Is It Unethical to Prescribe Orthoses for Children with Asymptomatic Flatfoot Deformity?

None of us have a crystal ball, Simon , but we can look at the evidence anecdotally from what we have seen over the years and that which is published (although the value of the latter is frequently questionable these days) - and make an informed opinion about what might be the best option of care, including prevention. I don't have a problem with bone restructuring or remodelling as you suggest; it's a normal response. But it's not the only consideration in determining whether to intervene - indeed I would argue that in some cases, clinical evidence of progressive remodelling would be an primary indicator to intervene - whether that be palliatively or dynamically is another argument altogether.

You manage to survive another thirty years of this business and the kid and his dad comes back to see you - the kid's matured into his dad's feet and his dad has gnarled tree stumps at the end of his legs as he hobbles in - still pain free in his feet but now waiting for the hip, knee and lower back surgery that's looming on the horizon. But you can reassure him that the bones his feet are like cast iron now after all these years of constant stress - only it's not really bones now but just bone as most of the joints are pretty much fused together. But it shouldn't ever fracture and probably won't even hurt that much and in that narrow respect, they remain asymptomatic. He asks:

You say,

He says:

And you say...

 

It is a common misconception that the intended goal of foot orthoses for flatfooted children should be to produce "normal arched feet".

When parents of children with flatfeet ask me whether custom foot orthoses have the potential to increase the arch height over time, I tell them that I have only seen this happen once in 30 years in treating well over a thousand flatfooted children with foot orthoses. I tell them that, rather, the main goal of custom foot orthoses for their flatfooted child is to improve gait function, improve their walking and running endurance, decrease their symptoms and to prevent further progression of their flatfoot deformity.

I likewise tell them that custom foot orthoses are much like custom eye glasses in their therapeutic goals. Custom foot orthoses will not likely change the structure of the feet over time any more than custom eye glasses will likely change the structure of the eyes over time. However, custom foot orthoses will improve the function of their child's walking and running gait just as custom eye glasses will improve the function of their child's ability to see clearly. In other words, it is a change in function that is the goal with custom foot orthoses and custom eye glasses, not a change in structure.

Therefore, the therapeutic goal of treatment with custom foot orthoses for flatfooted children, symptomatic or asymptomatic, should not be to achieve "normal arched feet". Rather the therapeutic goal of treatment with custom foot orthoses for flatfooted children should be to:

1) reduce their excessive subtalar joint pronation moments so that their foot and lower extremity may function more normally during gait,

2) reduce the excessive medial longitudinal arch flattening moments in their growing foot so that further plastic deformation of their foot skeleton will not occur over time which may lead to further progression of their flatfoot deformity,

3) reduce the abnormal internal stresses within the structural components of their foot and lower extremity so that not only will symptoms be prevented when they are physically active, but also so that physical activity, in itself, does not become painful stimulus for them to be seek a more sedentary lifestyle during their youth and adolescence.

Certainly, this seems quite consistent with biomechanical modelling of the flatfoot deformity, the known biomechanical effects of foot orthoses, the known viscoelastic nature of structural components of the foot and lower extremity, and my clinical experience of treating these flatfooted children over the past three decades.

Great discussion!:drinks

 

Viz. you are trying to reduce the levels of stress to tolerable levels within the tissues, which is what the body is doing via remodelling: by adding strnegth to the tissues in high stress regions plastic deformation will be avoided under the same loading. At the risk of repeating myself, if the child is asymptomatic it seems reasonable to assume that the body is managing this process adequately and monitoring is all that is required. As Rob Kidd pointed out, a child asking to be carried on long walking trips, tripping, appearing clumsy with complaints about knees, hips or back is symptomatic, an requires a different approach.

If foot orthoses are analgous to eye glasses as suggested and that change in structure is not achieved through the wearing thereof, then clearly there is no benefit in applying these to the asymptomatic child, we don't give asymptomatic children eye glassess- right? Rather it should be better to wait until symptoms develop such that the foot orthoses can be manufactured to have the requisite design features to alleviate the symptoms more specifically which may or may not have developed at that point in time. Or, do we just give them a "meat pie" and hope that it covers it?

 

Simon,

I admire your advocacy of the principle of "first, do no harm", and I acknowledge the limitations of the available evidence in this area. But I think you protest the point to much.

I sit very much on the same side of the fence as Kevin. I agree wholeheartedly that the principle of orthotic use in asymptomatic flatfoot (especially frontal and sagittal plane dominant deformity) is to reduce tissue stress that will generally and predictably increase pathological forces in the medial column, and elsewhere. We are not 'fixing' anything. But we are using our understanding of anatomy, pathology and tissue stress theory to the best of our current understanding to reduce mechanical load on articular surfaces and connective tissues which will likely deteriorate and fail prematurely. Engineering 101. Most paediatric orthopaedic (and podiatric) surgeons will follow this philosophy when considering tendo Achilles lengthening and lateral column lengthening for the more severe end of the paediatric deformity spectrum, such as CP and spina bifida.

There are countless examples of asymptomatic conditions which are treated in medicine. Hyperlipidaemia, hypertension and hyperglycaemia (the holy trinity) in cardiovascular medicine are the most commonly managed conditions in Western medicine. They are, by and large, asymptomatic. However, they are almost universally considered to lead to pathological changes in multiple systems.

There are life long smokers that live to 100 and die peacefully in their sleep. Just because not every smoker dies of coronary artery disease or lung cancer, does not dispel the argument that counseling and intervention with smokers reduces the risk of these conditions occurring.

Just because hyperlipidaemia doesn't cause symptoms, should we then ignore it? It would be considered malpractice.

Likewise, a substantially medially deviated STJ axis in a paediatric patient which is not resolving with age must at some point be considered a risk factor for PTTD, medial column osteoarthritis and the range of common degenerative MSK pathologies of the foot and ankle - which typically only become symptomatic with age, increase body mass and articular cartilage degeneration.

Like many on this forum, in my 20 years of clinical practice, it is common to see parents bring in asymptomatic pes plano valgus children for assessment. If this is not reducing of its own accord after age 6, or is in fact worsening I will consider orthotic management. The most salient clinical finding I tend to base this on (where consistent with equinus, hypermobility and a medially deviated STJ axis) is dorsal enlangement of the 1st MT-cuneiform or N-C joints, suggestive of early onset osteophytosis.

Truth be told, I have been a silent observer of these arguments around the ethics of treating paediatric flatfoot for far too many years. I live in hope that podiatrists can stop arguing this issue one day, but I suspect it will be close to the time I retire.

Maybe one day we might also see the non-treatment of asymptomatic flatfoot as risk factor for a malpractice or negligence claim....:butcher:

LL

 

Simon,

a quick question if I may?

Say you get a 8 year old with symptomatic Flatfoot Deformity, which you treat with a device.

We for this question can say the child has no major soft tissue or boney changes, but they have a tripping history, tired feet after walking or standing for a period of time.

Your assessment shows a medial deviated STJ axis, increased supination resistance etc etc all the standard stuff.

At the 4 week review, patient comes back, loves life, device is very comfortable, no more complaining of tired feet, and Mum and Dad have noticed much much less tripping.

So basically the patient is Asymptomatic.

Would you ever adjust the device at review ? or just say great see you in x months.

* I also understand you maybe Devil's Advocate for this thread

 

I'd say great see you in a 6 months, give me a call if anything changes.

Mike, I find one of the best ways to get a mental workout is to enter into a debate and take an alternate viewpoint

 

Why age 6?

 

And I would think for many it would be the same, which is where it gets complex, when is the precription enough?

When the people who treat Asymptomatic child patients know enough correction is enough, I for 1 treat asymptomatic child patients because lets face it it not often there is asymptomic child patient brought in by parents etc , there is usually some issue, but like most of us I have thought , what is right or not.

In Sweden they have a word Lagom, which basically means the perfect amount, it came from the Viking times, they would open a flask of some drink and pass it around the table, if everyone took what they wanted and by the time it returned to the start it was empty and no one missed out it is said to be Lagom

Finding Lagom is easier said than done, espically without some way to measure

as has been said

Great Discussion:drinks

 

The correct amount might be more significant than many appreciate, Mike. Going back to the eye glasses analogy, Kevin said:

Which isn't strictly true in children. This study http://www.ncbi.nlm.nih.gov/pubmed/12445849 that intentionally gave some of the children a slightly under-corrected prescription of eye glasses showed changes in the structure of the eye and an acceleration of their myopia.

Lets hope everyone prescribing foot orthoses for asymptomatic paediatric flat foot are getting those prescriptions right; no meat pies please.

Regardless, if the foot orthoses modify the magnitude, point of application, timing and direction of the forces acting on the foot, to reduce the pronation/ arch flattening moments acting on the foot, in turn the body must modify the tissues structures via remodelling in the response to the modified loading. In the case of our asymptomatic paediatric flat-foot, this should result in a weakening of the tissues that provide counter forces to the pronation/ arch flattening moments because that's how the bodies adaptation to forces works via it's cellular remodelling mechanisms. So, lets just hope they keep wearing those foot orthoses or they gonna become symptomatic pretty rapidly and have problems when they loose them, the dog eats them etc. because the tissues just won't be able to readapt quickly enough to deal with the loading without them.

 

Well spoken LL

I don't deal any more with pediatric patients, but my main focus is the diabetic patient. And I face the same question every day, to provide prophylactic therapy or not. How many diabetic ulcers have I seen in which I said to myself, If I had just taken action earlier, this might have been prevented.

The prophylactic treatment of patients for many medical conditions continues to be a statistical, economic and philosophical debate on many levels.

I know that I will incur the wrath of some "modern-thinking" people out there when I invoke the name of Root, but one of the things I learned from him was that we should not be treating "flat-foot". The term is obsolete and should be totally discarded from the diagnosis books. I believe that we need to return to the idea of Lovett and Cotton (1898) when they talked about determining whether the patient has any reserve of pronation available. This involves doing such novel things as trying to measure the available ROM that the patient has to work with, and to determine whether patients function such that the joints could be said to be subluxing (a still rather nebulous term at best). It also means looking for etiologies of abnormal pronation, e.g. MDSTJA, short Achilles, etc., that would prevent the patient developing a normal foot.

Of course in my old age, I'm being much more informative and less dogmatic when I discuss with patients need for treatment of asymptomatic conditions, because I am very well cognizant that my crystal ball isn't always clear. It is well documented a large number of ailments that are effectively treated with mechanical in-shoe devices, and one continually asks, "couldn't it have been prevented?" I explain this to patients. I also point out that there are many people with "flat feet" that function asymptomatically their entire life. I then let people make up their mind as to what philosophy they want to follow. If they're the vitamin-taking-organic-only type of person, a large number will want to take preventative actions. On the other hand if they're the MacDonald's-generation type, many will elect to take a wait and see attitude. The important thing I realize is that the patient is always in control. I look forward to that the day when we will be able to predict with much better accuracy foot ailments, but right now we're about as accurate as Poor-Richard's Almanac was in predicting the weather.

Best wishes,
Daryl

 

Well said, Daryl.

 

With all these thoughts in mind, even though I have no problems treating some asymptomatic children with flatfoot deformity with custom foot orthoses, this does not also mean that I advocate treating all children with flatfoot deformity with custom or pre-made foot orthoses. I am very, very selective of which pediatric flatfoot patients that I recommend foot orthosis treatment to.

The more severe the deformity, the worse the symptoms, the more abnormal the gait pattern, and the more severe the genetic predisposition toward developing painful flatfoot deformity, the more likely I am to recommend custom foot orthosis therapy. The milder flatfoot deformity, the less the symptoms, the more normal the gait pattern and the lack of presence of genetic history of adult painful flatfoot deformity, the more likely I am to recommend just periodic observation of these flatfooted children with no treatment.

I feel it is just as unethical for a podiatrist to treat all pediatric flatfoot patients with foot orthoses, regardless of the factors I listed above, as it is unethical for a podiatrist to not offer some form of orthosis treatment to an asymptomatic flatfooted child with obviously abnormal gait and a strong family history of painful adult flatfoot deformity. The ethical podiatrist will not be thinking about how much money they will make on treating the flatfooted pediatric patient when they decide on what treatment to recommend. Rather, the ethical podiatrist will first consider the well-being and future life of the flatfooted child when considering what treatment to recommend.

Regardless of the discussion on medical ethics, treating children effectively with custom foot orthoses requires good biomechanical knowledge of foot and lower extremity biomechanics, an ability to accurately assess walking and running gait patterns in children, and the ability to make a comfortable and functional custom foot orthosis for these pediatric flatfoot patients, and the ability to properly modify custom foot orthoses if problems occur.

Do all podiatrists have these vital skills that are required to successfully make therapeutically effective custom foot orthoses for pediatric patients with flatfoot deformity? Absolutely not!

Therefore, if the podiatrist doesn't have these skills, then they need to refer these flatfooted pediatric patients to a podiatrist or other foot-health practitioner who does have these skills for proper treatment. Alternatively, if they don't have these skills and still want to treat these patients, then they need to enroll themselves in courses where these skills are taught so that they are not harming these children by making uncomfortable, non-functional foot orthoses that cause abnormal gait, cause abnormal forces and moments and, ultimately, cause worse pathologies to develop in these patients than if these patients had never received treatment at all.

Remember, it is not first your duty to treat every patient regardless of your skills. Rather, it is first your duty to do no harm.

 

Back to the start, is an "obviously abnormal gait" a symptom? As such can these individuals be called asymptomatic?

OK, I've had hypothetical scenarios thrown at me for the last couple of days so I'll throw one back, lets say we have an asymptomatic flatfooted child with what you perceive to be an "obviously abnormal gait". You make them foot orthoses, at review they have now developed pain, when previously they had none. What do you do?

 

FIX the ORTHOTIC! (and apologize that you may have not fully understood the problem, or overlooked something in your original rx)

I would remind everyone of what one of my mentors, Leonard Levy, use to say: "We don't treat foot problems. We treat people who have foot problems."

 

With regard to positive family history, lets us remember that the offspring get one additive half of their genetic information from each parent and do not share identical environments to either parent. I can go into detail regarding this but basically the heritability of offspring on one parent is b (slope of the regression) = 1/2 heritability squared; offspring on the mid-parent (mean of both parents) b= heritability squared. What is the heritability of flat-foot?

I got a young man coming in for review on Saturday, he has no immediate family history of flat-foot. He has accessory navicular and a hell of a flat set of feet though.

 

As opposed to remove it? The orthotic isn't broken, but you have managed to break the child- is that ethical? Surely we should fix the child that we've broken?

 

I believe we discussed this in another thread recently, Simon.

Therefore, subjective complaints are symptoms. Lack of subjective complaints means the patient is asymptomatic. "Obviously abnormal gait" is a sign, not a symptom nor a subjective complaint.

 

As Daryl said, the orthosis will need to be adjusted or, rarely, will need to be remade in order to make the patient asymptomatic. However, some slight "odd sensation" is normal in these patients when they first are dispensed their orthoses. Pain is not normal at initial dispensing. These patients should have no pain or discomfort at the three week post-orthosis dispensing review appointment and should be showing improved gait function compared to having no orthoses in their shoes. If pain is present at three weeks post-dispensing, then the orthosis needs to adjusted.

 

When you assess the asymptomatic patients gait it is your subjective opinion that it is "obviously abnormal" since "obviously abnormal" cannot be objectively assessed. So the patient is asymptomatic and there are no objective signs here either? Perhaps it is the clinician with the symptoms then? You still haven't defined normal, nor abnormal gait function, Kevin. Anyway, since you didn't define who'd made the observation of an "obviously abnormal gait" in your posting, Kevin, let us assume that the four year old patient has said this, therefore they are symptomatic. The great thing about semantics is that anyone with a reasonable understanding of one upmanship can join in- right?

At what age is a patient able to provide a list of symptoms? Clearly this means that many paediatic conditions are symptomless. Perhaps this is where Lucky Lisfranc (anonymous poster, and we all know how we feel about that, yet this individual seems to have been accepted as anonymous for many years- just an observation), get their "magical" age of 6 years from to initiate treatment?

 

Why do you choose to adjust, rather than remove? Let's say you adjust and they still come back in pain, how many times do you adjust before you remove and admit that the orthoses have created pain where previously there was none? Is it ethical to create pain in previously pain-free patients?

Judge: so you initiated treatment without any symptoms nor objective signs, your action lead to pain where previously there was none; you have no good quality published scientific evidence to suggest that your intervention may have prevented any problems in the patients future, nor that if left alone the patient should not have gone on to lead a pain-free existence due to the "shape" of their feet. How do you wish to plead? Ethical or Unethical?

I'll leave that to those with more experience of standing in front of a judge than I to decide upon.

Anyway, as Mike twigged earlier today, when this thread came up I decided to play Devil's advocate and to take a contrary stance in the discussion that ensued since this is something I have previously found useful as an exercise to reexamine my own beliefs and understanding about subject matters that I am interested in. Besides "brown-nosing" and agreement doesn't help to develop good threads and useful debate on Podiatry Arena and we hadn't had a good old chin-wag for ages. I hope some of you have been caused to think about your own beliefs on this subject matter through my actions here, that you have read a couple of new papers and maybe learned something new. If not, then never mind; from a selfish point of view I've gained some more knowledge and insight here.

Do I treat "asymptomatic flat-foot in children"? I'll let you decide but I don't have any more time to devote to this thread.

Is there a message here when it comes to treating asymptomatic paediatric flat-foot? https://www.youtube.com/watch?v=Jmg86CRBBtw

 

That is always an interesting scenario. I would caution against the use of the terms 'unethical', 'ethical' or 'malpractice' in this context; adverse outcome might be more appropriate providing the dispensing clinician can demonstrate some knowledge and explanation of what they were trying to achieve. That said, I have seen some devices that have not only created symptoms but developed plantar ulcerations due to their inappropriate prescriptions and in one case led to a BKA - and in my view was clearly negligent Where you draw the line between malpractice and adverse outcomes is another matter and one for the lawyers, but I think we need to be careful before we start using that kind of terminology routinely in debates like these.

Whether it be paediatric flat foot or adult acquired flat foot, determining correct prescriptions is always challenging. Whilst I admire the capacity for measuring forces and applying the laws of physics and mechanics to understand better what is happening to tissue when we use 'functional' devices, we are a long way off from quantifying their effect accurately. In gross deformities where there is complete collapse of the medial arch and associated structures rigid and semi-rigid devices with some degree of 'correction' may very well be contraindicated, especially where there are systemic or low tolerance factors - but if you are minded to go down this route, then expect to see some disgruntled and happy patients in equal measure. It will be an interesting research project for aspiring podiatrists when imaging technology advances sufficiently so we can see the bone and tissue morphology that is taking place within the foot when we use orthosis and insoles in these difficult patients. I suspect it will be an eye opener.

If you can excuse some simple thinking for a moment, but I think occasionally we can get too caught up in a particular mindset or ideology to the neglect of others which may have equal importance in your armament. The problem I have with using functional/corrective/root-based rigid/semirigid devices in these conditions where you are effectively propping up a part of the body is that it is still impossible to accurately measure what forces these devices are applying to the various structures in the foot and what effect it is having on them. If we expect to see remodelling changes in the unsupported foot as a result of the boney alignment - then the use of in shoe devices will produce the same. You may hope that be positive, but that depends on your prescription.

In light of the somewhat dismissive tone you adopt re "meat pies" I would suggest you're missing a trick, Simon. I think the material properties in these conditions are of equal if not greater importance than any prescriptive add-ons like external and intrinsic posts, skives and plate modifications. Reducing the external pathological forces can be achieved in many ways - not just by altering the positional interface with functional devices. Incorporate a material whose properties are force absorbent rather than deflective and you achieve similar if not better outcomes. Use in conjunction with a subtalor artheroesis and you achieve a degree of correction and comfort you could previously only dream about - providing the surgical outcome is good. Whether you achieve 'functional improvement' is another argument - and how could you reasonably measure this would be highly contentious anyway, in my view.

I have to say that I have only used devices and/or "mince pies" in a relatively small number of asymptomatic patients over the years - probably less than 150. Most asymptomatic children don't consult us - why would they? Only the concerned parent might seek some advice. My criteria for intervention is similar to Kevin and Daryl's re history and gait - but I also consider the child's activity too. Those children participating in high impact activity in conjunction with the other factors I would consider intervention for example. Do no harm - yes. Try to prevent any harm - equally, yes. Same principles for adult acquired flat foot but different considerations. Try fitting even something like a non-posted, medium density PU TCIs to a someone with PTTD, deltoid atrophy and a talor diastasis and you get an unhappy patient who has just shelled out £300+ for something they can't tolerate for more than a few hours. Fit them a set of non prescriptive mince pies and change them every four weeks and you have a very happy patient indeed. Sometimes the K.I.S.S. principle really does work.

 

You might want to look at the title of the thread!

For the record, one last one before I've got to go, a "meat pie" is a 4/4 posted neutral shell, it stems from "Morgan's Meat Pie paradigm", I don't have time to explain right now, Kevin knows.:drinks

Ta-raa. https://www.youtube.com/watch?v=CdsFuwavfVs

 

I have the title of the thread very much in mind. I know Gary's approach very well having worked with him for a couple of years. This is Russell's Mince Pie Paradigm - battered and deep fried with extra chilli. Remind me to give you some next time we meet.. :drinks

 

The patient's parents are instructed to remove the orthoses from their child's shoes if, after my orthosis adjustment, they are still having problems with the orthoses.

This is no different than what the rest of the medical profession does when confronted with a patient that is developing problems with a new oral medication that they have prescribed. They tell the patient to either decrease the dosage of the medication or discontinue the medication.

It would be unethical to do nothing about the orthosis pain in an asymptomatic child who is getting orthoses. It is ethical to modify the orthosis in an attempt to make the orthoses non-painful or tell the patient's parents to remove the orthoses if pain continues to occur.

 

I would love to find that thread on Morgan's Meat Pie Paradigm where Root's orthosis prescription protocol was being criticized. Was this on Podiatry Mailbase?:drinks

 

Yep, a long time ago my old friend. As I recall you, Achilles and I made out that we had a new protocol, but not telling anyone what it was... really, I got to go though.

 

Found it!

Thread date: September 10, 2000 on JISC Mailbase:

https://www.jiscmail.ac.uk/cgi-bin/webadmin?A2=podiatry;d24e3259.00

 

And probably still underpins 99.5% of devices prescribed today.

 

OK, you got me, I read Jeff's reply (bless him) and I must confess I laughed so much that a little bit of wee came out- prostate isn't what it used to be. Can you access the rest of the thread, Kevin?

 

It was quite a thread with probably 20 responses to it. I was able to access it by signing into my JISC mailbase account.

Let's see if this link works for you.

https://www.jiscmail.ac.uk/cgi-bin/...D33285C45C3D39C&Y=kevinakirby@comcast.net#586

There are some real gems here on JISC Podiatry Mailbase Archives with some of them dating back to 1998. That was when we had some amazing discussions. Now, it seems like Newsbot does all the posting here on Podiatry Arena......in other words....no discussions....just news....:sinking:

 

I wanted to report back on this young man that I have just reviewed following dispensation of foot orthoses.

The boy is a keen sportsman being a competitive sprinter and rugby player. He was diagnosed as having accessory navicular by a local orthopaedic surgeon. To the best of my knowledge this diagnosis was made clinically, without x-ray confirmation. He complained of pain from footwear irritation over both navicular. The surgeon had suggested surgery with a tendon transfer of the PT, which the parents had declined at this stage and brought the child to me via a physio colleague instead. The physio had provided OTC foot orthoses (3 pairs) which were unsuccessful. Initially, I had attempted to modify the OTC devices given the outlay that the parents had already made on 3 pairs of OTC devices, but this was unsuccessful so we agreed to go down the custom orthoses route- polyprop UCBL'ish type device with shell dropped below navicular, 18 degree modified heel skives, poron topcover with medial flange extension with "donut" padding to navicular.

At review, both parents and patient were delighted with the father commenting "they have absolutely transformed him, his friends say his running is back where it used to be", the mother added: "he doesn't complain of pain anymore".

They have ordered a second pair of devices. :drinks

I've added a photo of his PT tendon, which seems to be subluxing over the medial malleolus.

 

Nice. Good job, Dr. Spooner! It is these types of cases that make me really appreciate being a podiatrist.....being able to heal people without surgery....and allowing them to continue doing the sports that they love.:drinks

 

Nice pics. Especially the tendon. Couple of questions. What are you aiming to achieve with these devices and over what period? Have you had any radiographs or scans done? What advice have you offered re surgery?

 

Reduce pain; until out-grows these devices; no radiographs; surgery may still be required at some stage.

 

What age is he?

 

Can't remember off the top of my head, think he's about 8-9, if it's important I'll check his records on Monday.

 

These are always good patients to see. The problem is always deciding what long-term management you think appropriate. It's always difficult without examining the patient and commenting solely on photographs however from the midstance without devices there is considerable medial displacement and I can well see why you are using the type of devices and inclination skive angle to get him pain free. The problem will always be what happens when he stops using the devices. Going back to the comments on the thread about remodelling - are you hoping to achieve some permanent structural correction in conjunction with reducing any symptoms and if you are, why not consider a bilateral artheroesis in conjunction with orthoses?

 

Yes, there will obviously be remodeling, is it my aim to bring about structural changes- not really, but they'll happen anyway, Already discussed arthroesis, but since I'm not a surgeon, I'd leave that to the surgeon to decide. Parents not keen on surgery.

Thats all I have time for, Mark.

 

Good luck with him. I count myself very fortunate to have worked with one of the best podiatric surgeons around in the last ten years - Lewis Stuttered in Rochdale - who specialised in subtalor implant surgery after his daughter Francesca underwent the same procedure in the USA. I managed many of his patients post surgery with foot orthoses where the principle aim was to limit the stress on the implant by fitting suitably posted devices - the advantage being that the prescription was more manageable. It is eight years since the first patient we jointly managed had her surgery and the changes in her foot structure are remarkable - I'll try and locate her photographs and post them up later. The next question I would have about this approach is whether the foot is sufficiently remodelled and stable enough for her to have the implant removed even to the point where she can discard her orthotics. I hope I can be around long enough to see whether that would be a possibility - but I do think it offers the podiatrist considerable promise, especially in these patients.

I'm delighted this condition and its management is getting another airing, even under the guise of an ethical dimension on intervention. The question of ethics has never really come into it for me and I had to smile when I read Rob's paper for the first time. You can easily tell if an author is an academic or a clinician! When I have seen very flat footed children - even asymptomatic ones - my first thought are what might happen to this child in 40, 50, 60 years time? Are they more at risk of developing a problematic foot in old age? Should I try and do something to prevent that? These are the questions you must ask - why? I can well remember the first time I saw a patient with chronic PTTD, acquired flat foot then an eventual diastasis and thought "Holy Sh!t"! The cork and latex insoles that I had been trained to make weren't going to make much impression on her and it was quite a challenge to keep her upright never mind mobile. She eventually went on to have a failed triple arthrodesis and subsequent BKA - but that was end stage progression; she had a history of paediatric flat foot which she had orthopaedic inserts and boots as a child, but then nothing after 16 years of age. It was a slow deterioration. More often than not we see patients at the clinical or preclinical stage when they first become symptomatic and the real challenge is to stop the progression. If I were to be honest, that has not always been possible - especially with the limitations on lab manufacture, materials and footwear - and probably knowledge. Every foot is different; the end result may be the same but there can be a variety of structures responsible for the dysfunction; understanding which are involved and how best to manage them in a prescriptive device takes a lot of trial and error and can be hugely frustrating. But I think it remains one of our most important roles. I also have to say that sometimes we are guilty of focussing on the smaller picture in so far as much of the time we are simply managing the symptoms and relieving the structures that are reacting to the various stresses at play, whether that be the PTT or medial ligament & etc., when they become symptomatic - and that is essentially the argument against non intervention in the asymptomatic child, as it takes too a narrow view of the overall risk attendant in this condition and we should, wherever possible, try and mitigate that risk. I do think, however, that there is another interesting debate to be had on the ethics of surgical intervention in the asymptomatic paediatric flat foot - but I think it needs to be had as there is a fantastic potential permanent benefit for these children that profession could be the driving force for.

I think that managing these conditions in conjunction with a refoot stabilisation procedure like the artheroesis is one of the most exciting developments in podiatry - if you can get excited about things like that. It would be good if you could find a proficient podiatric surgeon nearby, Simon and approach them to see if they would be interested in a joint project. With your experience in foot orthoses I'm sure it would be a success - and a tremendous benefit for your patients. :drinks

 

I guess that depends on the definition of "heal". If the objective is to keep the child asymptomatic or to eliminate symptoms, then that's probably fine. But if surgery can be used concurrently with orthotic management to correct a structural anomaly then I don't see why we should restrict ourselves to one particular approach for if it is successful then it would would lend itself to be more appropriate of that description. You must have seen/performed quite a few of these procedures, Stateside, Kevin. How routine are they in paediatric flat foot cases and what are the outcomes?