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KID STUFF 2012: Pediatric clinical news update

In our second annual pediatric special section,LER updates you on the latest research and clinical news to help optimize man- agement of your littlest lower extremity patients. Topics include cerebral palsy, , juvenile idiopathic , ACL , footwear, obesity, and the pros and cons of screening.

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Energy efficiency with AFO use varies in cerebral palsy patients ...... 26

Biomodel could help researchers optimize clubfoot brace design...... 27

Juvenile idiopathic arthritis study reveals footcare information gap...... 28

Early ACL surgery could lower risk of associated damage ...... 29

Wearing athletic shoes affects some performance measures ...... 30

Dynamic data in obese children may suggest gait compensation ...... 31

Experts debate relative benefits of screening feet for risk factors...... 32 Sponsored with educational grants from...

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Energy efficiency with AFO use varies in cerebral palsy patients Longer strides lead to increased work

By Samantha Rosenblum

Ankle foot orthoses (AFOs) are regularly enced a decrease in work of more than prescribed to children with walking disabil- 10%, with an average reduction of 31%. ities resulting from cerebral palsy, yet the But six patients experienced an increase effects of AFOs on energy recovery and in work of more than 10%; their average work during gait are still unclear. increase was 24%. In a study published in the March Overall, although AFO-assisted gait 2012 issue of Clinical Biomechanics, was found to be more pendular with an research ers from the University of Virginia improved recovery factor, the external in Charlottesville found that although AFOs work on the user’s center of mass was not can reduce the work needed to walk for reduced as the improved mechanics were some children with cerebral palsy, they do offset by increased variations of the poten- Photo courtesy of Cascade DAFO. tial and kinetic energies. not do so for others. these things better.” Maximum values for potential and ki- Most children had an increase in Energy efficiency should be consid- netic energies were higher and minimum stride length, gait speed, and energy re- ered in the context of a patient’s gait me- values were lower throughout the gait covery, but the increase in energy recov- chanics, Davids said. cycle for the AFO condition than the bare- ery did not decrease the external work. “It’s hard to always say which quality foot condition. This was not surprising, Additionally, there was a great variability in is the clinical priority,” he said. “If an AFO Bennett said, as increased stride length is the measures related to work—while use is extremely energy efficient, that would be of the AFO reduced work for some chil- the deciding factor. However, if there is dren, others experienced no change or a Longer steps require only a subtle difference in energy expen- negative effect. diture but it improves stability or other as- “The main culprit is that longer steps greater energy excursion, pects of gait, gait mechanics would be the result in greater energy excursions, which which was not offset by the deciding factor.” the improved gait mechanics could not According to Bennett, energy expen- overcome,” said Bradford Bennett, PhD, efficiencies of altered diture is still important even if gait me- research director of the Motion Analysis walking mechanics. chanics are improving. and Motor Performance Laboratory and “For most of these children, and as assistant professor of research in the De- they get older, it is the high cost of walking partment of Orthopaedic Surgery at the that is the limiting factor,” he said. “Dou- known to increase energy variation. The University of Virginia School of Medicine bling or tripling the cost of locomotion is large variations in the measured energies in Charlottesville. similar to the cost if one ran very hard from were offset by improved energy recovery, To examine the effects, researchers place to place.” yet the improvements were not enough to observed 21 children with spastic diplegic In the end, however, it’s up to the pa- decrease the net work. cerebral palsy who wore AFOs. A full body tient. Although these findings are not nec- marker set of 38 markers was attached to “A brace must provide a functional essarily new, such research may help each patient, who then walked with and benefit for children to embrace it and wear physicians in prescribing AFOs in the fu- without their prescribed AFOs at a self- it,” Davids said. “If it doesn’t improve what- ture. selected speed while three-dimensional ever their clinical problem is but maybe is “It’s worthwhile to do work like this data were collected. energy efficient, it will be rejected. Comfort because the more we understand how Devices worn by the study partici- and function are what determine a suc- braces work, the better we are at prescrib- pants included solid AFOs and hinged cessful outcome.” AFOs with a plantar flexion stop. The re- ing patient by patient,” said Jon Davids, sults for the two groups were combined, MD, assistant chief of Samantha Rosenblum is a journalism stu- as there was no statistically significant dif- at Shriners Hospitals for Children—North- dent at Northwestern University in Evan - ference between them, Bennett said. ern California in Sacramento. “Even ston, IL. AFO use was associated with signifi- though they’ve been used for many years, Source: cant increases in stride length and gait there are still many things we don’t under- Bennett BC, Russell SD, Abel MF. The effects of speed, but the effect on work varied within stand about what they do and don’t do. foot orthoses on energy recovery and work during gait in children with cerebral palsy. Clin Biomech the group. Eight of the 21 patients experi- This kind of research helps us understand 2012;27(3):287-291.

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Biomodel could help researchers optimize clubfoot brace design Method includes complex rotations

By Emily Delzell

A surrogate biomodel of a child’s lower computed tomography, converting that extremities, in particular the ability to image data into solid models, scaling the model movement along multiple axes of solid models to match that of an average rotation, could help improve researchers’ 5-year-old, then using rapid prototyping to biomechanical understanding of bracing convert the scaled solid model back into for clubfoot. a physical form,” DiMeo explained. The multicenter team of investigators The biomodel’s components include who developed the biomodel reported on skeletal structure constructed from acry- their testing of the complex surrogate in lonitrile butadiene styrene (ABS) resin and September in the Journal of Pediatric Or- muscle- systems and thopaedics (JPO). made from springs, cables, and elastic Clinicians now achieve high rates of cord. The JPO paper validated the bio- The surrogate biomodel undergoes testing in An- clubfoot deformity correction using the model’s reliability and repeatability for drew DiMeo's lab. Photo courtesy of Andrew Di - Ponseti method (See, “Clubfoot conver- measuring forces applied by different Meo, PhD. sion: Nearly all surgeons adopt Ponseti braces, demonstrating an error rate be- method, August 2012, page 11); once cor- tween 1% and 6%. something we’re pretty well aware of clin- rected, however, children’s feet retain a Co-investigator Jose Morcuende, MD, ically but haven’t been able to test in the stubborn tendency to relapse. Children PhD, associate professor of orthopedic lab until now.” who stop postcorrection brace use at 2 surgery at the University of Iowa in Iowa DiMeo, he noted, is preparing a sec- years have relapse rates of up to 56%; City, told LER that problems of compliance ond paper that details the use of the bio- among children who wear braces until model to compare an ankle foot orthosis they are aged at least 4 years, the relapse and a flexible bar brace as well as different rate is 11%, study authors reported. Poor compliance, which bracing parameters. “Dr. [Ignacio] Ponseti revolutionized primarily involves patient “The surrogate model allows unbi- treatment of children with clubfoot by turn- ased comparisons between braces and ing a debilitating surgery into a gentle ma- comfort, is compounded brace parameters. For example, the stan- nipulation. His method, however, relies by a lack of evidence for dard of care suggests a brace be worn heavily on patient compliance to wear a with the bar length set to width,” brace for up to five years after correction,” optimal brace parameters. DiMeo said. “What happens if the width is said study lead author Andrew DiMeo Sr, set slightly wider or narrower? These sub- PhD, director of industrial relations and as- tle brace adjustments can have an impact sistant professor of the practice in the Uni- with clubfoot bracing, which are largely on how well correction is maintained.” versity Department of Biomedical dictated by patient comfort, are com- Morcuende noted lessons gleaned Engineering at North Carolina State Uni- pounded by a lack of evidence and con- from the biomodel will help clinicians de- versity and the University of North Car- sensus regarding optimal brace para- termine which brace types best prevent olina at Chapel Hill. meters, including spring lengths and loads children from experiencing relapse and In an attempt to improve both the applied to muscle-tendon systems. The further treatment. bracing itself as well as patient compli- biomodel, DiMeo said, can characterize “This is the first biomechanical model ance, DiMeo and colleagues designed a and a compare a number of brace param- to test the different bracing parameters for surrogate biomodel with the biomechanics eters, including bar width, external rota- clubfoot and is a unique, complex model of a 5-year-old child, featuring complete tion, and dorsiflexion angle. that I think will be very helpful to test the lower extremity anatomy with joint articu- “We have clinical experience showing available braces and to narrow down lation and kinematic capabilities. us what works and what doesn’t, but we’ve which ones are working and which ones Investigators based the model on an- not had a good way of testing the best po- are not,” he said. thropometric data detailed in a reference sition to produce an optimal stretch with- text of normal human measurements. out having difficulties with the and Sources: “We then used the Ponseti Training the ,” he said. “Dr. DiMeo was able to DiMeo AJ, Lalush DS, Grabt E, Morcuende JA. De- velopment of a surrogate biomodel for the investiga- Model as starting point, converting the demonstrate, for example, that a too-wide tion of clubfoot bracing. J Pediatr Orthop 2012;32(7): physical model into image data using x-ray bar results in a knock-kneed effect. This is e47-e52.

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Juvenile idiopathic arthritis study reveals footcare information gap Issues involve custom foot orthoses

By Larry Hand

A Scottish study suggests foot care in chil- podiatric medicine at the University of dren with juvenile idiopathic arthritis (JIA) Western Sydney in Australia. “Further re- falls short because of poor access to care search is required to determine what as- and negative perceptions about custom pects of footwear are important to parents, foot orthoses. Experts say those issues as well as young and adolescent boys and may be less prevalent in the US but em- girls.” phasize the need to educate patients, par- Further research is needed on how, ents, and referring clinicians about the specifically, foot orthoses affect foot me- benefits of lower extremity care. chanics and inflamed and soft tis- Photo by Vincent Giordano/Trinacria Photography The study, published online in July in sues, and if the benefits of custom foot (www.trinacriaphotography.com), courtesy of Clinical the Archives of Physical Medicine and Re- orthoses justify the costs, Hendry said. Prosthetics & Orthotics. habilitation, identified six key themes that “The current evidence suggests that emerged from conversations with four customized foot orthoses are reasonably get into appropriate FOs,” Volpe said. teenaged patients, two parents, three pe- effective in reducing foot pain in inflamma- The 2005 study found that 15 chil- diatric rheumatologists, and six other tory arthritis conditions,” he said. “There is dren with JIA wearing custom semirigid healthcare professionals. The participants as yet no significant evidence that foot or- foot orthoses with shock-absorbing posts were from two National Health Service thoses halt the destructive inflammatory experienced significantly greater improve- processes associated with conditions such rheumatology centers in Glasgow, UK. ment in pain and function at three months Patients identified pain as the main than children who only used supportive impact of the disease, and cited physical Research supports use of athletic shoes or off-the-shelf shoe inserts. activity and footwear problems as causes The authors argued that the cost of the of pain. However, patients said they were foot orthoses for JIA pain custom orthoses ($250—$350 per pair) “prepared to endure high levels of pain relief but has not yet over time would be less than other med- and stiffness” if they could maintain mobil- ical interventions. ity, which was the main impact of disease examined effects on However, the study authors also cited by healthcare professionals and par- wrote that, because materials and meth- ents. Patients also perceived that pain and inflammatory processes. ods used in fabricating custom orthotics mobility impairment interfered with their vary, “the needs of the patient, whether ac- abilities to perform everyday tasks or par- as rheumatoid arthritis and JIA. This ques- commodative, biomechanical, or func- ticipate in , which also resulted in tion needs to be addressed through clini- tional, influence the choice of orthotic.” feelings of distress, depression, and isola- cal trials using sensitive imaging tech- If the patients in this recent study had tion. niques.” better access to lower extremity care, Patients and parents all reported Volpe said, many more of them would problems finding appropriate and comfort- The study’s findings related to access have been able to benefit from the pain- able shoes. All participants complained to care likely are not what one would find reducing effects of foot orthoses. about lack of access to lower extremity in the US, said Russell Volpe, DPM, profes- “In the face of the Powell study, that specialists. The healthcare professionals sor of orthopedics and pediatrics at the expressed reluctance to refer because New York College of Podiatric Medicine in some of the clinicians thought FOs were a they perceived a lack of evidence support- New York City. ‘waste of time’ betrays a sad ignorance on ing the effectiveness and cost efficiency of Noting that the effectiveness of foot their part,” he said. foot orthoses for JIA patients. While some orthoses for pain reduction in juvenile Larry Hand is a writer based in Massachu- considered the devices beneficial for eas- arthritis was documented in a 2005 ran- setts. ing pain, others considered foot orthoses domized study by Powell et al published in Sources: “as a waste of time and money due to non- the Journal of Rheumatology, Volpe sug- Hendry GJ, Turner DE, Lorgelly PK, Woodburn J. compliance.” gested that the effects on pain alone Room for improvement: patient, parent, and practi- “Finding solutions for footwear diffi- should be enough to justify the use of foot tioners’ perceptions of foot problems and foot care in juvenile idiopathic arthritis. Arch Phys Med Rehabil culties experienced in this patient group is orthoses. 2012 Jul 25 [Epub ahead of print] challenging,” said lead author Gordon J. “The already documented ability of FOs Powell M, Seid M, IS. Efficacy of custom foot orthotics Hendry, PhD, formerly of Glasgow Cale- in improving pain and functional status in children to reduce pain in juvenile arthritis patients with juvenile idiopathic arthritis: a randomized trial. J donian University and now a lecturer in should be enough to see that these children Rheumatol 2005;32(5):943-950.

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Early ACL surgery could lower risk of associated knee damage Patterns mirror those seen in adults

By Cary Groner

Timing of reconstruction surgery after pe- “The ACL plays an important role in diatric anterior cruciate (ACL) in- stabilizing the motion of the on the juries seems to be related to the ,” Padua said. “In those 150 days of prevalence of meniscal and chondral in- moving around, the patient may induce a juries discovered during those surgeries, meniscal or injury that wasn’t according to new research published in there initially.” the September issue of The American Such collateral damage increases the Journal of Sports Medicine. risk of subsequent (OA), a Researchers from the University of particularly troublesome prospect in

Texas Southwestern Medical Center in young patients, Padua noted. istockphoto.com #3325267 Dallas retrospectively reviewed the “If a kid with a torn ACL decides to records of 241 pediatric patients who had delay surgery, then goes on to damage “I don’t think you can conclude that undergone primary ACL reconstruction their , they are at high risk for delay led to meniscal ,” she said. 150 days from injury or sooner and 129 getting OA in their twenties or thirties,” he “You can say there’s an association, but patients treated more than 150 days out. said. we have no way of knowing whether the In the early group, 37.8% had medial Although the study suggested that patients started out with those meniscal in- meniscal tears (MMTs) versus 53.5% in delayed surgery may lead to higher rates juries at the time of trauma.” the delayed group; rates of lateral menis- of meniscal injury, other experts have “It would be great to see what the rate cal tears (LMTs) were similar (about 57%) urged caution in interpreting those results. of meniscal injury was one day after the in both groups. Patients with meniscal ACL tear, then compare it as time went tears, moreover, were more likely to have on,” agreed Dumont. “This was an obser- a chondral injury in that compartment. The findings call into vational study done at the time of surgery, but I think it makes sense that if you have “The historical treatment algorithms, question the popular in terms of leaving these injuries alone, an unstable knee, and there are structures have been based on the hope that the theory that meniscal inside it that are undergoing abnormal stresses, it’s more likely to sustain menis- children would heal. But the meniscus is injuries in children will not a highly vascular structure, especially cal injury.” as you move toward the inside, so our heal themselves. Regarding the findings that patients hopes of it healing itself may be un- had more lateral than medial meniscal founded,” said Guillaume Dumont, MD, tears—but that the lateral tear rate wasn’t chief resident in orthopedic surgery at the “The study documents the status of affected by the time lag between injury University of Texas Southwestern Medical the meniscus at the time of surgery, but and surgery—Dumont noted that this is Center in Dallas, and the paper’s lead au- not at the time of injury,” noted Cynthia also seen in adult populations. thor. “Children are more active than the LaBella, MD, associate professor of pedi- “Adults with an acute ACL tear are rest of the population, so we may see a atrics at Northwestern University's Fein- more likely to have a lateral higher prevalence of injury down the line berg School of Medicine, and medical associated with it, and as time goes on the in younger kids with ACL-deficient knees, director for the Institute for Sports Medi- rate of medial meniscal tears increases. It’s just because they’re the ones who are par- cine at the Ann & Robert H. Lurie Chil- difficult to say exactly what motion in the ticipating in sports every day and running dren’s Hospital of Chicago. “As a result, we knee is causing that, but it indicates to me around the schoolyard.” don’t know whether those meniscal tears that there are abnormal stresses in the That activity level may contribute to were a result of the initial trauma or accu- medial compartment of the ACL-deficient the increased prevalence of meniscal in- mulated during the interval between it and knee,” Dumont said. juries associated with delayed surgery in surgery.” Cary Groner is a freelance writer in the San the study, said Darin Padua, PhD, ATC, a It’s an important distinction, LaBella Francisco Bay Area. professor in the Department of said, because if the meniscal damage oc- Source: and Sports Science and director of the curred concurrent to the ACL injury, Dumont GD, Hogue GD, Padalecki JR, et al. Meniscal Sports Medicine Research Laboratory at elapsed time to surgery isn’t as crucial as it and chondral injuries associated with pediatric ante- the University of North Carolina at Chapel would be if the meniscal damage resulted rior cruciate ligament tears: relationship of treatment time and patient-specific factors. Am J Sports Med Hill. later due to unstable, ACL-deficient knees. 2012;40(9):2128-2133.

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Wearing athletic shoes affects some performance measures Standing long jump distance improves

By Cary Groner

Research has recently begun to clarify running, shoes had three primary effects: a footwear’s effects on gait and functional reduction in swing-phase leg speed, shock performance in children, but the broader attenuation, and encouragement of a rear- implications of the findings remain a mat- foot strike pattern. ter of debate. Other studies have reported similar re- At the 2012 International Foot & Ankle sults. For example, a 2009 paper by Lythgo Biomechanics (i-FAB) Congress in Sydney, et al in Gait & Posture reported that chil- Australia, researchers from the University of dren’s gait speed, step length, stride length, Sydney presented a poster delineating the support base, and step and stride time all difference between children’s performance increased with athletic footwear, whereas istockphoto.com #12122817 barefoot and in athletic shoes. The re- foot angle and cadence decreased. An- Wegener and others and concluded that searchers had nine boys and 10 girls other of Wegener’s studies found that chil- the reported gait and performance (mean age, 10 years) perform four activities dren’s school shoes increased sagittal changes are probably neutral to positive. barefoot, then in athletic shoes, in a ran- ankle motion during loading and propul- “These are fairly minute gait changes,” domized order. The activities were a single- sion, but decreased frontal plane motion he said. “Some are biomechanically logical leg balance test (eyes open, then closed); during midstance and propulsion. changes in sagittal plane ankle motion, a standing long jump; and a timed running The practical implications of such re- and there are other principles of the effect agility test in which the subjects ran 10 m search remain to be determined, Wegener of shoes on gait that can be extrapolated four times (they picked up an object at the acknowledged. to how they’ll affect children.” end of one 10-m leg, carried it on the next Volpe does think that, where children leg, dropped it, and picked up another to “Shoes do change the way are concerned, minimal is better. carry—hence the “agility” aspect of the test). “I generally like a lighter-weight shoe The researchers reported that shoes the foot functions, but they with soles that aren’t too thick,” he said. “It did not alter single-leg balance whether should have a firm counter to prevent ex- subjects’ eyes were open or shut, nor did also provide protection.” cessive rearfoot motion, and it should they have any significant effect on running bend easily in the ball.” agility. Shoes did, however, improve stand- Volpe rejects the idea suggested by ing long jump performance; the authors — Caleb Wegener some that wearing shoes weakens the speculated that this may have been due to feet, however. a perception of better protection, improved “There’s no evidence that the devel- friction between the outsole and the car- “Shoes reduce motion, which could opment of the muscles of the longitudinal peted surface, better transfer of force from reduce the stimulus to the muscles, which arch is hampered by shoes,” he said. “But the calves, or some combination of these. could impede muscular development,” in a child, you don’t want anything so Lead author Caleb Wegener, an Aus- Wegener said. “But we need to confirm heavy or bulky that it’s going to cause big- tralian podiatrist and PhD candidate at the that hypothesis.” ger alterations in gait.” university, told LER that additional data, un- In fact, when younger, Wegener often available at the time of the conference, competed in track and field events bare- Cary Groner is a freelance writer in the San showed that shoes negatively affected foot, on a grass track. He acknowledges Francisco Bay Area. standing jump height—an effect possibly that barefoot athletic competition has its Sources: caused by the shoes’ weight. limits, however. 1. Wegener C, Greene A, Millar R, et al. Children’s functional performance barefoot and in sports shoes. An earlier review by Wegener and his “I’d never play soccer or basketball J Foot Ankle Res 2012;5(Supp1):31. colleagues found that about 75% of pedi- barefoot,” Wegener said. “Shoes do 2. Wegener C, Hunt AE, Vanwanseele B, et al. Effect of children’s shoes on gait: a systematic review and atric gait variables differed between walking change the way the foot functions—but meta-analysis. J Foot Ankle Res 2011;4:3. barefoot and wearing shoes. Shod children they also provide protection.” 3. Lythgo N, Wilson C, Galea M. Basic gait and sym- walked faster, taking longer steps with Russell Volpe, DPM, professor of or- metry measures for primary school-aged children and young adults whilst walking barefoot and with greater ankle and knee motion and in- thopedics and pediatrics at the New York shoes. Gait Posture 2009;30(4):502-506. creased tibialis anterior activity; on the College of Podiatric Medicine in New York 4. Wegener C, O’Meara D, Hunt AE, et al. Three- dimensional ankle kinematics in children's school other hand, shoes reduced foot motion and City who has written about athletic foot - shoes during running. J Foot Ankle Res 2012; increased the support phase of gait. During wear for children, examined the studies by 5(Supp1):20.

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Dynamic data in obese children may suggest gait compensation Low force values surprise researchers

By Christina Hall Nettles

An Austrian study exploring the role of “It would be interesting to find out about genu valgum and flatfoot in obese and nor- their maximum forces normalized to body mal weight children found obesity was weight.” associated with higher peak plantar pres - Sarah Shultz, PhD, ATC, a lecturer in sures, but lower maximum force while walk- exercise and science at Massey Uni- ing, when forces were normalized to body versity in Wellington, New Zealand, and

weight. lead researcher of orthopedic complica- istockphoto.com #9709469 The findings suggest compensation tions of childhood obesity, highlighted the may occur in gait and that dynamic meas- Austrian findings of increased contact area necker stressed. ures may be more clinically important than during standing and increased plantar pres- He anticipates future studies that iden- static views. sures during gait in the obese children. tify the age of obesity onset might better in- Lead author Robert Bernecker, MS, “What is remarkable is that the obese dicate the point at which it leads to genu and his team at the University Clinic for children are displaying larger contact area valgum. Physical Medicine & Rehabilitation in during static standing [which is often seen “Moreover, it would be a great idea to Salzburg, Austria, analyzed 34 children, 13 as a mechanism for maintaining balance] compare obese children with different char- of whom were obese (mean body mass and still showing greater peak pressures acteristics concerning genu valgum and index of 31.2) and had genu valgum and/or during walking,” she said. flatfoot,” he added. flatfoot. Using a force platform system, the Shultz’s concern is that surface areas Michele M. Zembo, MD, MBA, assis- researchers assessed contact area, maxi- of children’s bones do not grow proportion- tant dean for clinical education at Tulane mum force, and peak pressure during 10- ately to their weight. University School of Medicine in New Or- second single-leg stands and during gait; leans, has treated many overweight chil- they also assessed contact time during gait. dren in more than 25 years of practicing For the static condition, obesity was High plantar pressures in pediatric orthopedic surgery. Dynamic studies, including gait analy- associated with significantly greater contact heavier children despite area. During gait, obesity was associated sis, are an essential component of evi- with significantly higher peak pressures and increased contact area dence-based clinical decisions that also depend on experience and observation, greater contact time for all areas of the foot may be evidence of except the toes, but lower normalized max- Zembo said, but there is also a role for imum force in the hind foot and the big toe. on bones and joints. static measures. The findings were presented in August at “The majority of foot problems in the Expert Scientific Meeting, held in Aal- obese children that families worry are de- borg, Denmark. “Bones and joints that are absorbing formities are actually caused by poor-fitting The lower normalized dynamic forces the impact of these forces are not any shoes,” she said. “In such cases, a static in the heavier children may indicate some larger than those in a child who does not footprint placed on the upturned shoe sole type of compensatory gait adaptation. carry extra mass,” she said. is essential for explaining what is happening However, a slower gait in the obese chil- Injuries that may occur as a result of in- to the child’s foot inside that shoe every dren than in the normal-weight children creased force when obese children com- day.” may also have contributed to the findings, pensate or modify their gait include stress Christina Hall Nettles is a freelance writer Bernecker said. fractures and plantar fasciitis, Shultz said. based in Monroeville, AL. Bernecker believes a future study “There are also possible implications Sources: comparing a different static measure to tra- farther up the lower extremity kinetic chain, Bernecker R, Weghuber D, Landauer F, et al. Does ditional dynamic assessment is needed to which is already evident in the obese chil- genu valgum and/or flatfoot play a role in dynamic plantar pressures and static footprints in obese and elucidate his preliminary conclusions. dren in the Bernecker study who display non obese children? Presented at the 13th Expert Sci- “The maximum peak force, not nor- genu valgum,” she said. entific Meeting, Aalborg, Denmark, August 2012. malized, is a more widely used parameter The genu valgum, in fact, may be a Dowling AM, Steele JR, Baur LA. What are the effects of obesity in children on plantar pressure distribu- in scientific literature, and this parameter more critical risk factor for future pathology tions? Int J Obes Relat Metab Disord 2004; was significantly higher in our findings com- than flatfoot, Bernecker said. 28(11):1514-1519. Mickle KJ, Steele JR, Munro BJ. Does excess mass pared with those found in the extensive re- “Orthopedically, the first concern is the affect plantar pressure in young children? Int J Pediatr search by Dowling and Mickle,” he said. valgus misalignment, not the foot,” Ber- Obes 2006;1(3):183-188.

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Experts debate relative benefits of screening feet for risk factors Most question emphasis on flatfoot By Cary Groner

The value of screening programs for pedi- problems that could be identified or pre- atric foot problems—primarily flatfoot—was vented through screening. recently challenged in a commentary by For Ron Raducanu, DPM, who prac- Australian podiatrist Angela Evans, PhD, a tices in Philadelphia and serves as presi- researcher and lecturer in the Division of dent of the American College of Foot and Health Sciences at the University of Ade- Ankle Pediatrics (ACFAP), the argument laide. against screening doesn’t take a long This summer, in the Journal of Foot enough time frame into consideration. and Ankle Research, Evans examined the “They’re not following these children Australian practice of school-based screen - into adulthood, so they don’t know if the ing and found it wanting from the perspec- kids experience pain as they get older,” tive of World Health Organization (WHO) Raducanu said. “Is there malalignment of criteria. Reaction in the US has been the joints? Does it resolve? Are there very muted because there are few such pro- , or in-toeing, or problems? If grams here, but Evans’s paper may serve screening can prevent even one percent as a caveat to those who want to start of them from having issues down the road, istockphoto.com #4525226 them—and some do. then we are doing our jobs.” and refer to the appropriate specialists. WHO guidelines specify that screen- Louis DeCaro, DPM, who practices in The problem with such an approach, ing programs for health conditions should Amherst, MA, and is vice president of the according to Edwin Harris, DPM, is that meet several criteria: the problem should ACFAP, plans to roll out a school screening there may be so many potential issues as- be important and clearly defined; it should program to help identify at-risk foot types sociated with each category that school be recognizable while latent or at an early nurses could end up classifying nearly symptomatic stage, and its natural history every foot as pathological. Harris, an asso- adequately understood; and treatment Problems that could be ciate professor of orthopedics and rehabil- should modify its course. identified or prevented itation at Loyola University Medical Center “These criteria are not fulfilled for pe- in Maywood, IL, saw a similar phenome- diatric flatfoot,” Evans told LER. through screening include non when he was involved in school Her paper points out that develop- femoral or tibial torsion, screening for scoliosis 20 years ago. mental (sometimes called physiologic or “It led to the term ‘schooliosis,’ be- normal) flatfoot occurs in 45% of pre- equinus, and genu varum. cause orthopedists were dealing with this school children, but decreases to 15% in huge incidence of false positive screening 10-year-olds as the foot develops. results,” he said. “If you’re going to use the “Some flat feet do remain in older in the near future, beginning with an as- kind of classification DeCaro proposes, children,” she said, “but unless they’re sessment of the methodology in his local you have to have some feet that are con- symptomatic, the need to treat is unclear.” district. sidered normal, and the number of classi- So why screen? Some argue that pe- “I agree with Dr. Evans that the way fications cannot lead to a high incidence diatric flatfoot shouldn’t necessarily be the foot screenings have been done is a waste of false positives. The instrument must be focus. of time,” DeCaro said. “Basically, they’re validated to ensure that it accurately iden- “We need more screening, not less, checking for flat-footedness, which has tifies cases with a high risk of future pathol- because there are huge numbers of chil- flaws related to subjectivity and doesn’t ogy. Also, it must be possible to train dren in the US with foot malalignments consider the natural maturity of the foot. school nurses to use the instrument as ac- that are not identified until they are well When we go into the schools, I propose curately as a podiatrist, with a low rate of into adulthood, when they have significant putting every child into one of six cate- false positives.” problems,” said Russell Volpe, DPM, pro- gories, taking a brief social and family his- fessor of orthopedics and pediatrics at the tory, and assessing other symptoms such Cary Groner is a freelance writer in the San New York College of Podiatric Medicine in as coordination, fatigue, and endurance.” Francisco Bay Area. New York City. DeCaro’s goal is to train school Sources: Volpe includes femoral or tibial tor- nurses to assess children’s foot types ac- Evans AM. Screening of foot problems in children: is this practice justifiable? J Foot Ankle Res 2012; sion, equinus, and genu varum among cording to his system, then sort the data 5(1):18.

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