Podo Pediatrics Identifying Biomechanical Pathologies

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1 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

2 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 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

3 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

4 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

5 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

6 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

7 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

8 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

9 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

10 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

11 31 ANKLE / ACHILLES EQUINUS 11

12 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

13 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

14 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

15 Specialist Treatment Custom orthotics Achilles stretching P.T. Surgery Tendo Achilles Lengthening Gastroc Recession IN-TOED FEET 15

16 Parental Complaint Parental Complaint Pigeon Toed Duck walk Waddling Metatarsus Adductus 16

17 From Your View 17

18 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

19 Etiologies- Common Osteochondrosis (Sever s Disease) Plantar fasciitis Achilles enthesitis or tendonitis Retrocalcaneal bursitis Biomechanical Causation Gastroc Equinus Pronation Forefoot instability 19

20 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

21 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

22 SHIN SPLINTS Parental Complaints Aching legs at night Painful legs in the morning Worse following activity Etiology Developmental Biomechanical 22

23 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

24 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

25 CHILDHOOD DEFORMITIES Club Foot 25

26 Ligamentous Laxity 26

27 Polydactyly Megadactyly 27

28 Cavus Foot caused by meningitis 28

29 Brachymetatarsia Syndactyly Ectrodactyly 29

30 Thank You 30

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