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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Severs Disease

This is a good one:

Sever's Injury: A Stress Fracture of the Immature Calcaneal Metaphysis. Journal of Pediatric Orthopedics. 24(5):488-492, September/October 2004.Ogden, John A. MD *; Ganey, Timothy M. PhD ++; Hill, J. David MD +; Jaakkola, Juha I. MD +

Magnetic resonance imaging (MRI) in children with a presumptive diagnosis of Sever's apophysitis and with continuing pain after conservative treatment demonstrated bone bruising within the trabecular bone of the metaphyseal region adjacent to the calcaneal apophysis. Limited portions of the apophyseal secondary ossification center showed similar increased signal changes. MRI studies following treatment with immobilization showed subsidence or disappearance of the metaphyseal but not any apophyseal signal changes commensurate with improvement in symptoms. Accordingly, the disorder commonly referred to as Sever's "apophysitis" may be a metaphyseal trabecular stress fracture, similar to the toddler's calcaneal stress fracture that has minimal or no involvement of the apophyseal ossification center, and thus should not be referred to as an apophysitis. Rather, it appears to be an overuse injury causing microinjury within the developing metaphyseal "equivalent" trabecular bone that has not completely adapted to the changing biologic (biomechanical) requirements of the growing, athletically active child.

Ask a question about Severs disease at the Foot Health Forum.

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Severs Disease

This is a good one:

Sever's Injury: A Stress Fracture of the Immature Calcaneal Metaphysis. Journal of Pediatric Orthopedics. 24(5):488-492, September/October 2004.Ogden, John A. MD *; Ganey, Timothy M. PhD ++; Hill, J. David MD +; Jaakkola, Juha I. MD +

Magnetic resonance imaging (MRI) in children with a presumptive diagnosis of Sever's apophysitis and with continuing pain after conservative treatment demonstrated bone bruising within the trabecular bone of the metaphyseal region adjacent to the calcaneal apophysis. Limited portions of the apophyseal secondary ossification center showed similar increased signal changes. MRI studies following treatment with immobilization showed subsidence or disappearance of the metaphyseal but not any apophyseal signal changes commensurate with improvement in symptoms. Accordingly, the disorder commonly referred to as Sever's "apophysitis" may be a metaphyseal trabecular stress fracture, similar to the toddler's calcaneal stress fracture that has minimal or no involvement of the apophyseal ossification center, and thus should not be referred to as an apophysitis. Rather, it appears to be an overuse injury causing microinjury within the developing metaphyseal "equivalent" trabecular bone that has not completely adapted to the changing biologic (biomechanical) requirements of the growing, athletically active child.

Ask a question about Severs disease at the Foot Health Forum.

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Newborn Foot

New article in the latest issue of the American Family Physician on the Newborn Foot

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Newborn Foot

New article in the latest issue of the American Family Physician on the Newborn Foot

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