clinical heterogeneity, data were not pooled. All trials had potential for bias. Data from one trial (40 children with juvenile arthritis and foot pain) indicated that use of custom-made orthoses compared with supportive shoes alone resulted in significantly greater reduction in pain intensity (mean difference (MD) -1.5 points on a 10-point visual analogue scale (VAS), 95% CI -2.8 to -0.2; number need to treat to benefit (NNTB) 3, 95% CI 2 to 23), and reduction in disability (measured using the disability subscale of the Foot Function Index on a 100mm scale (MD -18.65mm, 95% CI -34.42 to -2.68mm). The second trial of seven to 11 year old children with bilateral flat feet (n = 178) found no difference in the number of participants with foot pain between custom-made orthoses, prefabricated orthoses and the control group who received no treatment. A third trial of one to five year olds with bilateral flat feet (n=129) did not report pain at baseline but reported the subjective impression of pain reduction after wearing shoes. No adverse effects were reported in the three trials.”

    To overcome the restrictions of a Cochrane systematic review we published a further systematic review which took into account all other non-clinical trials (McKenzie J, Evans AM, Rome K. A review of the evidence for non-surgical interventions for flexible pediatric flat feet. Eur J Phys Rehab Med. 2011; 47: 69-89).

    If Gab looks carefully at the current evidence he will find a wealth of information to commence his PhD. Textbooks and personal preference unfortunately may not be applicable if conducting a PhD.
  26. Gab Moisan

    Gab Moisan Member

    I think part of the answer is that no one knows what a foot orthotics does long term when treating an asymptomatic patient (according to the literature). Is it really going to prevent injuries? Or in fact, it will weaken the foot? A lot of people think that foot orthotic actually prevent injuries, but, I've heard a lot of minimalist shoes "believers" saying that foot orthotics will weaken the foot therefore it will more prone to be injured in the future. Without any evidence-based data, some people will always say it's unethical. According to my experience, this is problematic when dealing with the ethics committee...
    That's partially why I'm interested in the subject
  27. I find it very interesting that the same podiatrists/physicians who would claim that it is unethical to treat asymptomatic children with foot orthoses, orthoses which exactly fit the plantar contours of the children's feet, have no issue allowing their young daughters, teenage daughters and wives to wear shoes which are no resemblance to the shape of the human foot, being too tight in the toes, with excessively high heels and which, over time, will deform the toes and probably cause shortening of their Achilles tendons. However, to their own loved ones who are deforming their feet with such shoes, will say nothing to them, all for the sake of "fashion". If these podiatrists/physicians are female, they may even be doing it themselves on a daily basis all for the sake of "fashion".

    Why won't these same podiatrists/physicians also say that it is unethical to allow their female patients to wear these deforming shoes which cause so much foot pathology? Why aren't they speaking up about this?

    Please explain this one to me also. It makes absolutely no sense to me.:cool:
  28. I want to make another point on this topic.

    How many of you use the medial heel skive in the treatment of your patients with posterior tibial tendon dysfunction (PTTD)? I would assume most of you clinicians by now use the medial heel skive to treat PTTD since when I lecture here and other countries, it is a widely accepted practice (Kirby KA: The medial heel skive technique: improving pronation control in foot orthoses. JAPMA, 82: 177-188, 1992).

    Do you all realize that there is not one shred of research evidence that supports the use of the medial heel skive in the treatment of PTTD? But you still use it in your treatment of these individuals! Why? Maybe because it makes good sense and people feel better and walk better, that's why.

    What if some "authority" said it was unethical for you to use the medial heel skive since there was no research evidence that, over time, it would cause harm to the patients you were using it on? What would you do? Would you stop using it because of what this "authority" said?

    Now substitute pediatric flatfoot deformity for PTTD in the above scenario and see if see if you see any analogies with the declaration by "authorities" that it is "unethical" to treat children with flatfoot deformity that have abnormal gait and/or a family history of symptomatic flatfeet in the teenage or adult years.

    You all may want to chew on that one for a while.:cool:
  29. The key difference being a patient with posterior tibial tendon dysfunction is pathological whereas an asymptomatic child with flatter feet than average is not. What we don't have is a method of predicting pathology in these children.

  30. I have been careful to state in all my postings in this thread that the children I recommend treating are those asymptomatic flatfooted children that have significantly abnormal gait function and/or are the children of parents who, as themselves, had symptoms in their teenage or adult years due to their flatfoot deformity. I specifically did not ever say "an asymptomatic child with flatter feet than average" in any of these postings. I don't recommend treating these children with orthoses unless:

    1. They are symptomatic,
    2. They have significant gait abnormalities, and/or
    3. There is a history of familial symptoms/pathology due to flatfoot disorder.

    Now, Simon, do we have a method of predicting pathology in adults who have posterior tibial tendon dysfunction when treated with medial heel skive orthoses? Please list the research evidence which states that medial heel skive orthoses can be used safely and effectively in the treatment of posterior tibial tendon dysfunction. If there is no research, then why are we still using medial heel skive foot orthoses in their treatment? Isn't that unethical also?
  31. Kevin you wrote:
    What is "abnormal gait function"? For that matter what is normal gait function? How strong a predictor is positive family history in isolation? And how do we know any symptoms the parents may have had were due solely to their flat feet?
    See above for your advocation of treating asymptomatic children with flat feet. How do you define "flat foot", is a comparative to the average made in this decision process?

    You just stated that you recommend treating asymptomatic patients above.
    We don't need to predict pathology in adults who have posterior tibial tendon dysfunction because we already know what their pathology is. A better question might be can we predict the outcomes of intervention?

    The evidence we have is anecdotal.
  32. These are all good points, Dr. Spooner.

    My point in taking on this discussion is that most of the in-shoe treatments we podiatrists provide to our patients, including the various modifications of pre-made and custom foot orthoses (e.g. medial heel skive, lateral heel skive, reverse Morton's extensions, varus forefoot wedges, etc) that we use for adults and children foot and lower extremity pathologies, have very little to no research evidence as to how they work, how well they work, or whether they cause any long term problems with our patients. Therefore, without adequate evidence, we all have a choice to make, we either do little for our patients telling them:

    1. "Sorry, I can't offer this medial heel skive foot orthosis to you for your painful flatfoot due to your posterior tibial tendon dysfunction since there are no long term studies which clearly indicate my use of this type of foot orthosis is indeed helpful and may in fact be harmful to you, therefore it would be unethical for me to use this medial heel skived foot orthosis for you since it is not "evidence based".

    Or, alternatively you could tell your patient, what I tell my patients:

    2. "In my clinical experience, using a medial heel skived orthosis not only should work quite well at not only improving your symptoms, but also helping prevent further flattening of your arch and should improve your gait function. It makes good sense from a biomechanical standpoint and most patients show an immediate improvement in symptoms when using that type of foot orthosis in appropriate shoegear".

    Now, in regards to treating pediatric flatfoot deformities that have significant gait abnormalities but not yet have developed symptoms, why would we, as ethical health-care clinicians, not want to offer these children, and their parents, what we have learned by our years of effective conservative treatment of adults with painful flatfoot deformities with specially modified foot orthoses? In other words, why would we believe, given our current state of knowledge of foot and lower extremity biomechanics that correctly made foot orthoses can't help create sufficient external subtalar joint (STJ) supination moments, external rearfoot dorsiflexion and external forefoot plantarflexion moments to help counterbalance the excessive STJ pronation moments and rearfoot plantarflexion and forefoot dorsiflexion moments that continue to cause the flatfooted child to walk abnormally and possibly make their flatfoot deformity worsen over time?

    I ask all of you, which podiatrist then is the most ethical?

    1. That podiatrist that refuses to offer a child and their parents more normal gait function and possible prevention of future worsening of their flatfoot pathology by using a treatment, custom foot orthoses, that is over two centuries old, all because they claim there is insufficient research evidence that foot orthoses make a child's arch any higher over time, or

    2. That podiatrist that offers a child and their parents more normal gait function and possible prevention of future worsening of their flatfoot pathology by carefully evaluating the structure and function of the child, making custom foot orthoses, giving sound advice on shoegear, stretching, sports and then following that child closely for any problems during their years of growth and physical and mental development.

    I know which podiatrist I am.
  33. gavw

    gavw Active Member

    What is evidence based medicine (EBM)?

    The answer lies between clinical experience and the best external evidence. Hopefully this freely available BMJ article by Sackett, a pioneer of EBM, will contribute to this discussion. It is from 1996, but still incredibly relevent today:

  34. Please can Podiatry Arena offer a "like" button!!! Excellent points Kevin, as always!
  35. Boots n all

    Boots n all Well-Known Member

    Its called a "Thanks" button here, bottom right hand corner.
  36. Sally Smillie

    Sally Smillie Active Member

    Firstly feet and teeth are not the same. Correction of teeth position is largely for aesthetic reasons, in the main. However, the proof of effectivesness is easy for anyone to see, and very quickly obvious. We know that poor positioning will not self correct if left alone. This is not the case for feet. I don't think we are comparing apples to apples here.

    Secondly, gait dysfunction IS a symptom. Establishing the connection to foot posture is the tricky part, but not diffcult with knowledge and experience.

    Finally, "benefit of the doubt in regarding potential future problems" is not quite evidence. For all the years some of us have been treating children and the experience we have it is suprising that there is still no evidence produced that demonstrates a direct influence of wearing of foot orthoses altering the course of developement of a maturing foot OR demonstrable proof that accurately predicts foot that looks like X will develop Y. Nor a link that parents with such foot pathologies are 10/30/50/80% likely to pass that onto their childen. There are too many unknowns for it to be anywhere near a certainty.

    As a clinician however, there have been a few cases where the foot posture has been so extreme, and the parents with a lifetime of foot problems from an early age where I have treated with orthoses, but I arm them with the full knowledge that there wasnt much evidence, and may not have any effect etc. This is where I employ the benefit of the doubt. But these have been maybe 2 per year, and I work exclusively in paeds and in the NHS so ALL referrals in our catchment area come to me.

    I would have a hard time gaining ethics approval for a study that required to subject asymptomatic children to (any) treatment regime, let alone one that lasts for many years for something that there is precious little demonstrative evidence for the impact, or benefit.

    Perhaps we can run a transatlantic multicentre trial and if that would get around the ethics diffculties?

    evidence based practice is not a threat but a support
  37. Most physicians here in the USA would define a symptom as a subjective complaint, not an objective finding from exam. Do podiatrists in the UK or Australia say that a maximally pronated gait with lack of normal propulsion but no subjective complaints is a "symptom"?? in fact, I don't know of any podiatrists or medical doctors here in the USA that would call "gait dysfunction" a "symptom". They would call that an objective finding, not a "symptom".

    If this is the case that an individual with no subjective complaints, but with "gait dysfunction", is considered to be "symptomatic" in the UK and Australia, then that certainly changes things quite a bit in this discussion, doesn't it?!
  38. Boots n all

    Boots n all Well-Known Member

    This is a interesting debate.

    But through out it l dont see anywhere that some one has pointed to the age at which you plan to apply this study to.

    At what age are you going to call it a flat foot rather than a chubby foot, age 3, age 6? What is going to define it as a flat foot?
  39. If you were to suggest that foot orthoses can change the structure of a developing foot I would tend to agree - plenty evidence with serial splinting and casting, not to mention foot binding - to support that position. It's the use of 'correct' with all the implications others have gone on to cite, that will give you the greatest difficulty.

    Not that you shouldn't try...
  40. Good points, Mark. I have great difficulty in understanding how podiatrists who have the ability to understand how foot orthoses work using advanced modelling techniques such finite element analysis, forward dynamics and free body diagram analysis, where it can be clearly shown that foot orthoses have the potential to reduce or eliminate the pathological internal stresses within a flatfooted child that tend to cause permanent deformation of the osseous skeleton over time, also seem to have difficulty understanding how a custom foot orthoses, when appropriately designed, can not only immediately alter the function of the foot over time but also alter the structure of the osseous skeleton of the foot over time. External forces from custom braces on the teeth, back, hips and other body parts are used throughout the medical profession in an attempt to affect the growth of the osseous skeleton of a growing child. However, for some reason, there seems to be a problem with some podiatrists in some countries using the same time-tested medical techniques of applying external forces from a brace to a body part to to try and prevent a flatfooted child from becoming more flat and/or more pathologic over time.

    Do you have an explanation for this? Because, here in the USA, we commonly treat asymptomatic flatfooted children with significant gait abnormalities and/or significant family history of painful flatfoot deformity with custom foot orthoses. Is this just a UK and Australia podiatry thing or am I missing something here??

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