Practice Management Justification Pearls of Treating Non-Painful Pediatric Flat Feet

Transcription

1 Louis J. DeCaro, DPM Roberta Nole, MA, PT, CPed Practice Management Justification Pearls of Treating Non-Painful Pediatric Flat Feet

2 ROBERTA NOLE, MA, PT, C.PED President, Chief Product Developer Roberta Nole is owner of Stride, Inc. Custom Foot Orthotics (an Accredited ABC Orthotic Facility); Stride Physical Therapy & Pedorthic Center; and, Nolaro24, LLC - Maker of the QuadraSTEP and littlestep foot orthotics. She is a graduate of the University of Scranton (Biology); the University of Connecticut (Physical Therapy); and is also a ABC Certified Pedorthist. Nole is patented on a unique foot-typing algorithm that identifies 24 variations of the normal human foot (US Patent 7,789,840). Since 1989 she has specialized in biomechanical gait examination and rehabilitation of the foot and ankle. She has developed an educational training program entitled Clinical Analysis of 24 Adult Foot Types that is based on her original technology. She is a member in good standing of the American Physical Therapy Association, and the Pedorthic Footwear Association. Visit lease visit or or Roberta at bertstride@aol.com for further information and/or questions.

3 LOUIS J. DECARO, DPM Louis J. DeCaro. DPM received his degree of Doctor of Podiatric Medicine in 1999 from Barry University School of Podiatric Medicine in Miami, FL. He is in private practice in West Hatfield and a member of the surgical & medical staff at Franklin Medical Center as well as Holyoke Medical Center. Dr. DeCaro is currently Vice President of the American College of Foot & Ankle Pediatrics ( Dr. DeCaro is the routinely hosts both Pediatric and Adult Gait Biomechanics Clinics at his West Hatfield office. The clinics includes a multidisciplinary team, including but not limited to Physical Therapists (both pediatric and Adult), massage therapists, chiropractors, and orthotists. Visit lease visit decaropodiatry.com or Dr. DeCaro at drlouisjames@aol.com for further information and/or questions.

4 Better D FOOT TYPES THAT CONCERN YOUNG CHILDREN QUAD B: TOE IN GAIT QUAD D: DEVELOPMENTAL FLAT FEET QUAD F: ADULT ACQUIRED FLAT FEET (AFTER AGE 12-13) Worse D

5 MYTH BUSTER #1: It is Normal for Kids to Have Flat Feet It is normal for a baby's feet to look flat. The arch doesn't usually develop until age 3 to 4. By ages 5-6 a normal arch should be apparent. The arch of a baby s foot appears flat, largely due to a fat pad that fills the arch. Babies are born with skeletally immature foot until about the age of five, when all 26 bones form. A toddler should start ambulating around 12 months but lacks postural stability due to core and lower extremity neuromuscular weakness. There is a tendency for the child's flatfoot to be ignored or treated with benign neglect. THREE MYTH BUSTERS IT IS NORMAL FOR KIDS TO HAVE FLAT FEET THEY WILL OUTGROW IT GROWING PAINS ARE NORMAL

6 MYTH BUSTER #2: Kids Outgrow Flat Feet DEVELOPMENTAL FLATFOOT A frequently overlooked, inconspicuous condition that is the most common musculoskeletal abnormality affecting the foot of children under 6 years of age. A posturally deficient foot that has the potential to cause future deformity and disability. FLAT FOOTEDNESS IN KIDS IS NORMAL, UP TO A CERTAIN EXTENT! NOT ALL KIDS OUTGROW THIS CONDITION!!! THREE MYTH BUSTERS IT IS NORMAL FOR KIDS TO HAVE FLAT FEET THEY WILL OUTGROW IT GROWING PAINS ARE NORMAL

7 Assessing Calcaneovalgus Position Age Specific Parameters for Normal Right Feet Shown Vertical Bisection Of The Calcaneus In Weight Bearing Is Greatest At Age 1yo, When It Is About 6 valgus. Calcaneal Valgus Decreases 1 per Year Until About 6 Yrs of Age. At 6y.o. The Heel Should Be Vertical! Birth to 5 Ages 6-8 Ages 9-12 Normal Adult

8 24 FOOT TYPE CLASSIFICATION SYSTEM 24 Functional Foot Types 6 Functional Foot Groups Ideal RCS is 5 Inverted Contact Lenses Fitting Inventory

9 MYTH BUSTER #3: Growing Pains Are Normal Growing Pains are often written off as Normal Growth Issues. Common Warning Signs Pain (often knee and shin pain at night) Poor Balance Delayed Walking Antalgic Gait Fatigue Poor Coordination Growing Pains may be a warning sign of biomechanical dysfunction and should never be ignored! THREE MYTH BUSTERS IT IS NORMAL FOR KIDS TO HAVE FLAT FEET THEY WILL OUTGROW IT GROWING PAINS ARE NORMAL

10 GROWING PAINS ARE NOT ALWAYS NORMAL Consider Severity and Frequency of the Childs Symptoms. Remember that most episodes of symptoms may not involve the foot. Or, Frequent Recurring Episodes.

11 BIRTH TO 5 YEARS

12 Treating Children Ages: 1-5 Indications For Orthotic Intervention To Treat or Not To Treat That is the Question Most children don't take adult-like heel-toe steps until they are about three years old. If an arch forms when the child stands on their tiptoes, don't worry. When to Treat Asymptomatic Kids Under Age 5 1. When there is delay in reaching developmental milestones. 2. Protection for extreme medical conditions with risk of injury, EX: Osteogenesis Imperfecta, Neuromuscular Disorders, Hyptotonia, etc. 3. When the child is demonstrating poor balance, coordination and/or strength (along with PT). 4. When the heel remains excessively everted for their age. Functional Windlass Mechanism

13 MILESTONES AGES 10MOS TO 3YRS Physical & Language Emotional Social Jumps Runs Walks Stands

14 MILESTONES AGES 3-5 Physical & Language Emotional Social Motor Control Single Leg Stand / Jump

15 BIRTH TO THREE REHAB EARLY INTERVENTION THERAPY Marketing Tip: These Practitioners Are A Great Source For Pediatric Referrals.

16 KIDS TO 6-8 YEARS

17 Milestones for Ages 6-8 By the time a child reaches 6 to 8 years of age, gross and fine motor skills have become much more sophisticated and integrated. One of the most impressive changes is related to a child's coordination. They will now have the ability to finely coordinate independent movements of both the upper and lower extremities into a synchronous motion. Riding a two-wheel bicycle requires reciprocal leg motion coupled with arm movements to maintain a desired direction, all while maintaining balance to avoid falling. PHYSICAL MILESTONES FOR KIDS 6-8 YEARS OF AGE Concerns Include: Balance Coordination Posture Strength

18 THREE COMMONLY ENCOUNTERED MUSCULOSKELETAL DISORDERS IN KIDS AGES Developmental Flat Feet 2. Toe Walking: Contracture versus Idiopathic 3. Toe-In Gait: Structural Torsion versus Functional (Toe-Out Walking Occurs But Not Nearly As Common)

19 DEVELOPMENTAL FLATFEET BEYOND AGE 6 Recognition of the fact that the developmental flatfoot is the logical precursor of foot dysfunction, deformity, and resultant disability later in life will allow the practitioner to design a management program for today that will meet the foot health needs of tomorrow. Clin Podiatry Dec;1(3): LACK OF SYMPTOMS is an UNRELIABLE indicator of foot function in any age group TREATMENT GOALS Educate The Patient and Family Stabilize and Align the Osseous and Soft tissue Structures Reduce Calcaneal Valgus (Pronation) Promote Ideal Development (Posture, Balance, Coordination & Strength) Proper Shoe Wear Did someone say unstable foundation?... just sayin

20 CHILDHOOD OBESITY & FLAT FEET RESEARCH A 1999 study evaluated 1000 kids 4-13 years old, and found an abnormally high % of flatfooted children were overweight. An increase of flatfoot was seen in overweight children in a 2006 study of year olds A 2001 study of 243 children 8-10 years old found 16% had a low arch/flexible flatfoot in nonoverweight, and 24% prevalence in the overweight children. A 2001 study on 377 children that overweight children performed tasks poorly and worked more slowly Other Studies have revealed correlations between BMI and arch height.

21 Treatment Options for Developmental Flat Feet Custom Foot Orthotic DISCUSS TREATMENT OPTIONS Prefabricated Or Custom Foot Orthoses

22 TORSIONAL DEFORMITIES AND TOE WALKING

23 In-toeing and out-toeing is when toddlers walk with their feet turning inwards ("pigeontoed") or outwards. It usually corrects itself as your child becomes more confident on her feet. Treatment is indicated if the problem persists beyond toddlerhood, or worsens, especially if it only seems to affect one foot. Optimal Opportunity to Treat is Between Ages 5-9 years old. Toe walking is when a child walks on their toes without putting much weight on their heels. Persistent toe walking can be a sign of abnormally Short Achilles Tendons, and may need surgery or treatment by a physiotherapist. Idiopathic Toe Walking may be caused by foot pronation.

24 TOE-IN WALKERS Some basic facts about intoeing In-toeing is significantly more common than out-toeing and occurs in about 2 out of every 1000 children. Rotational problems are much more common in infants and young children than in adolescents. Structural Causes: 1. Tibial Torsion (boys & girls equally) 2. Femoral Torsion (girls 2x more than boys) 3. Metatarsal Adductus Think Bracing and Physiotherapy Idiopathic In-Toe Gait: May actually be a natural (habitual) compensation that a child adopts to overcome developmental flat footedness. Think FO s or Gait Plates and Physiotherapy

25 Treatment Options for Structural Torsion Tibial Torsion Transformer Wheaton Brace for Metatarsus Adductus Femoral Torsion Bracing Ineffective Intoeing means that when a child walks or runs, the feet turn inward instead of pointing straight ahead. It is commonly referred to as being "pigeon-toed. Consider the foot as a possible contributing factor. If the foot is flat, the medial hip rotators become tight (shortened), and the lateral hip rotators become weak. The foot and ankle musculature becomes weakened as well.

26 Treatment Options for Toe Walking Custom Foot Orthotic DETERMINE IF THE TOE WALKING IS IDIOPATHIC VERSUS TRUE CONTRACTURE Treatment options: Prefabricated Foot Orthotics Custom Foot Orthoses If Idiopathic, Note The Foot...It s Probably Flat. Toe Walking Kicks In The Windlass Mechanism And Stabilizes The Foot. Treat Conservatively By Controlling The Heel! Night Splints Surgery?

27 TREATMENT OPTIONS FOR IDIOPATHIC TOE-IN GAIT Custom vs Prefab Gait Plates

28 Better D FOOT TYPES THAT CONCERN CHILDREN QUAD B: TOE IN GAIT QUAD D: DEVELOPMENTAL FLAT FEET QUAD F: ADULT ACQUIRED FLAT FEET (AFTER AGE 12-13) Worse D

29 KIDS 9-12 YEARS (PRE-TEENS)

30 Consider Genetics Flat Feet Run In The Family! Evolution is genetics plus time Flat feet have a genetic component, and are more common in certain human populations and races. Like many other conditions, flat feet are considered multifactorial, meaning there may be influences from genetics, environment, and a combination between the two. If flat feet run in your family, it may be caused by a genetic trait that can be inherited. If you want to know if a child will outgrow their flat feet, check their parents and older siblings feet!

31 EVOLUTION OF THE ADULT FOOT As the child takes on its genetically predisposed adult foot shape, you will need to consider alternative functional orthotic designs. These can be custom or prefabs. More on this later..

32 Steps 3 & 4 Offer Confirmation! A C B D E F

33 COMMON PRE-TEEN PATHOLOGIES Osgood Schlatters disease or syndrome is an irritation of the patellar ligament at the tibial tuberosity. Calcaneal apophysitis (Sever s disease) is the most common cause of heel pain in young athletes. Patellofemoral Pain Syndrome (Runner's Knee) is a common knee problem in which pain occurs under and around the kneecap. Plantarfasciitis: Children with plantar fasciitis will feel pain on the bottom of the heel that sometimes will extend to the toes. Another common sign of plantar fasciitis is that the pain occurs as soon as weight is put on the foot after a period of inactivity has occurred. Shin Splints are an overuse injury caused by repetitive stress to the muscles, tendons and/or tissues associated with the shin bone (tibia) over a period of time, without enough rest to give the leg enough time to heal. Tibial Stress Fractures in teenage athletes are under-reported and more likely to affect girls than boys. Poor Posture and Postural Weakness including Genu Valgus (Knock Knees) Sesamoiditis (Jumping Sports)

34

35 PODOPEDIATRIC PROGRAM GOALS

36 PRIMARY GOAL WHEN TREATING KIDS IS EARLY INTERVENTION PREVENTION!!! Avoid Treating The Adult By Treating The Child! Too Often I Hear: I Only Treat Adults Correction is a poor substitute for prevention.

37 SECOND GOAL IS EDUCATION ENHANCE YOUR PATIENT S UNDERSTANDING OF THEIR UNDERLYING GENETICS AND THE BIOMECHANICS OF THEIR CONDITION What are Your Patients Looking At While They Wait?

38 THIRD GOAL IS OPPORTUNITY TO GROW YOUR PODOPEDIATRIC PROGRAM Mother, Father, Grandmother, Brother, Sister EVERYONE takes their shoes off. Supply Ample Seating in Case of a Family affair. Treating one kid a day will expand your practice. 20 kids a month 240 year one 480 year two 720 year three 960 year four 1200 year five

39 PEDIATRIC SCREENINGS Complimentary pediatric screening clinics can increase your patient base. Create families of patients. Create an opportunity to dispense prefabricated devices (cash based products) Enable you to develop an outgrowth program. Will earn you recognition as a pediatric specialist in your community.

40 IMPLEMENTING A PODOPEDIATRIC PROGRAM SUMMARY OF TREATMENT OPTIONS Podiatric Measures 1. Bracing for Structural Deformites 2. Custom Foot Orthotics For More Pathological or Extreme Cases 3. PreFabricated Foot Orthotics to Promote Proper Posture, Injury Prevention, or Less Severe Symptomatic Cases 4. Gait Plates 5. Night Splints Outside Referrals for Treatment 1. ROM 2. Strengthening Core and Limbs 3. Balance Training 4. Coordination & Agility 5. Proper Shoe Wear

41 WHO IS THE FUTURE OF YOUR PRACTICE? Question for You: If you have not yet started to treat kids in you office.what have you been waiting for? THE END