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Podo Pediatrics Podo Pediatrics 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 10 31 ANKLE / ACHILLES EQUINUS 11 Definition • Inability to dorsiflex above 10 degrees • Pathologic disease at less than zero degrees. 34 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 25 Ligamentous Laxity 26 Polydactyly Megadactyly 27 Cavus Foot caused by meningitis 28 Brachymetatarsia Syndactyly Ectrodactyly 29 Thank You 30.
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