Pediatric flatfeet correction with foot orthoses

Hi Kevin

I don't think you can quantify the different in approach from a regional or international basis. I certainly don't doubt that you can change the underlying osseous structure through external modelling and/or function. The question for me is not so much ethical but whether it is desirable. I can appreciate your analogy with dental braces, but the 'correction' here is mostly aesthetic - rather than to improve function. I guess in the treatment of paediatric flat foot the holy grail is to achieve both - however, I am a long way from being convinced that both are achievable. Let's say you take a three year old with the qualifying triad - an inherent flatfoot deformity and a family history of both deformity and attributable symptoms - and strapped their feet onto a high-arched rigid foot orthosis for a year. I strongly suspect that when you removed it, the child would present with a rectus foot - in appearance. But would it function like a similar foot through normal development? Probably not - as function is dependent on much more than osseous structure alone. If structure was the sole determinant of function then I would expect to see a much more aggressive approach to paediatric flatfoot correction using a combination of subtalor implants and MASS style rigid splints/devices to achieve pedal remodelling - but I don't think that is necessarily the best answer.

I have provided orthoses for asymptomatic paediatric flatfoot - mostly as a prohylaxis to prevent end ROM injury - but I am the first to point out to the parents, I cannot really quantify the efficacy of this Rx for all the obvious reasons.

Best wishes

 

Mark:

Thanks for your response.

When parents ask me whether their child will develop normal arches with foot orthosis treatment, I tell them that this event is not likely even though it may occur. I tell them, however, that I do expect the foot orthosis will prevent worsening of the flatfoot deformity, the foot orthoses will bring improvements in their gait function and the foot orthoses will be expected to increase their child's activity levels, all events that I have seen very many times now over the past 30 years of treating over a thousand children with custom foot orthoses.

In addition, I tell the parents that the purpose of the foot orthoses for their asymptomatic flatfooted child with a gait abnormality and/or a family history of painful flatfoot deformity is to no more change the arch structure or shape of their foot than they would expect eyeglasses to change the structure of their children's eyes if prescription eyeglasses were being made for their child's vision problem.

I tell the parents that the key to well-designed custom foot orthoses for their flatfooted child is to improve gait function and take the abnormal stresses off of the internal structure of their foot in an attempt to prevent future worsening of their deformity and attempt to prevent future foot and lower extremity pathology in much the same way that an eye doctor will prescribe eye glasses to improve their child's eye function and reduce their eye strain over time which may not only cause subjective symptoms, such as headaches, but may also cause learning difficulties.

Did you know, Mark, that, according to some podiatrists, you were being "unethical" by treating asymptomatic flatfeet with foot orthoses? Never mind, I'm sure you, like me, could care less what other podiatrists think about what you do in your practice for your patients.:drinks

 

Hi Kevin

That's pretty much what I would expect any podiatrist to say to the parents of a flatfooted kid who come asking for advice. Perhaps it's not surprising that some have an expectation that we can create a fully functioning arch from pieces of hard plastic under their child's foot - after all, if Rothbart can cure infertility and suicidal depression with flat rubber pancakes, then surely even lesser mortals in the podiatric world can fix a fallen arch...

It is an interesting topic though - we've seen the hugely successful Ponsetti Rx for TEV which was preceded by the old Denis-Browne Splints - both correcting a fairly gross foot/ankle anomaly. Perhaps in time, when we know better all the various influences in foot development, we may be able to offer early intervention to remodel the foot whilst maintaining or improving function, albeit, Probably not in our day.


All the best

 

And will those of us providing this treatment still be considered "unethical" by many podiatrists in doing so? It's unfortunate that many podiatrists are too afraid to use their knowledge of foot biomechanics to treat conditions that haven't been researched adequately with high level evidence...all being worried that the EBM police may blow the whistle on them.:butcher::boxing:

 

Water. Ducks. Back. :empathy:

 

Interesting thread, as a recent graduate i always thought that a study on something of a similar ilk could be beneficial. Obviously genetics has huge part to play in a childs foot type but i also can see an area of interest in that by controlling the environment(shoes+ orthotic) the foot is in during childhood you could perhaps reduce or prevent the likelyhood of developing lower limb conditions later on life that the child's parent/s may already have and that the child is already predisposed to genetically.... Probably too many variables to get a definitive result.

 

It's good to see that this old chestnut is still doing the rounds! I feel that the number of variables here create a minefield . Perhaps rather than looking at specific foot function a more global indicator such as the effect of a specific orthotic or/and footwear on stability function where there are measurable key indicators ! Just a thought!!

 

Good to see you are still alive and kicking, Tony!!:drinks

 

Thanks Kevin , like to dip my toe in occasionally !!