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I have an 11 year old female patient who is active (netball 3 x week, dancing 5hrs week). She has never had any foot or lower limb pain but her parents are concerned as her feet are "rolling inwards".

On examination she has ligament laxity and she pronates significantly in resting stance. Very low medial arch profile, navicular bulging, calc eversion on both feet

The question is should this patient be treated with orthotics as she is not in any pain and this does not inhibit her from doing any of the activities she wants to.

Any opinions would be greatly received as I am a Biomech Novice!

Thankyou

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See: other threads on hypermobility syndrome

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Short answer. No.

Asymtomatic, thus no indication for intervention. No pain and fully functional.

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Patient (age 6) "Mum, I know you're pregnant, but why is your bum big too?"

I can understand Sally's position on this. What I am unclear of is when you say "stance" do you mean static stance or stance phase of gait? It might be then when very active in her sport there may value to a simple orthosis but that in everyday matters might not need them? Just a thought.

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Ian Linane

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Podia-Clinic
Southwick
England
www.podia-clinic.com

Ronald Valmassy, DPM, was one of my biomechanics professors and also was my residency director during my Biomechanics Fellowship at the California College of Podiatric Medicine. Dr. Valmassy taught me a lot about children's feet and when to treat and not to treat them with foot orthoses.

First of all, I would never use the sole fact that a flatfooted child is asymptomatic at age 11 to refuse them treatment with custom foot orthoses. This assumes that foot orthoses have no ability to improve the kinetics of gait and no ability to improve the kinematics of gait. We know, from prior research in multiple scientific studies, that this is not the case and that foot orthoses can improve gait function by altering the kinetics and kinematics of gait. Do we simply look at a foot in a static weightbearing position and ask them whether there are any current symptoms or not to determine whether foot orthoses should be recommended? I hope not. There is no simple answer since the experienced podiatrist with a good knowledge of biomechanics will realize that this issue is not only very important but also requires more than just looking at the medial longitudinal arch structure of a static weightbearing foot before they give treatment recommendations for shoes and foot orthoses, whether over-the-counter or custom.

Secondly, we know that the structural components of the foot and lower extremity will have higher magnitudes of loading forces as the body weight increases. Therefore, an 11 year old child, that weighs 90 pounds will have signficantly less magnitude of loading forces acting on their internal structural components of their feet and lower extremities than when they mature into adulthood and add on another 50-60 pounds of body weight. Combine that fact with our knowledge that the peak ground reaction force (GRF) during walking is approximately 1.25 x body weight (BW) while during running the peak GRF is 2.5 - 3.0 X BW, for every pound that a child gains in body weight maturing into adulthood, an extra 2.5 - 3.0 pounds of extra GRF with each running step will be added onto their plantar foot with each running step. This added body weight will greatly increase the magnitudes of internal loading forces acting on the foot and lower extremity and likely greatly increase the risk of musculoskeletal injury.

Third, the familial history of foot and/or lower extremity problems will tell us quite a bit about what to expect in a flatfooted child. Were his parents also flatfooted and were they able to participate fully in sports and other weightbearing activities in their teenage and adult years or did they have symptoms that prevented them from being comfortable or painfree in these activities? Certainly if both parents were flatfooted and experienced no symptoms in their teenage and adult years from their foot structure, then I would likely not recommend foot orthoses. However, if the parents had a flatfoot and symptoms, I would definitely recommend foot orthoses for an 11 year old asymptomatic flatfooted child.

Fourth, and probably most importantly, what does the 11 year old flatfooted child show in their walking and running gait examination? Are they walking with normal propulsive mechanics and running with good mechanics, normal stride length, with no evidence of an antalgic gait? Do you think could improve their gait mechanics and their activity endurance with a foot orthosis? Or do tell the parent that "being flatfooted in normal" and never spend any time watching the child walk and run and analyzing their gait? I hope not.

Certainly, the orthodontic profession don't seem to mind recommending braces for the teeth of 11 year old children even when these children are asymptomatic. Orthodontists realize that as the child ages, the corrections in tooth alignment will take longer to occur with bracing an adult than when bracing a child. Why are so many podiatrists so afraid to recommend custom foot orthoses for children who are flatfooted, who may be asymptomatic currently but may have a famiy history of foot and lower extremity pain and may have quite abnormal gait patterns during walking and/or running? Do we wait for research that supports all the treatments that make good biomechanical sense for all our patients? I hope not. Or do we use our biomechanical knowledge to devise the best treatment plan for the patient while taking in all the facts regarding their foot structure, their specific biomechanics and their current and familial history? I hope so.

There is no simple answer to this complicated question and children should not be prevented from getting the best of care to prevent problems with their feet and lower extremities even if it involves a custom foot orthoses. The ethical and experienced podiatrist will recommend what the best treatment is in order to improve the gait function and prevent future problems for the flatfooted child, whether that includes no treatment or treatment with over-the-counter or custom foot orthoses. Our children's feet deserve our full attention, deserve our full biomechanical considerations, and not just a blanket statement that they should not be treated with foot orthoses if flatfooted and asymptomatic.

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Sincerely,

Kevin

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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
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