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Pediatric Flatfoot

Discussion in 'Pediatrics' started by LER, Feb 2, 2010.

  1. LER

    LER Active Member

  2. rodney

    rodney Welcome New Poster

    a very interesting read.It has always been a bit of a dilema if the child is asymptomatic and there is no family history of foot problems especially when you factor in the cost implications for the parents.Also there are lots of podiatrists that make plenty of money from orthotic therapy for children- is there not a conflict of interests?!
  3. Admin2

    Admin2 Administrator Staff Member

  4. Griff

    Griff Moderator

  5. Louise Wilson

    Louise Wilson Member

    I found that a very interesting read indeed, I regularly carry out podopaediatric clinics and I find that this is one of the most common complaints that the patients attend with. I personally tend not to fit an orthotic until the age of 5-6, unless of course the child is complaing of symptoms before this time in which case I will fit an orthotic. But for asymptomatic I prefer to wait until the foot is a little more developed.
  6. misriko

    misriko Member

    within the location i currently work in, the general consensus is not to treat paediatric flat foot till approx ages 5-7. reading this article is will divide clinicians on which route is ideal. many parents bring their children worried about flatfootedness in their children despite no symptoms, but would like 'results' in terms of thier childrens feet 'looking normal'. I agree with many aspects of the article and greater research into clinician D' amicos treatment of children of such a young age should prove interesting indeed.
  7. If there is a history of flatfoot in the family, and the child of 2-5 has a definite flatfoot, even though they are currently asymptomatic, then why would you not start treating the child with at least a varus heel wedge and medial longitudinal arch pad in their shoes, while their foot skeleton is still largely cartilagenous? In my opinion, it is unethical, given our state of knowledge of the biomechanics and growth patterns of the foot, to not treat these children at an early age at least with a low cost temporary orthosis to provide them with a better chance at developing a more normal foot architecture as an adult.

    Anyone want to debate this with me? I can't wait.:boxing::butcher:
  8. All right Kevin, I have a go just as a Devil Lawyer ( there should be a smilie for that one).

    1st what is a Normal foot ?

    Do you treat a Cavus foot the same as ie if a family has a cavoid foot type and the child comes in 2-5 years old with a cavoid foot type do you treat to "Normalize" the foot?

    So by changing the forces on the softer bone through the use of an orthotic, you are using Wolfs law in a positive sense to Normalize the foot- Would this be a good summary ?
    if so how much force do you decide is good for each patient and how does the enviromential factors of each child effect the force that you use on the foot with your device ? ie does an overweight child get a more controlling device or does a child who plays lots of sport get a more controlling device v´s a child who plays computer games ?

    Do you beleive an orthotic can "over correct" and child so they could have problems with excessive Supination as an adult ?

    Also at what age does the correct the "flat foot" then move to the tissue stress treatment approach? ie only treating the affected tissue by reducing the load on the tissue, not the foot type ?

    Thats it for now.
  9. Michael:

    I said a "more normal foot" not a "normal foot". A normal foot does not have the severely medially deviated subtalar joint (STJ) axis that the children with pes valgus deformity that I treat with orthoses have (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; Kirby KA.: Biomechanics and the treatment of flexible flatfoot deformity in children. PBG Focus, J. Podiatric Biomechanics Group, 7:10-11, 1999).

    Of course, Wolf's law is being used here by using a in-shoe varus heel wedge and medial longitudinal arch pad or a modified premade orthosis or a custom foot orthosis to increase the external STJ supination moment and increase the external forefoot plantarflexion moment acting on the foot during weightbearing activities. The force under the foot is not measured, but rather the gait of the child is assessed along with the subtjective response of the child to the orthosis therapy. This is the same regardless of the size and age of the child.

    The tissue stress approach does not ignore gait function. Here are the three goals of orthosis therapy using the tissue stress approach: 1) Reduce the pathologic loading forces on the symptomatic structural components. 2) Optimize gait function. 3) Cause no other pathologies. #2 is key here and replace symptomatic with "abnormally loaded" and I think the tissue stress approach works quite nicely in this case also.

    Michael, so you will also wait to age 5 or 6 to treat an asymptomatic child with a severely medially deviated STJ axis even though both parents have medially deviated STJ axes and have had problems with their feet ever since their teenage years? Please explain your mechanical rationale for such a clinical decision.
  10. Graham

    Graham RIP


    In an asymptomatic presentation what are the known pathological forces?

    Considering our movement away from varus heel wedging and pure arch support, how would this optimize gait?

    I would suggest that using orthoses, especially "arch Supports" meerly change the compensatory mechanisms and MAY in time lead to pathology of there own.
  11. I always considered weight of the child being very important. A child with less weight will not have the same resultant change from a device as a heavy patient, so instead of age in your option is weight an important factor in when to treat. Ie 30 kgs flat foot treat 20 kg flat foot reveiw when 30 kgs?

    So then if a child although rare with a lateral deviated axis you will treat as well ?

    Kevin I never said what I would do I was trying to discuss a point of View to get a better overall understanding. Since moving to Sweden I don´t treat children 2-5 ( apparently not allowed to by law, I found out the other day- long story). But in the past I have treated 2-5 years.
  12. The heavier the child, the larger the ground reaction force (GRF) and the larger will be the amount of GRF that is shifted medially with my pediatric flatfoot orthoses. I don't do anything different with heavier children other than I may add a little bit more correction which I evaluate, as in every patient, by observing their gait in walking and, specifically in all children, in their running.

    Michael, how do you assess the amount of force with the orthoses you make for adults? Is this different than how you treat children? Why?

    Yes, but only see the children with laterally deviated subtalar joint axes once a year. I see 1-3 new pediatric pes planus patients a week.

    From your questions, you made it sound like we should, for some unknown reason, use a different set of theoretical mechanical concepts for children between the ages of 2-5 than for those children that are 6 to adult. This is the reason I started this discussion and offerred up a challenge to all of you who believe this nonsense (maybe you don't believe this Michael, but you at least took up the challenge of discussing this with me).

    Please tell me, anyone!, what is the biomechanical reasoning behind not beginning to treat a child that is between 2 and 5 years old with obvious signs of abnormal foot structure and abnormal gait pattern but doesn't have any symptoms and has a family history of flatfoot deformity? This is what it all comes down to and why I consider that nontreatment of these children by some podiatrists to make absolutely no sense.
  13. Alright no more trying to lawyer for the Devil.

    I do agree that children should be treated, As discussed Wolfs law changes and Davis law should be considered very much so as well- Detoid ligament etc.

    To keep things going what do you say about the research that says there is No Evidence based medicine to treating 2-5 years olds?

    Can we over correct 2-5 "flat-footed" children which may lead to symptoms in the future and how do we address those issues?

    also you have said Family history plays a role in your treat or not to treat, what if Dad says I had same feet but "grew out of it as a teenager" how does that effect if you treat or don´t ?
  14. JB1973

    JB1973 Active Member

    Please tell me, anyone!, what is the biomechanical reasoning behind not beginning to treat a child that is between 2 and 5 years old with obvious signs of abnormal foot structure and abnormal gait pattern but doesn't have any symptoms and has a family history of flatfoot deformity?

    Kevin, what about the child who has obvious signs of abnormal structure but has NO family history of foot problems. is there ever a case when things are just better left alone, or at least monitored every 6 months or so with no orthotic therapy?
  15. georginaj

    georginaj Welcome New Poster

    Hi, I am a fourth year podiatry student and have been following all forums regarding paediatric flat foot. I am currently writing an assignment on asymptomatic paediatric flat foot and would greatly appreciate any reccommendations for relevant literature. I have been able to access articles by Angela Evans but have had trouble finding other articles/research on this topic. Any help would be welcomed thank you!
  16. bkelly11

    bkelly11 Active Member

    If you can access Angela Evans new book pocket podiatry guide paediatrics. You will be able to get all her references.
  17. georginaj

    georginaj Welcome New Poster

    Thank you! This has been very helpful.

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