DAVID LIDDLE PODIATRIST PAEDIATRIC FLATFOOT PODIATRY
To treat or not to treat Angela Evans PhD The paediatric flat foot proforma (p-ffp): improved and abridged following a reproducibility study Angela Margaret Evans*1, Hollie Nicholson2 and Noami Zakarias3 Journal of Foot and Ankle Research 2009, 2:25
To treat or not to treat Flexible flatfoot 1. Symptomatic - treat 2. Asymptomatic non developmental monitor 3. Asymptomatic developmental leave alone
What is symptomatic? Definition of symptom in English: 1. A physical or mental feature which is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patient: 1.1 An indication of the existence of something, especially of an undesirable situation:
Where is your line in the sand? Pain No pain but with the following: Gait abnormality Lifestyle restriction Family history of painful flatfoot deformity Signs of pathology eg 1 st MTPJ dorsal exostosis Significant risk of developing problems High supination resistance Medially deviated STJ axis Windlass dysfunction Abnormal or excessive wear patterns in otherwise good shoes Any of the above would have treatment options considered My line No pain and none of the above ie no symptoms at all
Considerations Degree of calcaneal eversion 7 degrees minus age May also use FPI or navicular height How much does the talus protrude and how far the forefoot gets abducted Is gait abnormal apropulsive or asymmetrical Are there issues with footwear abnormal wear or difficulty getting shoes to fit
Supination Resistance The patient is asked to stand in a relaxed position on two feet They are instructed to relax their feet during the test, and not help in any way The clinician places the tips of the index and middle fingers just beneath the navicular The clinician pulls directly upward (parallel to the tibia) The clinician notes the magnitude of force that is required to supinate the foot from its resting position The test is performed on the other foot Reliable in adults with experienced practitioners J Am Podiatr Med Assoc.2003 May-Jun;93(3):185-9. The reliability of the manual supination resistance test. Noakes H Payne C
Windlass function Jack s test Abductory twist 1 st MTPJ joint changes Dorsal lipping, hallux valgus, hyperextended distal phalanx
CRITERIA AND TREATMENT CONSIDERATIONS Symptoms Yes Genesis of tissue stress is NOT from foot deformity Orthoses may not be indicated? Physical therapies/onward referral Genesis of tissue stress IS from foot deformity Orthoses indicated What do you need the orthotic to do? Chose appropriate device
Types of orthotic devices Very simple EVA heel raises/wedges Felt OTC Feet in Motion 3 deg 5 deg TalarMade Silicone heel cups Modular/library devices Everflex Skeletal Balance Casted functional UCBLs (University of California Biomechanics Lab) Not forgetting the footwear!
Simple solutions Kids Feet in Motion Podotech Junior Talarmade 1 st line
Modular devices Everflex Skeletal Balance Varus/valgus extrinsic/intrinsic posts Various shell flexibilities 1-3mm thickness Shell cut outs 1 st met 1 st ray 5 th met Morton's/reverse Morton's extensions Cluffy wedges Met pads/domes, valgus/arch fill pads Heel raises/cushion pads/spur pads Various coverings
Casted functional UCBLs
CRITERIA AND TREATMENT CONSIDERATIONS No Symptoms Asymptomatic Outside normal limits Within normal limits Orthoses not indicated - Monitor/refer on Orthoses not indicated - advice/reassurance/discharge
PAEDIATRIC FLATFOOT DEFORMITY Genesis of tissue stress No Pain Yes Genesis of tissue stress Yes Pain No Gait abnormality? Within normal limits Orthoses not indicated - reassurance/discharge Outside normal limits Orthoses not indicated - Monitor? Orthoses not indicated? Physical therapies/onward referral Wedge OTC eg Kids FIM Modular Device eg SBS Casted Functional eg UCBL Lifestyle restriction Family history of painful flatfoot deformity Signs of developing pathologies e.g. 1 st MTPJ dorsal exostosis High risk of developing problems - High supination resistance - med dev STJ axis - Windlass dysfunction
Thank you Coffee time!!