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I’m a pediatrician with a question that I think would be answered best by a podiatrist. Allopathic physicians are trained not to intervene in cases of scoliosis unless the deformity is considerable (i.e. greater than 10 degrees). Given that limb length inequality can cause scoliosis, I view this “laissez-faire” approach as being closer to a policy of somewhat-less-than-benign neglect—especially when correction of the patient’s biomechanics might alleviate the spinal deformity.
I currently have a (premenarchal) 12 y/o female patient with documented 1cm lower extremity length discrepancy (comparing respective direct measurements from ASIS to medial malleolus) and a 7-degree scoliosis contralateral to the longer limb. My question for all the pods is: Do you think that orthotic inserts could be used to correct (or at least prevent the progression of) the spinal deformity? Thanks in advance for any input you can provide.
(I found a journal article that may be of interest to those of you contemplating the clinical scenario above. The paper deals with adults with scoliosis who have significant LLDs corrected with lifts. Although this study does not address my specific question it provided the impetus for my conjecture regarding the use of orthotic devices for treatment of minor scoliosis secondary to LLD.)
T Papaioannou, I Stokes and J Kenwright.
Scoliosis associated with limb-length inequality
J Bone Joint Surg Am. 1982;64:59-62.
Given that Dannenburg gives great emphasis to the spinal engine within his sagittal plane theory, it would seem plausible that reduced stress and load on the muscles via lifts would assist any treatment scenarios followed in attempting to at least reduce the progression of the deformity. I suspect that the activities of many muscles would also need to be educated so as to retain the new information via lengthy physio and paediatric treatment.
I’m a pediatrician with a question that I think would be answered best by a podiatrist. Allopathic physicians are trained not to intervene in cases of scoliosis unless the deformity is considerable (i.e. greater than 10 degrees). Given that limb length inequality can cause scoliosis, I view this “laissez-faire” approach as being closer to a policy of somewhat-less-than-benign neglect—especially when correction of the patient’s biomechanics might alleviate the spinal deformity.
I currently have a (premenarchal) 12 y/o female patient with documented 1cm lower extremity length discrepancy (comparing respective direct measurements from ASIS to medial malleolus) and a 7-degree scoliosis contralateral to the longer limb. My question for all the pods is: Do you think that orthotic inserts could be used to correct (or at least prevent the progression of) the spinal deformity? Thanks in advance for any input you can provide.
(I found a journal article that may be of interest to those of you contemplating the clinical scenario above. The paper deals with adults with scoliosis who have significant LLDs corrected with lifts. Although this study does not address my specific question it provided the impetus for my conjecture regarding the use of orthotic devices for treatment of minor scoliosis secondary to LLD.)
T Papaioannou, I Stokes and J Kenwright.
Scoliosis associated with limb-length inequality
J Bone Joint Surg Am. 1982;64:59-62.
Welcome to Podiatry Arena. It is good to have one of our medical colleagues from another specialty join us in this academic forum.
Here in the States, it is common for pediatricians to tell the parents of patients with very significant flatfoot deformity "Don't worry, they will grow out of it", when, in fact, many of these patients would have been better off being treated with foot orthoses during their growth years. This seems to be consistent with the "policy of somewhat-less-than-benign neglect" that you noted to exist with many of your pediatric colleagues in the treatment of scoliosis.
Instead of foot orthoses for this 12 year old girl, why not simply put a 10 mm heel lift into the shoe of the short limb? Having this much limb length discrepancy definitely may be one of the causative factors in the production of scoliosis in this young lady. It would make sense to offer the parents and patient something inexpensive and simple, such as a heel lift, to see if works to slow the progress of her scoliosis. I would only use foot orthoses for this young lady if the foot function was also suspect in causing her scoliosis.
Good luck and let us know if you have any other questions about your patients.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
The snake oil salesmen would argue that foot orthotics would be needed in cases like this.
The only time that I would have thought that foot orthoses would be indicated in those with scoliosis would be if the abormal foot function is asymmetrical. Many years ago Sanner showed that foot pronation can functionally shorten a limb by up to 1 cm, so if one side does it and the other dosen't then their is a greater potential from frontal plane proximal effects (ie scoliosis) ....but who is to say the scoliosis did not cause the asymetrical foot function.
I this case, I am with Kevin, a simple heel raise is probably all thats indicated.
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At the risk of being a snake oil sales man all I would contribute here is that when I have seen cases like this in adults it has not been uncommon to find the calcanei remain vertical at full weight bearing and the MTJ on one foot roll in considerably. Again there may be frontal plane aspects here and orthoses do appear to have aided the physiotherapy that has followed the intervention. Admittedly it might be possible to consider such adults as compensatory scoliosis rather than an actual one and again I have found it to be commonly accompanied by an upper trunk rotation (left or right). Is it possible that adjusting the LLD by half and checking and addressing any frontal plane anomalies that you can achieve your goal?
I this case, I am with Kevin, a simple heel raise is probably all thats indicated.
Come on Craig......you make it sound like you and I have never agreed before.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Interestingly my daughter has idiopathetic scoliosis, 7 degrees at 12 years of old, escalating to 47 degrees 18 months later, no LLD but both feet STJ pronation. She had spinal fusion two years ago and not a great success as one rod and screws has to be removed this year. Apparently she not only has the curvature, but also corkscrew deviation of the spinal column which invariably is more difficult to correct and she has a lot of discomfort.
The compliancy of orthotic devices for a 16 year old girl has been an ongoing issue.
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I’m a pediatrician with a question that I think would be answered best by a podiatrist. Allopathic physicians are trained not to intervene in cases of scoliosis unless the deformity is considerable (i.e. greater than 10 degrees). Given that limb length inequality can cause scoliosis, I view this “laissez-faire” approach as being closer to a policy of somewhat-less-than-benign neglect—especially when correction of the patient’s biomechanics might alleviate the spinal deformity.
I currently have a (premenarchal) 12 y/o female patient with documented 1cm lower extremity length discrepancy (comparing respective direct measurements from ASIS to medial malleolus) and a 7-degree scoliosis contralateral to the longer limb. My question for all the pods is: Do you think that orthotic inserts could be used to correct (or at least prevent the progression of) the spinal deformity? Thanks in advance for any input you can provide.
Hi WYSIWYG
As pelvic mechanics / torsion patterns can be significantly related to lower limb mechanics, I'd suggest a referral to a competent sports podiatrist / biomechanist to comment specifically on this case.
Is it possible for prescribed foot orthotics to be of assistance? Definitely.
In this case? Depends.
Will a heel lift be all that is required? Maybe.
More information required to answer these questions, so find a Podiatrist locally whom can contribute specifically.
It could make all the difference to this patient for a lifetime.
Scoliosis is a complex problem, and simply looking at LLD will not suffice to create positive outcomes. Herman postulated that scoliosis was a neurologic defect, in which there was an inability to accurately perceive "vertical". This results in abnormal postural tilts and twists unrecognized by the CNS, and therefore uncompensated (Burwell, "The Knottingham Principle"). Scoliotic gait is characterized by rotations of the upper body in an asymmetrical fashion. This then translates through the body to the foot, with each side being thrusted differently against the ground. Over sufficient time, as "form follows function", the spinal column becomes rotationally deformed as the normal compensatory mechanisms fail to adjust for the asymmetric motion. One of the reasons I believe you start to see these around age 9-10 is growth. The postural components become sufficient large (and different) enough to create a significant imbalance in gait.
From my perspective, the podiatric role is essential, but these patients need to have orthotics made via in-shoe pressure analysis. Their motions are too confusing to only visually evaluate, and often, orthotic correction need only be very subtle. The uneveness of the ground thrusts are visible through these systems, and once measured, correction becomes achievable. I strive to reach symmetrical movement of the center of pressure between R and L, and adjust orthotics according to changes evident in the testing process.
I have published my outcomes in CLBP subjects, and had an 84% success rate in a 12-24 month f/u period in subjects considerate at or near medical endpoint for CLBP. I have not published scoliotic treatment outcomes, but have had very satisfying results and have been able to follow many of them for many years. I have tried to "eyeball" scoliotic patients to make orthotics, but the in-shoe pressure measurement systems are so sensitive to (a)symmetry, it becomes an invaluable tool for this type of patient management.
Your feet are the foundation of your body and imbalances put extra stress on the entire skeletal structure.
Orthoses do not merely raise the arch, they help to ……….
Increase Bio-feedback
Maintain First Ray action
Provide structural integrity to the arches
Lock the Midtarsal joint
Maintain the calcaneal inclination angle
Reduce Subtalar joint eversion
Improve muscle function by help muscles function as
close as possible, etc.
Orthoses are worn by anyone with poor foot mechanics.
Both legs on my patient are of equal length but right leg appears and functions shorter d/t scoliosis tilting it up.
He walks more on front of right foot and heel of left as shown by wear patterns on his shoes.
Orthopedist wants me to give him heel lift for left (FOOT THAT FUNCTIONS AS LONGER) to tilt hip straight. I will make him an orthosis with built in lift 5/8"
How does the Podiatry Arena group feel about that?
Since nobody else has, I'll be the voice of doom here.
Do we have any kinematic studies which show that, beyond straight up heel lifts, in shoe orthoses affect even a temporary change on scoliosis?
Because when I read this
Quote:
Interestingly my daughter has idiopathetic scoliosis, 7 degrees at 12 years of old, escalating to 47 degrees 18 months later, no LLD but both feet STJ pronation.
It makes me think we're trying to ram a square peg into a round hole (no offence Carleen, you're just vocalising how many of us think, but some of us are better at wrapping long words around). We have a very rapidly progressing scoliosis (assuming its not a measurement error thing) which is a real concern. No LLD, good, and both feet pronation, good. The feet, no LLD and "pronation" at 12 YO sound pretty average, the progression of scoliosis does not. I struggle to credit that with any kind of causal link!
As to the improvement in LBP which Howard mentioned, we're talking about a condition with an improvement rate from placebos of around 40% (Haake). We're also talking about a condition where the natural history is for there to be acute attacks which self resolve and which may, or may not, recur. I've had episodes of back pain 4 or 5 times in my life, which lasted for a few months (longest 6) and which resolved. I didn't treat them. Perhaps if I had I'd have thought the treatment had fixed them.
I'm all for having a go, but lets not let our enthusiasm get away with us here. If we do, we do our patients a disservice.
Your feet are the foundation of your body and imbalances put extra stress on the entire skeletal structure.
Orthoses do not merely raise the arch, they help to ……….
Increase Bio-feedback
Maintain First Ray action
Provide structural integrity to the arches
Lock the Midtarsal joint
Maintain the calcaneal inclination angle
Reduce Subtalar joint eversion
Improve muscle function by help muscles function as
close as possible, etc.
Orthoses are worn by anyone with poor foot mechanics.
Again, I don't wish to be rude here. But I'm going to. These are all beautiful sounding things, most of which are unproven, and some of which mean exactly jack all. What is to "increase Bio-feedback"?! What is to "help muscles function as close as possible?"
Come to that, some orthoses do not reduce sub talar eversion. Some which mean to, don't and some are not meant to. And don't even start me on locking the MT joint.
If we're serious about helping people with scoliosis we need to do better than vague and nice sounding stuff like this.
Here in the States, it is common for pediatricians to tell the parents of patients with very significant flatfoot deformity "Don't worry, they will grow out of it", when, in fact, many of these patients would have been better off being treated with foot orthoses during their growth years.
Strikes me that these things are not muturally exclusive. I'm firmly in the "treat them" camp on paeds, but I also believe that most will be structurally improved by adulthood with or without intervention.
When it comes to pediatricians telling patient's parents that the child will outgrow the condition....it is more like the child outgrows the pediatricians practice! Pediatricians never get to see the adult manifestations of the issues they believe are "outgrown".
When it comes to pediatricians telling patient's parents that the child will outgrow the condition....it is more like the child outgrows the pediatricians practice! Pediatricians never get to see the adult manifestations of the issues they believe are "outgrown".
What appears to be idiopathic scoliosis may actually be functional scoliosis that can be effectively treated with foot orthoses in children who are hyperpronators, according to research from Chungnam National University in Daejeon, South Korea.
Both legs on my patient are of equal length but right leg appears and functions shorter d/t scoliosis tilting it up.
He walks more on front of right foot and heel of left as shown by wear patterns on his shoes.
Orthopedist wants me to give him heel lift for left (FOOT THAT FUNCTIONS AS LONGER) to tilt hip straight. I will make him an orthosis with built in lift 5/8"
How does the Podiatry Arena group feel about that?
You have to put the lift on the side with the high hip if it is a fixed curvature. Trying to force the long leg to tilt the pelvis rarely works in scoliotic patients.
Bruce
Just from a very practical perspective its going to be hard to fit 10mm into the shoes of a 12 year old female and get compliance, inside or outside. If no foot problems I would certainly go for heel raise.
We would also need to know where the scoliosis was. Mostly thoracic is going to be tough with the lumbar flexibility. If Px has foot problems certainly correct theses. They won't be helping. The vast majority of people who have a 5-10mm leg difference normally do so without scoliosis, so what is the relationship? However its probably worth a shot given there is not too much to lose.
I recently published the results of a study I did on adolescents between the ages of 10-18 (n=25). The results of this study suggested that one of the major determinants in the development of AIS (adolescent idiopathic scoliosis) was asymmetrical hyperpronation (Podiatry Review March 2013).
Admittedly, this study is not definitive and needs to be confirmed or refuted (double blind study preferrably). But it does suggest that a link does exist between how the foot moves and the development of abnormal spinal curves.
Not surprisingly. A past published study suggested that abnormal pronation unlevels the pelvis (JAPMA, 2006). And since the pelvis forms the base of the spine, it is very logical to suspect that when the pelvis unlevels, so goes the spine.
Why could not the exact reverse of your hypothesis be true, that is hyper-pronation develops from an tilted pelvis due to scoliosis, and how do we know there is not a third causal factor producing both scoliosis and hyper-pronation? Also can you explain how the scoliosis was measured? And a question of biomechanics, was there a straight lumbar spine? because a tilted pelvis would be more likely to produce a curve where accommodation is greatest. Was there radiological investigation to support the proposition and to exclude incidentals such as hip pathology? Idiopathic scoliosis is a complex 3-dimensional spinal deformity. As you say, the idiopathic form is believed to be multifactorial including genetic causes. simple common sense would tell that the patient is probably better off with their over-pronation corrected but to imply that this might be a "critical" factor and therefore a means of treating the scoliosis I suggest is a very tenuous conclusion.
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Of course, everything you have suggested is possible. That is why I placed the disclaimer at the end of my paper stating that this study was not definitive and needed to be repeated.
However, having said that, I believe that asymmetrical pronation is (or one of) a major determinant in the development of AIS. On my research website I have presented radiographic (kyphotic study), postural plates and 3D Formetric Studies which support the conclusion of this paper.
That case study has nothing to do with your current hypothesis, and it is one patient with all of the potential downfalls of that sample. Your patient could very well have got better without proprioceptive therapy. Perhaps the orthotics did absolutely nothing? I do not know, but no useful information at all about therapy can be drawn from that one patient, and neither is it proper to draw any conclusions from your paper as presented, as I think you indirectly say yourself.
You are absolutely correct, one patient does not prove or disprove an hypothesis.
It is not my intent to convince anyone of anything. It is my intent to present my research and its relevance (in my opinion) to what we see clinically.
On my research website I present findings from interesting studies - case in being - the radiographs taken of a patient pre vs post proprioceptive therapy. I could provide many other examples, but I found this one most interesting because the radiographs were taken and read by the radiologists at the hospital.
Orthotic Devices to Treat Scoliosis?
Re: Orthotic Devices to Treat Scoliosis?
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