Asymptomatic pediatric flatfoot

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 textbooks (usually depending if its published in the UK vs the USA - with the USA approach tending to be more interventionist). The evidence is limited - 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 observation vs intervention. Of course, the McDonald & Kidd paper is compulsory reading (I even promise them an exam question on it that more than half fail. HINT for students: READ THE QUESTION)

The notes the students get before the lecture are explicit:

"Considerable debate in literature as to natural history and the need to intervene if asymptomatic - ethical decision to intervene in consultation with parents.

General guidelines - treat if subtalar joint is pronated after heel off; symptomatic; severe; significant medial column collapse; significant transverse plane motion; history of symptomatic problems in parents "


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 . 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.


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Asymptomatic pediatric flatfoot

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 textbooks (usually depending if its published in the UK vs the USA - with the USA approach tending to be more interventionist). The evidence is limited - 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 observation vs intervention. Of course, the McDonald & Kidd paper is compulsory reading (I even promise them an exam question on it that more than half fail. HINT for students: READ THE QUESTION)

The notes the students get before the lecture are explicit:

"Considerable debate in literature as to natural history and the need to intervene if asymptomatic - ethical decision to intervene in consultation with parents.

General guidelines - treat if subtalar joint is pronated after heel off; symptomatic; severe; significant medial column collapse; significant transverse plane motion; history of symptomatic problems in parents "


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 . 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.


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Diabetic Foot Natural History

Some pretty bold claims were made on altering the natural history of the diabetic foot in this paper: Changing the Natural History of Diabetic Neuropathy: Incidence of Ulcer/Amputation in the Contralateral Limb of Patients With a Unilateral Nerve Decompression Procedure (Ann Plast Surg. 2004 Dec;53(6):517-522 Aszmann O, Tassler PL, Dellon AL.). The authors claims that "decompression of lower extremity nerves in diabetic neuropathy changes the natural history of this disease, representing a paradigm shift in health care costs. " All this based on being able to help diabetic neuropathy with decompression surgery. Given that the etiological pathways of diabetic foot complications are so multifactorial - especially the role of vascular disease in amputations, I can't see how improving one factor represents a "paradigm shift". Dr Dellon is doing some good work and has a number of publications on decompression surgery to relieve pressure on nerves in those with diabetic peripheral neuropathy.

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Diabetic Foot Natural History

Some pretty bold claims were made on altering the natural history of the diabetic foot in this paper: Changing the Natural History of Diabetic Neuropathy: Incidence of Ulcer/Amputation in the Contralateral Limb of Patients With a Unilateral Nerve Decompression Procedure (Ann Plast Surg. 2004 Dec;53(6):517-522 Aszmann O, Tassler PL, Dellon AL.). The authors claims that "decompression of lower extremity nerves in diabetic neuropathy changes the natural history of this disease, representing a paradigm shift in health care costs. " All this based on being able to help diabetic neuropathy with decompression surgery. Given that the etiological pathways of diabetic foot complications are so multifactorial - especially the role of vascular disease in amputations, I can't see how improving one factor represents a "paradigm shift". Dr Dellon is doing some good work and has a number of publications on decompression surgery to relieve pressure on nerves in those with diabetic peripheral neuropathy.

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Good friend of mine, Cameron Kippen has now ended his time at Curtin University to move on to other things. Read comments here. Cameron is well know for his sex and footwear work :-)

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Good friend of mine, Cameron Kippen has now ended his time at Curtin University to move on to other things. Read comments here. Cameron is well know for his sex and footwear work :-)

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Foot orthoses outcomes and kinematic changes

To get some debate going, I just posted this at Podiatry Arena:

"Foot orthoses outcomes and kinematic changes

1. We use various types of foot orthoses in clinical practice in an attempt to alter the pattern of rearfoot motion to "improve" biomechanics and make patients better.
2. Numerous outcomes studies, patient satisfaction surveys (many with methodological flaws) and RCT's show patient do get better with foot orthoses that attempt to alter the pattern of rearfoot motion.
3. The numerous kinematic studies (many with methodological flaws) are about evenly divided as to if foot orthoses do alter the pattern of rearfoot motion or not. Half show no differences in rearfoot kinematics and the other half show such small (but statistically significant) differences that the biological significance of those differences need to be questioned.

Does anyone see the paradox here? What we do clinically works, but not by trying to do what we think we are doing

In an attempt to resolve this paradox, one of our projects this year measured patient symptoms (FHSQ) at issue of foot orthoses and at 4 weeks follow up. At issue of foot orthoses, rearfoot kinematics was also measured with and without the use of the foot orthoses. Guess what we found? ---- there was no correlation between changes in the pattern of rearfoot motion and symptom reduction

This is troubling as I have spent most of my professional life trying to alter patient's pattern of rearfoot motion .... they get better, but not because of the changes in rearfoot motion

What say you? "

I don't think many people are grasping the significance of all the most recent reseach on foot orthoses, their effectiveness and how they work..... especially those with vested financial interests ;-)

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Foot orthoses outcomes and kinematic changes

To get some debate going, I just posted this at Podiatry Arena:

"Foot orthoses outcomes and kinematic changes

1. We use various types of foot orthoses in clinical practice in an attempt to alter the pattern of rearfoot motion to "improve" biomechanics and make patients better.
2. Numerous outcomes studies, patient satisfaction surveys (many with methodological flaws) and RCT's show patient do get better with foot orthoses that attempt to alter the pattern of rearfoot motion.
3. The numerous kinematic studies (many with methodological flaws) are about evenly divided as to if foot orthoses do alter the pattern of rearfoot motion or not. Half show no differences in rearfoot kinematics and the other half show such small (but statistically significant) differences that the biological significance of those differences need to be questioned.

Does anyone see the paradox here? What we do clinically works, but not by trying to do what we think we are doing

In an attempt to resolve this paradox, one of our projects this year measured patient symptoms (FHSQ) at issue of foot orthoses and at 4 weeks follow up. At issue of foot orthoses, rearfoot kinematics was also measured with and without the use of the foot orthoses. Guess what we found? ---- there was no correlation between changes in the pattern of rearfoot motion and symptom reduction

This is troubling as I have spent most of my professional life trying to alter patient's pattern of rearfoot motion .... they get better, but not because of the changes in rearfoot motion

What say you? "

I don't think many people are grasping the significance of all the most recent reseach on foot orthoses, their effectiveness and how they work..... especially those with vested financial interests ;-)

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The latest British Medical Journal has a full text article on Tibialis posterior dysfunction. Its a good review and has a podiatrist as co-author

There is some interesting speculation from the Journal of Pediatric Orthopedics on the causes of growing pains. ... problem is when someone talks or writes about growing pains, its not clear that we are talkng about the same thing.

....and a bit of fun in the Canadian Medical Association Journal on: Incidence of and risk factors for nodding off at scientific sessions .... I go to so many conferences, it has to be good to keep me awake :-)

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The latest British Medical Journal has a full text article on Tibialis posterior dysfunction. Its a good review and has a podiatrist as co-author

There is some interesting speculation from the Journal of Pediatric Orthopedics on the causes of growing pains. ... problem is when someone talks or writes about growing pains, its not clear that we are talkng about the same thing.

....and a bit of fun in the Canadian Medical Association Journal on: Incidence of and risk factors for nodding off at scientific sessions .... I go to so many conferences, it has to be good to keep me awake :-)

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