Cath Lab Digest

Yes. Ron Raducanu, DPM, FACFAS notes that orthotic treatment may help correct pediatric flatfoot and potentially prevent related biomechanical dilemmas as children move into adulthood.

   There continues to be quite a bit of controversy surrounding the treatment of pediatric flatfoot with custom orthotics. Given the continued emphasis on evidence-based medicine, this controversy is largely fueled by the lack of any empiric data to support the use of custom orthotics as a means to prevent future podiatric abnormalities or symptoms.

   The difficulty with relying on empiric data for this particular treatment modality is the lack of a standardized design to measure the modality in and of itself. In other words, how does one design a long-term study with a control group and a study group in this situation without compromising the test patients? There is no good justification to have a study where one child gets the treatment and the other does not just to “see what happens.”

   Unfortunately, this inherently brings into question the efficacy of the treatment itself. However, we must factor in the effect the treatment, or lack thereof, has on the patient.

   There is some data that suggests the torque surrounding the talus during a pronatory situation can affect the knee’s position as well as the position of the femoral head within the hip socket. There is also some data that suggests the treatment of the pediatric flatfoot with custom orthotics can permanently alter the mechanics of the child’s foot, thereby removing the need for custom orthotic support in the future. Unfortunately, the data for both of these theories are scant.

   Parents may bring in a pediatric patient for an evaluation of his or her feet. The child’s parents note they have been to other doctors and have been told that their young one’s problems are nothing to concern themselves with as the child will “grow out of it.” The parents say their child has been tripping a lot and is generally not able to keep up with the other children because of what they perceive to be a foot problem.

   After a thorough podopediatric history and physical, the podiatrist concludes that the patient does have a podiatric abnormality, confirming the parents’ concerns. However, since the patient is not complaining about pain or symptoms, is there a cause for concern or treatment?

   Of course there is a cause for concern. As educators and healers, our primary concern is the Hippocratic Oath. However, our patients need to feel at ease and confident in their doctor. Once again, there is no study that shows that a pediatric flatfoot left to its own devices will cause an eventual catastrophic podiatric situation.

   However, with what we know about biomechanics, it stands to reason that an abnormally positioned foot will eventually cause more harm than good.

   If one chooses to follow the “Do not worry. Your child will grow out of it” ideology, there is no separation by the parents between our profession and every other physician to whom they have taken their child. We have a tool to potentially aid in this child’s foot health so why not use it?

   One very daunting aspect of treating children is that they tend to be rather poor historians. Rarely can children under the age of 6 tell their parents that something “hurts.” Children generally need to be in substantial pain to be able to verbalize it.

   Indeed, trying to ascertain from children that their feet hurt during activity, particularly at a young age, is difficult. Once the child gets older, this becomes easier and easier, and can help to justify the use of an orthotic to support a potentially painful foot problem.

   Having a knowledgeable parent can be very helpful in evaluating the nature of the child’s pain. If a child limps at times, a parent can jog the patient’s memory as to how the patient felt during this episode. Any of these signs can also justify to the parent the need for an in-shoe device.