Podo Pediatrics Identifying Biomechanical Pathologies David Lee, D.P.M., D. A.B.P.S.
Purpose
• Identification of mechanical foot and ankle conditions • Base treatments • Knowing when to refer to a podiatrist
Topics
• Flatfoot (Pes Plano Valgus) • Equinus • Intoed feet (Cavo-adductor Varus) • Heel pain (Calcaneodynia) • Shin Splints • Various Pedal deformities
1 WHAT IS NORMAL?
At birth to ~9 months
• Ankle flexible to over 20 deg DF • No “C” shaped foot • No clicking or popping sounds • Babinski sign • Pull up 7-8mo.
9-16 months…
• Begin walking • Feet are fat, flat and floppy • Knees are always center or externally rotated, never internal. • Stance is wide and less stable • Stomping gait pattern
2 16-18 months
• Able to walk upstairs • Knee never internal • Still wide base and flat and floppy feet • Stomping still
3-7 years
• Able toe walk downstairs • Heel-to-toe walk • Watch for – Intoeing – Tripping – Tight ankle joint (equinus)
7 years and up
• Arch should be developed • Heel-to-toe walk • Heel is perpendicular to ground • Knees straight ahead
3 Neutral Internal Rotation
Early detection is important
• Prevent long term adaptation • Joint damage • Adult pathology – Heel pain, bunions, hammertoes, ankle instability, knee pain, shin splints, etc. • Ability to thrive physically and socially
4 THE FLAT FOOT
Visual Complaints by the Parent
• Tripping or falling • Poor balance- Clumsy • Feet look funny, walks funny • Shoes wearing out quickly
Social Complaints by the Parent
• Lazy, inactive, “doesn’t like going outside to play or play sports • Can’t keep up with friends • Runs slows • Complains a lot whenever outside • They’re fat or “chunky”
5 Subjective Complaints
• Usually very passive • Aching knees, legs, ankle, feet • Slow moving or running • Shin splints
Sidebar: A word about history…
Sidebar: A word about history…
• Familial predisposition •Birth • Infectious • Trauma • Chemicals or drug exposure
6 From Your View The weight bearing exam
• No airspace between the ground and arch • Ankle or midfoot moving midline • Heels are everted • Forefoot splaying • Knees internally positioned • Wide stance
7 Active Gait Exam
Active Gait Exam
• Early heel off • Wide or wider stance • Late collapse of the arch after heel off • Moving side to side
8 Radiographs
• Don’t order x-rays for the specialist – Proper views – Speciality exams – Weight bear versus non-weight bearing – Specialist able to have the xrays at the consult
Base Treatments
• High top shoes •Rest • NSAIDs • OTC inserts?
9 Specialist Treatment
• Therapy taping • Achilles stretches (addresses often concurrent tight achilles (equinus) • Heel lift • Physical therapy • Custom orthotics or AFO • Surgery
Making an Orthotic
Surgery
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ANKLE / ACHILLES EQUINUS
11 Definition • Inability to dorsiflex above 10 degrees • Pathologic disease at less than zero degrees.
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Visual Complaints by the Parent
• Toe walking / tip toeing • Limping • “Strut” gait
Subjective Complaints
• Flat feet complaints • Ankle pain / Sinus Tarsi pain • Shin splints • Pain worse in the morning when getting out of bed and goes away after walking a few minutes
12 Etiology • Soft tissue – Tight gastrocnemius – Tight soleus • Structural – Uncommon in children – Ankle damaged • Spurious
Affect on the lower extremity
Affect on the foot
• #1 contributor to: – Flat feet – Heel pain – Shin splints – Bunions – Ankle pain
13 Objective findings
• Ankle dorsiflexion less than 10 degrees with knee extended or flexed. • No heel contact • Usually compensated flatfoot
Severe Equinus Gait
Basic Treatment
• Achilles stretches • Heel lifts • OTC orthotics • Physical Therapy
14 Specialist Treatment
• Custom orthotics • Achilles stretching •P.T. • Surgery – Tendo Achilles Lengthening – Gastroc Recession
IN-TOED FEET
15 Parental Complaint
Parental Complaint
• Pigeon Toed • Duck walk • Waddling
Metatarsus Adductus
16 From Your View…
17 May not be negative consequence
• Could be stable • Could be unstable if and when begins to patient compensate
Treatment
• Orthotics • Achilles stretches if associated • Parental counseling
HEEL PAIN
18 Etiologies- Common
• Osteochondrosis (Sever’s Disease) • Plantar fasciitis • Achilles enthesitis or tendonitis • Retrocalcaneal bursitis
Biomechanical Causation
• Gastroc Equinus • Pronation • Forefoot instability
19 Objective
• Palpable pain on: –Calcaneal growth plate –Medial calcaneal tubercle –Achilles tendon –Retrocalcaneal bursa
Objective
• Palpable pain on: –Calcaneal growth plate –Medial calcaneal tubercle –Achilles tendon –Retrocalcaneal bursa
Objective
• Palpable pain on: –Calcaneal growth plate –Medial calcaneal tubercle –Achilles tendon –Retrocalcaneal bursa
20 Objective
• Palpable pain on: –Calcaneal growth plate –Medial calcaneal tubercle –Achilles tendon –Retrocalcaneal bursa
Basic Treatments
•Rest • Heel lift • NSAIDs • Gentle achilles stretches
Specialty Treatment
• Custom orthotics • Cast boot •NWB cast
21 SHIN SPLINTS
Parental Complaints
• Aching legs at night • Painful legs in the morning • Worse following activity
Etiology • Developmental • Biomechanical
22 Etiology
• Strain of the origin of the extensor muscles (ant. tibial and extensors) • Strain of posterior tibial m. • Most often caused by over pronation
Etiology
Etiology
• Uncommon: –Tibial stress fracture –Compartment syndrome • Growing Pains?
23 Objective
• Palpable pain along the medial margins of the anterior tibial muscle along the tibial crest, posterior leg compartment • Equinus • Calcaneal eversion
Treatment for mechanical causes
• Heel lift • Achilles stretches • NSAIDs • Antipronation shoes • Orthotics*
Treatment for other causes
• Further testing –MRI –Compartment pressures –Bone Scan
24 CHILDHOOD DEFORMITIES
Club Foot
26 Polydactyly
Megadactyly
27 Cavus Foot caused by meningitis
28 Brachymetatarsia
Syndactyly
Ectrodactyly
29 Thank You
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